management of schizophrenia

Question 1

developing token economies with schizophrenia

Answer 1

• classic demonstration of TE carried out by Teodoro Ayllon and Nathan Adrian
• trialled TE system in ward of women with schizophrenia
• every time participants carried out tasks such as making their bed, they were given plastic token embossed with ‘one gift’
• tokens could be swapped for ward privileges, such as watching a film
• number of tasks carried out increased significantly
• TE used extensively in 1960s and 70s, when norm for treating schizophrenia was long-term hospitalisation
• use has now declined in UK due to growth of community-based care and closure of psychiatric hospitals, also due to complex ethical issues raised by restricting rewards
• however, TE still remains a standard approach to managing schizophrenia in many parts of world

Question 2

rationale for token economies

Answer 2

• institutionalisation develops under circumstances of prolonged hospitalisation
• one outcome is development of bad habits, such as ceasing to maintain good hygiene
• Johnny Matson identified 3 categories of institutional behaviour commonly tacked by TE (person care, condition-related behaviours, social behaviour)

modifying these behaviours doesn’t cure schizophrenia but has 2 benefits -
1) improves person’s quality of life within hospital, for example social interaction for a usually sociable person
2) normalises behaviour, makes it easier for those who have spent time in hospital to adapt back into community life, for example getting dressed in the morning

Question 3

what is involved in a token economy?

Answer 3

• tokens are given immediately to individuals when they carry out a desired behaviour
• target behaviours decided on an individual basis, important to know the person in order to identify appropriate target behaviours for them
• tokens have no value in themselves, later swapped for more tangible rewards
• having a form of immediate reward is important because delayed rewards are less effective
• tokens therefore administered as soon as possible after target behaviour

Question 4

theoretical understanding of token economies

Answer 4

• TE an example of behaviour modification, based on operant conditioning
• tokens are secondary reinforcers as they only have value once the person has learned that they can be used to obtain meaningful rewards
• meaningful rewards are primary reinforcers
• tokens that can be exchanged for primary reinforcers are called generalised reinforcers
• in order for tokens to become secondary reinforcers, they are paired with primary reinforcers
• at the start of TE programmed, tokens and primary reinforcers are administered together

Question 5

evaluation strength - evidence of effectiveness

Answer 5

• Glowacki identified 7 high quality studies between 1999 and 2013 that examined effectiveness of TE for people with chronic mental health issues, involved patients living in a hospital setting
• all studies showed reduction in negative symptoms and a decline in frequency of unwanted behaviours
• increases validity of TE

Question 6

evaluation limitation - counterpoint to evidence of effectiveness

Answer 6

• 7 studies is a small evidence base to support effectiveness
• one issues with small evidence bases is the file drawer problem
• leads to a bias towards positive published findings because undesirable results have been ‘filed away’
• particular problem in reviews that only include a small number of studies
• serious question over evidence for effectiveness of TE

Question 7

evaluation limitation - ethical issues

Answer 7

• use of TE gives professionals power to control behaviour of patients
• inevitably involves imposing one person’s norms onto others, especially problematic if target behaviours are not identified sensitively
• eg. someone who likes to get up late may have this personal freedom curtailed
• more seriously, restricting availability of pleasures to people who don’t behave means that seriously ill people have an even worse time
• legal action by families who see their relative in this position has been a major factor in the decline in the use of TE
• benefits of TE may be outweighed by impact on personal freedom and short-term reduction in quality of life

Question 8

evaluation limitation - alternative approaches

Answer 8

• other approaches with comparable evidence base that do not raise same ethical issues
• review by Chiang concluded that art therapy might be a good alternative, small evidence base but is a high-gain, low-risk approach to managing schizophrenia
• NICE guidelines recommend art therapy for schizophrenia
• there are better alternatives to TE systems