Specification: Token economies as used in the management of schizophrenia. 

Token economies are a behaviourist approach to the management of schizophrenia, where tokens are awarded for desired behavioural change. 

When it was introduced in the 1970s, it was mainly used with long-term hospitalised patients to enable them to leave the hospital and live relatively independently in the community. It is particularly aimed at changing negative symptoms of schizophrenia, such as low motivation, poor attention and social withdrawal. 

How does it work?

1. Clinicians set target behaviours that they believe will improve the patient’s engagement in their daily activities. For example, these target behaviours might be something as simple as the patient brushing their hair, or a more socially orientated behaviour such as persevering with a task. 

2. Tokens then are awarded whenever the patient engages in one of the target behaviours, and these tokens can be exchanged for various rewards at a later date. 

3. The idea behind token economy is that the patient will engage more often with desirable behaviours because the behaviours become associated with these rewards and privileges. 

4. With the token economy, the tokens in themselves are neutral. However, to give the neutral token value it needs to be repeatedly presented alongside or immediately before the reinforcing stimuli (e.g. the reward). By pairing the neutral tokens with the reward, the neutral token acquires the same reinforcing properties. As a result of this process of classical conditioning, these neutral tokens become secondary reinforcers and so can be used to modify the behaviour in people with schizophrenia. 

5. During the early stages of the treatment, frequent exchange periods mean that the patients can be quickly reinforced and target behaviours can then increase in frequency. The effectiveness of the token economy may decrease if more time passes between the presentation of the token and exchange for the reward. 

Evaluation of token economy

Some research indicates that token economy is effective in managing schizophrenia. Ayllon and Azrin (1968) used a token economy on a ward of female patients with schizophrenia, many of whom had been hospitalised for years. They were given plastic tokens, each embossed with the words ‘one gift’ for behaviours such as making their beds. These tokens were then later exchanged for rewards such as being able to watch a film. The researchers found that the use of a token economy with these patients increased dramatically the number of desirable behaviours the patients performed each day. Also, Dickerson et al. (2015) reviewed 13 studies, finding the technique useful in increasing the adaptive behaviour of people with schizophrenia, which also implies it is an effective treatment. It was found to work best in combination with drugs, though the specific benefits of the technique when used as a combination were not identified. This evidence suggests that token economies should not be seen as a treatment for schizophrenia in itself. 

There are problems with how research into the token economy in people with schizophrenia is carried out. Comer (2013) suggests that a major problem in assessing the effectiveness of token economies is that studies of their use tend to be uncontrolled. When a token economy is introduced into a ward, typically all patients are brought into the programme rather than having an experimental group that goes through the token economy programme and a control group that does not. As a result, patients’ improvements can only be compared with their past behaviours rather than a control group. This comparison may be misleading as other factors, like increased staff attention, could be causing patients’ improvement rather than the token economy. 

One advantage of a token economy is patients becoming more independent and active, which has the knock-on effect of nurses’ increased respect for the patients, leading to the patients becoming even more motivated and developing positive self-esteem. This indicates that token economies are an effective way of helping with institutionalisation which occurs when a patient has been in the hospital for a long time. Also, where token economies have been used on hospital wards they have helped to create a more healthy, safe and stable environment. Staff and patient injuries reduce, therefore decreasing staff absenteeism and emergency incident levels. 

However, any positive effects of the treatment are short-lived. The treatment does not appear to work long-term as the desirable behaviour becomes dependent on reinforcement. Upon release into the community, reinforcement ends leading to high re-admittance rates. It appears that without the professionals there to constantly reinforce the behaviour of people with schizophrenia, they are not able to engage in the target behaviours outside of the hospital setting. Therefore, token economies do not work outside of the hospital. 

Some question the ethics behind this treatment, arguing it is humiliating for people with schizophrenia. For example, to make reinforcement effective, clinicians exercise control over important primary reinforcers such as food or privacy. Patients may then exchange tokens if they display the target behaviours. However, it is accepted that all human beings have certain basic rights that cannot be violated regardless of the positive consequences that might be achieved by manipulating them. 

Possible exam questions

1. Outline and briefly evaluate one study in which a form of psychological therapy was used to treat schizophrenia. (4 marks)

2. Describe and discuss the effectiveness of psychological therapies for schizophrenia. In your answer, refer to evidence. (16 marks)

3. Discuss the view that schizophrenia should be treated using psychological therapies view. (16 marks)

4. Patients with schizophrenia are mostly treated with anti-psychotic drugs. Describe and discuss at least two other ways in which schizophrenia might be treated. Refer to empirical evidence in your answer. (16 marks)

5. Outline and evaluate two treatments for schizophrenia. (16 marks)

6. Outline and evaluate one psychological therapy for schizophrenia. (8 marks)