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A* AQA A Level 8 marker on Management of schizophrenia - token economy
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Discuss token economies as a management strategy for schizophrenia (8 marks)Token economy is a management strategy, based upon the Skinner’s principle of operant
conditioning, which is used to help patients with schizophrenia in institutions modify their
maladaptive behaviours. Ayllon and Azrin (1968) trialled a token economy system in a ward of
women with a diagnosis of schizophrenia. Patients were given tokens for demonstrating desirable
behaviours such as making their bed or cleaning up. These tokens act as secondary reinforcers
because they can be exchanged for primary reinforcers. Token economy can help with avolition, a
negative symptom of schizophrenia, however it is does not address many of the symptoms of
schizophrenia, it is simply a strategy used to positively shape the behaviour of patients in institutions
to make them easier to manage.
One limitation of token economies to manage schizophrenia is the ethical issues. The implication of
token economies gives the professional power to control the behaviour of their patients. This
inevitably involves imposing one person’s norms on to others, which can be problematic if target
behaviours are not identified sensitively. For example, someone who likes to get up later may have
their personal freedoms stopped. Restricting the availability to pleasures to those who don’t behave
as desired means that seriously ill patients, who are already experiencing distressing symptoms of
schizophrenia, have an even harder 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 around the world. This
is a limitation because it means that the benefits of token economies may be outweighed by their
impact on the patient's personal freedom and short-term reduction in quality of life.
To continue, one problem with token economies is that they are very difficult to continue once a
person is outside a hospital setting. This is because target behaviours cannot be monitored closely,
and tokens cannot be administered immediately. On the other hand, some people with
schizophrenia may only get the chance to live outside a hospital if they personal care and social
interaction can be improved. And perhaps the best way to achieve this is using a token economy
during hospital care.
One strength of token economies for the management of schizophrenia is evidence for their
effectiveness. Glowacki et al (2016) identified seven high qualities 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. This is a
strength as it demonstrates the value of token economies in the world.
A further limitation of token economies is the existence of more pleasant and ethical alternatives.
Even if token economies can be helpful for managing schizophrenia there are other approaches with
the comparable evidence base that do not raise the same ethical issues. For example, a review of
Chaing et al (2019) concluded that art therapy might be a good alternative. The evidence base is
regularly small and has some methodological limitations but appears to show that art therapy is a
high gain low risk approach is managing schizophrenia. Even if the benefits of art therapy are
modest, this is generally true of all approach to treatment and management of schizophrenia and
unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical
abuses. NICE guidelines recommend art therapy for schizophrenia. This a limitation of token
economies because it suggests that art therapy may be a more suitable alternative.
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