Managment Of Schizophrenia - A03 (token Economy)

Question 1

Evidence for effectiveness

Answer 1

One strength of token economies for the management of schizophrenia is evidence for their effectiveness.
Krista Glowacki et al. (2016) identified seven high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issues such as schizophrenia and involved patients living in a hospital setting. All the studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours.
This supports the value of token economies.

Question 2

Counterpoint

Answer 2

However, seven studies is quite a small evidence base to support the effectiveness of a technique. One issue with a small number of studies is the file drawer problem. This phenomenon leads to a bias towards positive published findings because undesirable results have been ‘filed away. This is a particular problem in reviews that only include a small numbers of studies.
This means that there is a serious question over the evidence for the
effectiveness of token economies.

Question 3

Ethical issues

Answer 3

One limitation with the use of token economies to manage schizophrenia is the ethical issues raised.
The use of token economies raises ethical issues because it gives professionals considerable power to control the behaviour of people in the role of patient. This inevitably involves imposing one person’s (or institution’s) norms on to others, which is especially problematic if target behaviours are not identified sensitively.
For example, someone who likes to look scruffy and get up late might have these personal freedoms curtailed. Perhaps more seriously, restricting the availability of pleasures (eg. having sweets or seeing films) to people who don’t behave as desired means that seriously ill people, who are already experiencing distressing symptoms, 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 token economies.
This means that the benefits of token economies may be outweighed by their
impact on personal freedom and short-term reduction in quality of life.

Question 4

Alternative approaches

Answer 4

A further limitation of token economies is the existence of more pleasant and ethical alternatives.
Even if token economies can be helpful for managing schizophrenia there are other approaches with a comparable evidence base that do not raise the same ethical issues. For example, a review by Mathew Chiang et al. (2019) concluded that art therapy might be a good alternative. The evidence base is regularly small and has some methodological limitations, but it appears to show that art therapy is a high-gain low-risk approach to managing schizophrenia. Even if the benefits of art therapy are modest, this is generally true for all approaches to treatment and management of schizophrenia and, unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical abuses. NICE guidelines recommend art therapy for schizophrenia.
This means that art therapy might be a good alternative to token economies.