Anorexia: Social Treatments - Token Economy

Question 1

Which learning theory does token economy base its principles on to shape behaviour?

Answer 1

Operant conditioning.

Question 2

Define ‘positive reinforcement’.

Answer 2

Receiving something positive due to displaying a desired behaviour.

Question 3

Define ‘negative reinforcement’.

Answer 3

Avoiding something negative due to displaying a desired behaviour.

Question 4

Define a ‘primary reinforcer’.

Answer 4

A direct reward based on our basic urges and needs.

Question 5

Give an example of what a primary reinforcer would be for a token economy.

Answer 5

Family time.

Question 6

Define a ‘secondary reinforcer’.

Answer 6

A reward that can help gain a primary reinforcer.

Question 7

Give an example of what a secondary reinforcer would be for a token economy.

Answer 7

A token to accumulate in order to access a primary reinforcer.

Question 8

Define ‘punishment’.

Answer 8

Receiving something negative for not displaying a desirable behaviour.

Question 9

Give an example of what a punishment would be for a token economy.

Answer 9

Not receiving a token when promised, or getting one taken away.

Question 10

Define a ‘variable ratio’ schedule of reinforcement.

Answer 10

Changing the number of times a desired behaviour is displayed before a reward is received.

Question 11

Define a ‘fixed ratio’ schedule of reinforcement.

Answer 11

Having a set number of times the desired behaviour should be displayed before rewarding a reinforcer.

Question 12

Define a ‘variable interval’ schedule of reinforcement.

Answer 12

Changing the time between each reinforcer rewarded as long as the desired behaviour is shown at least once.

Question 13

Define a ‘fixed interval’ schedule of reinforcement.

Answer 13

Having a fixed time in which a reinforcer is rewarded after as long as the desired behaviour is shown at least once.

Question 14

Describe how a token economy programme is used for treating anorexia (9 points)

Answer 14

• They take place in closed institutions with controlled environments, such as in hospitals
• The staff and patient establish primary reinforcers and when secondary reinforcers should be awarded for target behaviours, such as eating a full meal, cooking, going shopping for food, achieving their target weight or attending CBT sessions
• if a target behaviour is shown, they will be positively reinforced- e.g. could be praise or social media time.
• Primary reinforcers can include time with family with secondary reinforcers of tokens
• Negative reinforcement can also be used with things such as a target behaviour being show, leading to removal from a task they don’t enjoy (doing the dishes)
• tokens can be plastic counters or stamps on a card that are exchanged for a primary reinforcer
• The reinforcers should be given immediately to maintain trust and engagement in the programme
• Shaping is used with tokens being easy to gain at first but getting increasing harder as they progress in order to become more subtle to mirror the outside world, such as sitting at a table to eat food being reinforced at the start changing to eating the whole meal
• Objective measures such as weight gain or number of tokens received are a reflection of progress

Question 15

How is shaping used in TEP?

Answer 15

• tokens are initially easy to gain, yet become harder as they progress through the programme.
• may initially begin with sitting at the dinner table
• as time goes on, they will be required to eat the meal before any reinforcement is given
• gradually become more subtle to mirror the real world, as when released the pattern of reinforcement will differ greatly

Question 16

Target weight?

Answer 16

A specific target weight should be set as treatment goals upon which time a patient would then graduate from the hospital programme to an outpatient programme of individual therapy.

Question 17

Why is it done in a hospital?

Answer 17

Controlled environment of an institution allows reinforcement to be manipulated more precisely than other settings.

Question 18

Detail on the tokens

Answer 18

Patient and carers decide together what it can be exchanged for- patients must feel apart of and involved in this process.

Question 19

Detail on the target behaviours

Answer 19

Target behaviours must be something achievable and realistic for the patient- to increase confidence and engagement in the programme.

Question 20

Name 4 supporting and rejecting studies for TEP

Answer 20

• field
• Garfinkel
• Paul and Lentz
• Sonoda

Question 21

Supporting study (G)

Answer 21

Garfinkel et al can be used to support the effectiveness of TEP. They reported a successful operant conditioning programme using a variety of reinforcers which were individualised for 5 female AN patients, resulting in rapid weight gain to premorbid levels. During the initial 7 days in the hospital, the patients were observed by the medical and nursing staff, and on the basis of their observations, rewards were tailored to them, with goals being set for both daily and weekly weight gains. Garfinkel found that weight gain was rapid and patients discomfort was minimised- thus showing the effectiveness of TEP as a way of treating AN.

Question 22

Supporting evidence (S)

Answer 22

Sonoda (1974) supports. Sonoda reports the case of a 10 year old with AN treated with appetite stimulants for 2 months without results. She weighed 20 kg, about 30% below normal. The girl then received a form of TEP- were praise and encouragement was given for eating but no attention for refusal, and a token economy system. After acquiring 4 tokens for desirable behaviours, she was rewarded with a bicycle- and she got a token for each kilo she gained. Only after the introduction of TEP did she achieve any progress, and reached her target weight in 9 months. Therefore showing that token economy is more effective than other treatments

Question 23

Rejecting study (P+L)

Answer 23

Paul and lentz reject TEP as an overall effectiveness of TEP as a form of treatment for AN. They found that 11% of patients in a psychiatric ward needed drugs alongside a TEP programme. This suggests that TEP’s may be ineffective when used in isolation from other treatments. Additionally, anorexic patients may need additional psychological support such as CBT in order to come to terms with their gradual weight gain which TEP’s do not offer, reducing the overall efficacy of their treatment.

Question 24

Rejecting study (F)

Answer 24

Field et al rejects the effectiveness of TEP. Field looked at the treatment of young people with behavioural problems, involving TEP’s. The researchers found that, although the programmes were effective on the whole, there were still a number of young people who did not respond. A special and more immediate programme was put in place for these young people, were rewards were more immediate and frequent, and it found these amendments were successful. This suggests that TEP’s are only successful if they are designed specifically so that the pattern of rewards suits the individual, so cannot be carried out on a large-scale basis.

Question 25

Ethics.

Answer 25

A weakness of TEP’s is that there are high levels of social control exercised by staff to the patients. With TEP’s, the staff are in control of the target behaviour and when the tokens are administered, meaning there may be a power balance between the patient and the practitioner. When social control is too extreme, learned helplessness can occur, whereby AN patients give up trying to engage in the programme if it is too difficult to obtain rewards and so the high levels of social control can reduce the efficacy of the programme overall. BUT more ethical than drug treatments.

Question 26

Side effects

Answer 26

A strength of TEP’s is that there are no direct side effects. The treatment itself has no side effects as it focuses on reinforcement of desirable behaviours through tokens so that they are reproduced to gain a primary reinforcer. This means that ads it focuses on behavioural support and treatment and not through biological methods, it offers a more individualised treatment with no negative side effects that antipsychotics such as olanzipine may result in. However sometimes cases are so severe medication must be taken alongside for additional psychological support. Antipsychotics such as olanzapine or SSRI’s such as citalopram can be taken to reduce co-morbid symptoms such as anxiety- which reduces a patients fear around eating food. Despite these positive effects, they can also come with some dangerous side effects such as tardive dyskinesia and a decrease in emotional spontaneity. Therefore side effects from antipsychotics may cause someone to stop taking them and lose faith in the programme as a treatment for their AN.

Question 27

different treatment

Answer 27

* Drug treatments as an alternative therapy * Antipsychotics and SSRIs are administered to reduce co-morbid symptoms of depression and anxiety that also cause weight gain * This may be more effective due to the more immediate effect of weight gain rather than a long procedure of TEP- so can quickly stabilise a patients weight.

Question 28

expense

Answer 28

A weakness of Token economy programmes is that they can take a long time. Certain patients may need a longer time on the programme due to the severity of their case or not responding to the tokens given to them when they reproduce a target behaviour. This can therefore become very expensive due to paying for stay in an institution as well as the therapy sessions, meaning that individuals may have to drop out of the therapy if they can no longer afford it. By increasing drop out rates before the target weight has been reached, there is an increased chance of relapse and this may cause an individual to worsen.