management of schizophrenia: token economies Flashcards
what are token economies for schizophrenia?
reward systems used to manage the behaviour of people with schizophrenia, particularly those who have developed patterns of maladaptive behaviour through spending long periods in psychiatric hospitals
developing token economies with schizophrenia: ayllon and azrin (1968)
- trialled a TE system in a ward of women with a diagnosis of schizophrenia
- every time ps carried out a task eg. making bed, clearing up they were given a plastic token embossed with the words ‘one gift’
- these tokens could be swapped for ward privileges eg. watching a film
- number of tasks carried out increased significantly
describe the history of TE use for schizophrenia
- used extensively in 1960s and 70s when the norm for treating schizophrenia was long-term hospitalisation
- use has now declined in UK
- still standard approach to managing schizophrenia in many parts of the world
why has the use of TEs declined (in the UK)?
- growth of community-based care
- closure of many psychiatric hospitals
- complex ethical issues raised by restricting rewards to people with the condition
how does institutionalisation develop?
under circumstances of prolonged hospitalisation
what is the consequence of institutionalisation?
- people often develop bad habits. eg. not maintaining good hygiene, stop socialising with others
- understandable response to living without routine and small pleasures experienced in everyday life
rationale for TEs: matson et al. (2016)
identified 3 categories of institutional behaviour commonly tackled by means of TEs:
- personal care
- condition-related behaviours (eg. apathy)
- social behaviour
what are the benefits of modifying specific behaviours?
- improves person’s quality of life in hospital setting
- ‘normalises’ behaviour, making it easier for people who have spent time in hospital to adapt back into life in the community eg. getting dressed in the morning
what is involved in a token economy?
- tokens (eg. coloured discs) are given immediately to individuals when they have carried out a desirable beahviour
- tokens have no value in themselves but are swapped later for more tangible rewards
why is it important to have an immediate reward for target behaviour?
delayed rewards are less effective
examples of rewards in a hospital setting
- objects: sweets, magazines
- activities: film, walk outside
- appointment with a social worker to plan for life after hospitalisation
target behaviours: cooper et al. (2007)
- target behaviours are decided on an individual basis
- important to know the person to identify the most appropriate target behaviour for them
what are token economies based on?
TEs are an example of behaviour modification - a behavioural therapy based on operant conditioning
what are the primary and secondary reinforcers in token economies?
- token = secondary reinforcer
- meaningful reward = primary reinforcer
how are tokens secondary reinforcers?
only have value once person receiving them has learned that they can be used to obtain meaningful rewards
what are generalised reinforcers?
powerful secondary reinforcers which can be exchanged for a range of different primary reinforcers
what must be done for tokens to become secondary reinforcers?
- paired with primary reinforcers
- at the start of a TE programme, tokens and primary reinforcers must be administered together
evaluation: evidence of effectiveness (glowacki et al. 2016)
- identified 7 high quality studies published from 1999-2013 that examined the effectiveness of TEs for people with chronic mental health issues such as schizophrenia who lived in a hospital setting
- all studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours
evaluation: glowacki et al.’s (2016) evidence is flawed
- 7 studies is small evidence base to support the effectiveness of a technique
- file drawer problem ie. bias towards positive published findings as undesirable results are filed away
- particular problem in reviews that only include a small number of studies
evaluation: ethical issues
- gives professionals power to control behaviour of patient
- one person or institution’s norms are imposed on to others, especially if target behaviours are not identified sensitively
- restricting the availability of pleasures to people who don’t behaviour as desired means that seriously ill people, who are already experiencing distressing symptoms, would have an even worse time
- legal action by families who see their relative in this positive has been a major factor in the decline in the use of token economies
evaluation: more pleasant and ethical alternatives (chiang et al. 2019)
- art therapy might be a good alternative
- small evidence base with some methodological limitations, but art therapy appears to be a high-gain low-risk approach to managing schizophrenia
- pleasant experience without major risks of side effects or ethical abuse, even if benefits are modest
- NICE guidelines recommend art therapy for schizophrenia
evaluation: not useful outside of hospital
- very difficult to continue once outside hospital settings
- target behaviours cannot be monitored closely
- tokens cannot be administered immediately
- improved behaviour may cease once outside of hospital setting
evaluation: need to use in hospital
- some people may only get the chance to live outside a hospital if their personal care and social interaction improve
- can achieve this with TE system during hospital care
