Management of schizophrenia Flashcards
Development of token economies
Allyon and Azrin used a token economy in a schizophrenia ward. A gift token was given for every tidying act. Tokens were later swapped for privileges.
Token economies were extensively used in the 1960s and 70 - decline in the UK due to a shift towards care in the community rather than hospitals and because of ethical concerns
They still remain a standard approach to managing schizophrenia in many parts of the world
Matson et al’s three categories of institutional behaviour commonly tackled by the means of token economies
Personal care
Condition related behaviours (e.g apathy)
Social behaviour
Modifying these behaviours does not cure schizophrenia but has two major benefits which are…
Quality of life - token economies improve the quality of life within the hospital setting e.g putting on make up or becoming more sociable with other residents
Normalises social behaviour - making it easier to adapt back into the community e.g getting dressed or making your bed
Involvement in a token economy
Tokens (e.g coloured discs) given immediately after a desirable behaviour. Target behaviours are decided individually based on knowledge of the person (Cooper et al)
Tokens have no value themselves but are swapped for rewards e.g sweets or magazine or activities like a film or a walk outside
Tokens are immediately following target behaviours because delayed rewards are less effective
Theoretical understanding -> operant conditioning
Token economies are an example of behaviour modification based on operant conditioning
Tokens are secondary reinforcers - exchange for rewards (primary reinforcers which are directly rewarding -> food)
Tokens that can be exchanged for a range of different primary reinforcers are generalised reinforces - these have a more powerful effect
One strength of token economies
Evidence of effectiveness
EVALUATION: Evidence of effectiveness
P - The effectiveness of token economies in managing schizophrenia is one of its advantages.
E - Glowacki et al. found seven high qualityresearch on the effectiveness of token economies in hospitals that were published between 1999 and 2013.
E - Every study revealed a decrease in the frequency of unwanted behaviours and negative symptoms.
L - This demonstrates why token economies are valuable
COUNTERPOINT TO EVIDENCE OF EFFECTIVENESS
Seven studies is quite small evidence base. One issue with such a small number of studies is the file drawer problem, which means that there is bias towards published findings -> undesirable results have been filed away.
This means that there is a serious question over the effectiveness of token economies
Limitations of token economies
Ethical issues
Existence of more pleasant and ethical alternatives
May not generalise beyond the hospital setting
EVALUATION: Ethical issues
P - One limitation is the ethical issues it has raised
E - Professionals have the power to dictate to others how they should behave, which includes forcing their norms on others (a patient might want to appear scruffy, for example).
E - Furthermore, denying pleasures to those who act badly makes really ill individuals, who are already dealing with upsetting symptoms, considerably worse off.
L - This indicates that the short-term decline in quality of life and influence on freedom may outweigh the advantages of token economies.
EVALUATION: Existence of more pleasant and ethical alternatives
P - Another limitation is the existence of more pleasant and ethical alternatives
E - Alternative strategies don’t bring up ethical issues For instance, Chiang et al. state that art therapy is a high-gain, low-risk strategy for treating schizophrenia.
E - Art therapy is a joyful experience, even though its advantages are limited. This is true for all approaches to treating and managing schizophrenia.
L - Given that there are no negative impacts or ethical wrongdoing, art therapy may be a good substitute for token economies.
EVALUATION: May not generalise beyond the hospital setting
Inpatients in psychiatric units receive care around-the-clock, which gives staff members better control over how to watch over and treat patients. However, because outpatients only receive day treatment for a few hours each day, it is impractical to reward the patient every time they perform a desirable act. This leads to a scenario where the intended behaviour becomes dependent on the reinforcer; hence, relapse is likely if the reinforcer stops providing the desired activity.
This is a disadvantage of the token economy since it might only be beneficial to hospitalised patients to alter their undesirable behaviour, not much help to patients who live in the community.
EVALUATION ExTrA: Benefits
A problem with token economies is that they are hard to continue outside a hospital setting. Target behaviours cannot be monitored closely and tokens cannot be given immediately
On the other hand some people may only get the chance to live outside a hospital if their personal care and social interaction improves
This suggests that it is worth it, despite the issues around using them in hospital to give people a chance outside the hospital
