Schizophrenia - The Token Economy as management

Question 1

The basic token economy cycle

Answer 1

1) Children has no access to tokens and no access to desirable activities or items
2) Child engages in desirable ‘target behaviours’
3) Child is given tokens or engaging in these target behaviours
4) Child trades tokens for desirable activities or items

Question 2

Key parts of the token economy

Answer 2

1) Primary reinforcers = anything that gives pleasure or removes an unpleasant state and so are reinforcing (make behaviour more likely to be repeated)
2) Secondary reinforcers = have no value to the individual but acquire reinforcing properties as a result of being paired with primary reinforcers.
3) Selective reinforcement = a type of behaviour modification which seeks to increase the occurrence of certain behaviours by responding to desired behaviours with a pleasurable stimulus, while seeking to extinguish undesirable behaviours by not responding to those.

Question 3

Token economy in schizophrenia management

Answer 3

• Token economy is a form of behavioural therapy used in the management of schizophrenia. It is used to shape and manage behaviour so that patients in long stay hospitals are easier to manage.
• It involves desirable behaviours being encouraged through selective reinforcement. (Skinner)
• Rewards (tokens) are given immediately as secondary reinforcers when patients engage in desirable behaviours e.g. getting dressed in the morning, making a bed, taking medication etc.
• Although these tokens have no value in themselves, they can be swapped later for more tangible rewards (primary reinforcers). For example, sweets, magazines, privileges such as a walk outside the hospital.
• Therefore, this encourages the desirable behaviour to be repeated because they have become associated with rewards and privileges.
• Whilst modifying these behaviours doesn’t cure schizophrenia, it improves the patients’ quality of life and makes it more likely that they can live outside a hospital setting.

Question 4

Evaluating the token economy as a management for schizophrenia - Weaknesses

Answer 4

1) Token economies only aim to make schizophrenia more manageable and improve the patients’ quality of life. Then help by making patients’ behaviour more socially acceptable so that they can better reintegrate into society.
- Whilst this is worth doing, it should not be confused with curing schizophrenia. Token economies do not address symptoms of schizophrenia, so they are not a ‘treatment’.
- Therefore, whilst token economies may provide patients with strategies that they can use to manage their current symptoms, they do not effectively cure schizophrenia.

2) Token economy raises ethical issues. For example, in order to make reinforcement effective, clinicians may exercise control over important primary reinforcers such as food, privacy or access to activities that alleviate boredom. However, it is generally accepted that all human beings have basic rights to food, privacy etc. that cannot be violated regardless of the positive consequences that might be achieved by manipulating them within a token economy programme.
- Additionally, primary reinforcers become more available to those with mild symptoms than those with more severe symptoms that prevent them from complying with desirable behaviours. Therefore, the most severely ill patients suffer discrimination and some families have challenged the legality of this.

Question 5

Evaluating the token economy for managing schizophrenia - Weaknesses cont.

Answer 5

3) A major problem in assessing the effectiveness of token economies is that studies of their use tend to be uncontrolled. When a token economy system is introduced into a psychiatric ward, typically all patients are put onto the programme rather than having a control group that does not.
- This means that patients’ improvements can only be compared with their past behaviours rather than a control group, which may be misleading as other factors (e.g. an increase in staff attention) could be causing the patients’ improvement rather than the token economy. Therefore, the research evidence can’t provide as strong support for the effectiveness of token economy as previously thought. (lack of internal validity)

4) Token economy has only really been shown to work in a hospital setting. There are problems administering the token economy method with outpatients who live in the community. Within a psychiatric ward setting, inpatients receive 24 hour care and so there is better control for staff to monitor and reward patients appropriately. In the community, outpatients only receive day treatment for a few hours a day and so the token economy method can only be used for part of the day.
- Therefore, even if token economy did produce positive results within the ward setting, these results may not be maintained beyond that environment, limiting the long-term effectiveness of token economy as a method to manage schizophrenia. (lacks ecological validity)

Question 6

Evaluation of token economies - supporting evidence

Answer 6

1) Dickerson et al. (2005) reviewed 13 studies of the use of token economy systems in the treatment of schizophrenia. 11 of these studies reported beneficial effects that were directly attributable to the use of token economies.
- This supports the effectiveness of token economy in increasing the adaptive behaviours of those with schizophrenia. However, they did caution that many of the studies reviewed had significant methodological shortcomings that limited their impact in the overall assessment of token economies in this context.