token economy

Question 1

Why use token economies

Answer 1

Some people with schizophrenia suffer from negative symptoms, including apathy and social withdrawal. As a result these individuals lack interest in aspects of normal healthy life such as washing, eating and maintaining their physical appearance. Research has looked at ways of decreasing these negative symptoms and encouraging such individuals to take part in more positive behaviours. - encourage positive behaviour

Question 2

what is token economy based on

Answer 2

operant conditioning

Question 3

How do token economies work

Answer 3

Tokens are awarded immediately whenever the patient engages in one of the target behaviours, and these tokens can later be exchanged for various rewards and privileges. This immediacy of reward is important because it prevents ‘delay discounting’, which is the reduced effect of a delayed reward. Tokens are secondary reinforcers because they only have value once a patient has learned that they can be used to obtain rewards. The idea behind token economy is that the patient will engage more often with desirable behaviour because the behaviours become associated with these rewards and privileges - any kind of day trips or outings are good rewards for brushing teeth and engaging with other patients etc.

Question 4

Evaluation

Answer 4

Evidence of effectiveness
P - One strength of token economies for the management of schizophrenia is evidence for their effectivenss.
E - Glowacki et al. 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.
E - This supports the value of token economies

However, seven studies is quite 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 number of studies. This means that there is a serious question over the evidence for the effectiveness of token economies.

Ethical issues
P - One limitation with the use of token economies to manage schizophrenia is the ethical issues raised.
E - The use of token economies raises ethical issues because it gives professionals considerable power to control the behaviour of patients. This inevitably involves imposing one person’s norms on to others, which is especially problematic if target behaviours are not identified sensitively. For example, someone who likes to get up late might have this personal freedom taken away from them. Perhaps more seriously, restricting the availability of pleasures like having sweets or watching 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.
E - 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.

Alternative approaches
P - A further limitation of token economies is the existence of more pleasant and ethical alternatives.
E - 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 found that art therapy might be a better alternative. The evidence base is regularly small and has some methodological implications, 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 and is recommended by NICE guidelines.
E - This means that art therapy might be a good alternative to token economies.