Management of SZ

Question 1

What are token economies?

Answer 1

• this is a form of behavioural modification where desirable behaviours are encouraged by the use of selective reinforcement
• e.g. people are given rewards when they engage in socially desirable behaviours
• the tokens are secondary reinforcers but can be exchange for primary reinforces

Question 2

Who carried out a classic demonstration of token economies and what did they do and fine?

Answer 2

• Ayllon & Azrin
• trialled a token economy system in a ward of women with SZ > every time the p’s carried out a task such as making their bed they were given a plastic token with the words ‘one gift’
• these tokens could then be swapped for privileges e.g. being able to watch a film
• they found that the number of tasks carried out increased significantly

Question 3

Why has the use of token economies declined since the 60s/70s?

Answer 3

• due to the growth of community based care & the closure of many psychiatric hospitals
• also because of the complex ethical issues that they raise by restricting rewards to people with mental disorders
• still a standard practice in other parts of world

Question 4

How does institutionalisation develop and what is the outcome?

Answer 4

• develops under circumstance of prolonged hospititalisation
• one outcome is that people develop bad habits e.g. not maintaining good hygiene, stop socialising with others , more reliant

Question 5

What are the three categories of institutional behaviour commonly tackled by token economies according to Matson et al?

Answer 5

• personal care
• condition related behaviours (e.g. apathy)
• social behaviour

Question 6

What are the two major benefits of modifying institutional behaviour?

Answer 6

• improves the quality of life within the hospital setting e.g. makeup for someone who cares about their appearance
• it normalises behaviour, which makes it easier for people with SZ to adapt back into the community e.g. getting dressed

Question 7

How do tokens economies work?

Answer 7

• tokens (e.g. coloured discs) are given immediately to individuals when they have carried out a desirable behaviour
• target behaviours are decided on an individual basis
• tokens have no value but are swapped for tangible rewards
• delayed rewards are ineffective > should be immediate

Question 8

How can operant conditioning be used to understand token economies?

Answer 8

• tokens are secondary reinforcers because they only have value when the person receiving them has learned that they can be used to obtain meaningful rewards e.g. sweets or a walk outside
• these meaningful rewards are primary reinforcers
• tokens that can be exchanged for a range of different primary reinforcers are called generalised reinforcers
• at the start S & P reinforcers are administered together

Question 9

What is a strength of token economies for the management of SZ?

Answer 9

• evidence for their effectiveness
• Glowacki et al > identified 7 high quality studies that examined the effectivenss of token economies for people with chronic mental health issues such as SZ
• all the studies showed a reduction in the frequency of unwanted behaviours
• which supports value of token economies

Question 10

What is counterpoint to the strength of token economies?

Answer 10

• seven studies is quite a small sample of evidence to support the effectiveness of a technique
• one issue with a small number of studies is the file drawer problem which leads to a bias towards positive published findings because undesirable results may be filed away
• serious question over the evidence for the effectiveness of token economies

Question 11

What is a limitation of the use of token economies to manage SZ?

Answer 11

• the ethical issues raised
• token economies gives professionals a considerable power to control the behaviour of people in the role of patient
• this inevitably involves imposing one persons norms on to other, which is problematic if target behaviours are not identified sensitively
• e.g. someone who likes to look scruffy & get up late might have these personal freedoms taken from them
• moreover, restricting the availability of pleasures to people who don’t behave as desired, means that seriously ill people who are already experiencing distressing symptoms have a even worse time
• this means the benefits of token economies may be outweighed by their impact on personal freedom & short term reduction in the quality of life

Question 12

What is another limitation of token economies?

Answer 12

• is the existence of more pleasant and ethical alternatives
• there are other approaches with a comparable evidence base that do not raise the same ethical issues
• e.g. a review by Chiang et al concluded that art therapy might be a good alternative > because evidence shows that art therapy is a high gain low risk approach to managing SZ
• unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical abuses
• NICE recommend art therapy for SZ + better alternative

Question 13

What is another limitation of token economies for managing SZ? EvL extra

Answer 13

• token economies are difficult to apply outside of structured settings such as hospitals
• Their success depends on consistent reinforcement > may be hard to maintain in community settings or at home
• Once the structure is removed, the learned behaviours may not persist > limits the long-term usefulness of the approach
• this weakens its external validity, as patients often return to environments where the token system is not in place.