Token Economy

Token Economy: Psychology Definition

Token economy systems (TES) are a form of psychological therapy based on operant conditioning, which uses a reward system to manage maladaptive behaviours. Good behaviours earn tokens (secondary reinforcers) that can be exchanged for a reward (primary reinforcers), such as magazines or favourite foods.

TES can be used as a means of changing the behaviour of a patient with schizophrenia, and they are not a new concept in the world of psychology.

• Early research, as seen in Wolfe (1936), investigated the effectiveness of token rewards for chimpanzees, where chimpanzees could discriminate tokens and their associations with prizes such as food. Other systems then adopted TES, as the focus on behavioural alteration and maintenance gained traction.
• TES was a widely used therapy in the 1960s because many patients were institutionalised in hospital settings. Allyon and Azrin (1968) were some of the first to explore TES as a form of motivational therapy and rehabilitation.

Today, families are more likely to care for patients with schizophrenia at home, with increased access to education and help for patients. TES has declined in popularity in recent decades for several reasons discussed below.

Token Economy for Schizophrenia

Token economy systems have been used since the 1960s to help treat patients with schizophrenia. Token economies encourage ‘correct’ behaviours in the patient and discourage ‘incorrect’ behaviours. These actions are usually related to a patient’s positive and particularly negative symptoms, such as depression, social withdrawal and poor motivation.

Despite being placed in an institution primarily to treat their illness, institutionalisation can exacerbate a patient’s 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 further exasperated 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. Through operant conditioning, TES can address these problems, in which desired behaviours are repeated and learned.

Token Economy: Examples

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.

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

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

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

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 that are predetermined, exhibiting ‘better’ or more desirable behaviours, ultimately combating their symptoms.

Patients have to 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.

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

Evaluation of Token Economy: Psychology

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

Advantages and Disadvantages of Token Economy

Let’s discuss some of the advantages and disadvantages of token economy systems. First, the advantages:

• Allyon and Azrin (1968) found that 45 female patients with schizophrenia in a psychiatric ward showed significant improvements in their symptoms and behaviours after the introduction of a TES. For instance, they would receive a reward for showering. Before this, patients had behavioural issues and displayed aggressive tendencies. Allyon and Azrin (1968) demonstrated how TES can help control and treat symptoms and behaviours associated with schizophrenia.
• 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 problems, including only a small evidence base that supported it.

• McMonagle and Sultana (2000) reviewed TES over multiple studies. They found that while TES 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).

Now, let’s explore the disadvantages of token economy systems:

• Allyon and Azrin (1968) conducted their study on female patients, and the results cannot be generalised to male patients, as a result.
• 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, and it is unethical to deprive people of their rights.
• 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 patient’s daily life. It is normal to have ‘off-days’, where you feel less motivated. It would be unfair to deprive you of your favourite things because you were having a bad day. 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 the hospital using TES did not remain once they were discharged, suggesting issues with maintenance that TES suggests it excels at.