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Token Economy

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Token Economy

Token economy systems (TES) are a form of psychological therapy in which a reward system is used to manage maladaptive behaviours.

Maladaptive behaviours prevent the patient from adapting to new or difficult situations.

Good behaviours earn tokens (such as checkers, stars on a chart, or a tally marking system) exchanged for a reward. TES are a means of changing the behaviour of a patient with schizophrenia. They are based on operant conditioning theory (a form of learning that uses a reward and punishment system for behaviour).

The token economy system was a widely used therapy in the 1960s because many patients were institutionalised in hospital settings. Maladaptive behaviours tend to develop during prolonged hospital stays, which was a common problem in the 1960s. Today, families are more likely to care for patients with schizophrenia. TES has declined in popularity in recent decades for several reasons discussed below.

Token Economy Reward systems Schizophrenia StudySmarterToken economy systems defined with tokens and rewards, Tyler Smith - StudySmarter Originals

How does token economy work for schizophrenia?

To treat patients with schizophrenia, TES follows a process to encourage ‘correct’ behaviours in the patient whilst also discouraging ‘incorrect’ behaviours. These actions are usually related to a patient’s positive and negative symptoms.

For example, if a patient suffers from despair and refuses to get dressed when he does get dressed, he receives a token.

Despite being placed in an institution primarily to treat their illness, institutionalisation can exacerbate their symptoms. Bad habits and maladaptive behaviours may develop, such as problems with hygiene, disruptive behaviour, and decreased socialisation with other patients/staff.

This can be exacerbated by the fact that these behaviours impact the caregivers’ treatment of the patient, as constant aggression and acts of violence can cause caregivers and physicians to dislike the patient despite their best intentions. TES can address these problems through operant conditioning, in which desired behaviours are repeated and learned.

Primary and secondary reinforcers

When a patient enters a hospital for treatment and a TES is used, the first step is for the patient to begin associating the token with the reward. The targeted behaviours are identified and should be observable and measurable for fairness.

  1. Primary reinforcer: the reward serves as the primary reinforcer. It is intended to show the patient what they can achieve by engaging in desirable behaviours. Examples of token economies include sweets, magazines, films, and day trips.

  2. Secondary reinforcer: tokens act as secondary reinforcers. The patient can tangibly earn what they can then be exchanged for a reward.

Token Economy Systems Schizophrenia StudySmarterToken economy system in action, Tyler Smith - StudySmarter Originals

Matson et al. (2016) identified three categories of problematic behaviours that develop in a hospital and can be addressed through the use of token economies:

  • Personal hygiene (problems with hygiene such as showering, changing clothes, and brushing teeth).

  • Illness-related behaviours (problems with positive and negative symptoms).

  • Social behaviour (problems in dealing with other people).

It is important to note that TES effectively reduces symptoms and addresses the above problems. However, it is not a cure (Matson et al., 2016¹).

The secondary enforcer (token) gains power by being associated with a desirable reward. Patients then work toward earning these rewards with a certain number of tokens (predetermined), exhibiting ‘better’ or more desirable behaviours, ultimately combating their symptoms.

Allyon and Azrin (1968) noted that patients want to perform certain behaviours. They may be encouraged, but factors such as the person’s current level of motivation may influence the impact of the token economy on their behaviour.

Thus, in the case of schizophrenia, TES addresses symptoms by:

  • Encouraging patients to perform a desirable behaviour, such as getting dressed for the day and taking a shower (if they suffer from negative symptoms, such as avolition, this can be a significant problem affecting their day).

  • Immediately after performing this behaviour, they receive a token. The token must be spent directly, as any delay will reduce the effect of TES.

  • After earning a certain number of tokens, they can exchange them for rewards, such as a day trip or a walk in the garden.

The programme must be tailored to the patient and address their motivation and personal goals to be effective.

Evaluation of token economy systems in psychology

The use of TES has both strengths and weaknesses. For an audit, it is essential to understand what these are and how studies highlight these problems.

Strengths

  • Glowacki et al. (2016), in a meta-analysis of seven high-quality studies of the effectiveness of TES in hospitals, found that all studies showed the following:

    • Decreased negative symptoms.

    • A decrease in the frequency of undesirable behaviours (violence and aggression).

  • They concluded that the use of TES to treat symptoms in inpatient psychiatric settings should be considered. However, the study had some problems: only a small evidence base supported it, leading to the file-drawer problem (a bias toward positive outcomes undesirable results have been filed/tucked away). There is also no evidence of sustained effectiveness outside of the psychiatric setting.

  • McMonagle and Sultana (2000) reviewed TES over 15 years. They found that while they reduced negative symptoms (by acting as a motivational tool), it was unclear whether patients maintained these behaviours after the treatment programme. It was also noted that the results might not be reproducible, so their clinical validity is questioned.

  • Dickerson et al. (2005) reviewed 13 controlled studies of TES and found that TES effectively increased adaptive behaviours and decreased maladaptive behaviours. However, the historical context and methodological issues limit the studies (such as bias and sample selection).

Weaknesses

  • Ethically, there are issues with TES. First and foremost, it gives professionals/medical staff significant power of control over the behaviour of the patients. It imposes a ‘norm’ that, whilst it may be appropriate in societal settings, it is not fair to expect this perfection off of patients (for example, a patient may not want to dress a certain way for the day, or may prefer to bathe every two days). This is a restriction of personal freedoms.

  • Milby (1975) found that whilst TES is effective in hospital work, upon review, the studies were found to be both poorly designed and lacking sufficient follow-up data.

  • TES may work well with mild symptoms of schizophrenia, such as issues with avolition and aggression/violence. However, it may aggravate more distressing symptoms by removing pleasurable/escapist activities from the patient. If they are not performing well, and are therefore not earning tokens, it has a significant impact on the patients daily life. This has led to legal action in the past, as families are not okay with personal liberties being taken away from the patient.

  • Although TES is a way to alleviate symptoms, it is not a cure. Kazdin (1982) found that changes that were developed during a patient’s time in hospital using TES did not remain once they were discharged.


Token Economy - Key takeaways

  • Token economy systems (TES) are a form of psychological therapy in which a reward system is used to manage maladaptive behaviours. Good behaviour earns tokens that are then exchanged for a reward.
  • TES has fallen out of favour for several reasons. In the 1960s, it was a widely used therapy because many patients were institutionalised in hospital settings. Today, families usually care for patients with schizophrenia, so independence reduces the need for hospitalisation.
  • TES uses primary (rewards) and secondary (tokens) reinforcers.
  • TES is effective in reducing negative symptoms and some positive symptoms.
  • It is ethically questionable because it restricts personal freedoms, and studies supporting it have problems with its methodological validity. TES works in the hospital, but the behaviours developed are not maintained outside the hospital.

Frequently Asked Questions about Token Economy

An example of a reward used in token economy systems is sweets or magazines. Any reward that can reinforce ‘good behaviour’ can be used in a token economy system.

A token economy system that can be used to manage behaviour can be rewarding a schizophrenic patient who bathes after refusing to do so with something they desire. This can be a day trip out or one of their favourite books. This reward encourages positive behaviour. 

It encourages desirable behaviours in patients and discourages undesirable or maladaptive behaviours. The token economy is used in the hopes that it eventually reduces symptoms and establishes good routines. 

In a token economy, tokens are used to encourage desirable behaviours. It involves assessing a patient and identifying their reinforcers (primary and secondary) and then basing the token system around this. 

Token economy systems (TES) are a form of psychological therapy that utilises a reward system to manage maladaptive behaviours.

Final Token Economy Quiz

Question

What are token economy systems?

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Answer

Token economy systems (TES) are a form of psychological therapy in which a reward system is used to manage maladaptive behaviours; patients earn tokens through good behaviour and then exchange them for rewards.

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Question

What theory does TES rely on?

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Answer

The theory of operant conditioning.

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Question

What are maladaptive behaviours? 

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Answer

Maladaptive behaviours are behaviours that prevent patients from adapting to new or difficult situations – most often they result in negative/difficult behaviours.

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Question

What are some examples of ‘incorrect’ behaviours?

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Answer

Issues with bad hygiene, disruptive behaviours, and lower socialisation with other patients/members of staff.

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Question

What are primary reinforcers in token economy systems?

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Answer

The reward acts as the primary reinforcer.

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Question

Give an example of a reward a patient with schizophrenia can earn.

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Answer

Examples include: 

  • A day out walking in a park.
  • Sweets and treats.
  • Access to films.
  • Access to magazines.

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Question

What are secondary reinforcers in token economy systems?

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Answer

The tokens act as the secondary reinforcers.

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Question

What three categories did Matson et al. (2016) establish of institutional behaviour affected by token economies?

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Answer

Personal care, condition related behaviour, and social behaviour.

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Question

 What did Allyon and Azrin (1968) find in their study?

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Answer

Patients have to want to do certain behaviours for TES to be applicable.

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Question

Give an example of a negative symptom of schizophrenia that TES affects.

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Answer

Avolition.

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Question

What is TES effective in?

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Answer

It is effective in reducing negative symptoms, increasing adaptive behaviours, reducing maladaptive behaviours, and causing a decline in undesirable behaviours.

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Question

What are the weaknesses in TES?

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Answer

It gives professionals/medical staff significant power of control over the behaviour of the patients. It also has methodological issues in the studies that were reviewed and is not maintained outside of a hospital setting.

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Question

Describe the Glowacki et al. (2016) study.

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Answer

Glowacki et al. (2016), in a meta-analysis of seven high-quality studies of the effectiveness of TES in hospitals, found that all studies showed decreased negative symptoms and a decrease in the frequency of undesirable behaviours (violence and aggression).

Show question

Question

What did Kazdin (1982) say about TES? 

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Answer

Kazdin (1982) found that changes that were developed during a patient’s time in hospital using TES did not remain once they were discharged. Although TES is a way to alleviate symptoms, it is not a cure. 

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