About the Book

• The Lady and the Unicorn: A Psychological Metaphor



• Dreaming�With Eyes Wide Open: Schizophrenic Hallucinations



• Information Processing in Schizophrenia



• Clarification of our Clinical versus Forensic Function: Dual Relationship



• Art Psychotherapy



• Lord of the Rings: A Psychological Metaphor



• Aviation Psychology



• So, You have just been Passed by a Girl! A Holley Carborator may help



• Approaches in Memory Rehabilitation



• Memory Enhancement Module



• Negaunee Center



• The Final Transition



• Is Deinstitution- alzation a Misnomer



• Token System: a Psychiatric Case Study



• A Token Economy System: Inpatient Psychiatric Population



• Insight: An Aspect of Neurocognition

The purpose of this article is to present an overview of a token economy program which has been implemented as a clinical treatment approach for psychiatric in-patients residents. The token economy program provides a systems approach for structuring of program activities on an extended care unit. The emphasis of the program is upon both improving daily living skills as well as ameliorating specific target behaviors which impede community placement. Finally, the advantages and disadvantages of the token system with the psychiatric population are discussed.

It is well established that the psychiatric populations experience a spectrum of disorders including thought, mood and behavior. These types of psychiatric disorders are complex in their varied nature and at times require a multidisciplinary approach for the subsequent treatment and remediation. Over the years of working directly with the psychiatric population, we have recognized a number of treatment approaches which seem to be effective in managing and mitigating a few of the more salient symptoms of mental illness. Psychotropic medications, psychotherapy have provided the mental health system with a mainstay for handling many of the symptoms manifested by the mentally ill. However, behavioral therapy has become increasingly considered as a possible conjunctive therapy for symptoms of mental illness.

Many individuals with mental illness come to the attention of the court, psychiatric facilities and hospitals as a direct consequence of their public behavior. Thus, it makes sense that our treatment approach should focus upon addressing these aberrant behaviors; for example, withdrawal, agitation and neglect of their basic needs. The Token Economy Program has an empirically proven record of being successful in addressing a multitude of behavioral concerns. The effectiveness of the token program for the chronic psychiatric population has been extensively examined. (Atthowe & Krasner, 1968; Ayllon & Azrin, 1964, 1968; Davidson, 1970; Liberman, 1970; Schaefer & Martin, 1969; Wincze, Leitenberg, & Agras, 1972; Nelson & Cone, 1979; Gericke, 1965; Stenger & Peck, 1970; Chase, 1970). Furthermore the token system has been examined with different populations such as the dually diagnosed (Beard & Hayter, 1987; Stoneman, Munk & Bowden, 1988) and with the developmentally disabled (Baker & Goncalves, 1987; Burgess, 1978).

The Token Economy Program can be perceived in terms of a systems approach toward behavioral management. Rimm and Masters, (1979) have stated that �a token reinforcer is an object with redeemable value, one that can be traded for an actual reinforcer of another kind of material, social or activity� (p. 173). The token program�s theoretical basis is grounded in well established learning theories of reinforcement motivation. In addition to the appreciation of the importance of both structure and consistency inherent in the token system. Furthermore, Rimm and Masters, (1979) have indicated that:

The use of easily managed tokens also removes the necessity for the contingent dispersion of bulky messy and otherwise unmanageable reinforcing events. Perhaps the primary advantage however is the ability to by manipulating the rate of exchange to allow the individual to work over an extended period of time for a single highly potent reinforcer. At the same time, the staff is able to dispense tangible if basically symbolic reinforcers after each response with short temporary delays. Both of these factors to serve increase the effectiveness of the reinforcers. (p. 191)

The Meadowview unit is an all male behavioral management basic living and extended care unit. Patients are often transferred to this unit due to one or more of the following reasons:

Currently, token economy system has been used in terms of basic daily living skill but this role could be expanded to many areas of daily functioning. Furthermore, we have implemented a program to address some of the more aberrant behaviors. These aberrant behaviors have brought many of the mentally ill patients to the attention of the mental health facility.

The purpose of the unit token economy point system is to provide an organized and structured program which emphasizes and reinforces positive behavior. The staff�s primary focus is to observe, elicit and reinforce desired behavior although patient participation is voluntary. Even patients who initially refused are offered daily point cards and encouraged to participate. Points are only given, (never taken away). The participants are never threatened with losing points. Rewards for specific criteria (see Definition of Point Award) are given only when met and include verbal praise, points and backup reinforcers from the token store.

The individual is responsible for their choice of clothing. It is expected that the clothing be clean, no food stains, dirt or odor, and the choice of clothing is appropriate for the weather. Encouragement for color matching socks, belt, and pants zipped, and shirt buttoned and clothing tucked in appropriately � 5 points for clean and appropriate clothing.

Caring for their living space is especially important for future independent living. Emphasis for their bed is made up daily including sheets, pillows, blankets, is tucked in which is finally neatly covered with by a bedspread. The resident�s personal locker and dress contains clean clothes and are hung up and appropriately. Furthermore, personal items are placed in a neat fashion inside drawers; clothes are placed inside laundry bags � 5 points.

Residents use all utensils appropriately and eat at a reasonable pace, discuss topics of interest to them and appropriate to meal time. All residents are responsible to inform staff and know that they are eligible for points upon completion of a task.

To reinforce appropriate positive behavior and compliance with treatment plans. The program allows the patients to earn points for completing daily living activities which would be expected to complete independently in the community. Points may also be earned for attending structured activities and meeting specific targeted positive behaviors. The points may be saved for another day or spent on various items in the point store. Items available range from food products to clothing, cologne and cassette tapes.

Items Points Item Points

Ice Cream 25 Puzzle Books 75

Yogurt 35 Deodorant 75

Pudding 30 Shampoo 75

Pop 30 Toothpaste 30

Chips 30 Soap 30

Gum 30 Socks 25

Small candy bar 15 T Shirts 75

Marshmallow Pies 20 Bandannas 10

Nutty Bars 25 Hats 200

Coffee, tea, tang 10 Tapes 400

Hot Chocolate 20 Batteries 50

Penny Candy (2) 5 Shirts 75-200

Raisins 10 Fruit drink 30

Granola Bars 20

The Meadowview staff serves various important roles in the unit token economy program. First each involved therapist is responsible for providing immediate positive reinforces via giving pints on individual cards following participation in group and individual activities. Secondly, the Meadowview staff run the token store daily (Monday-Friday) for one hour between (3:00-4:00pm) This includes reinforcing patients� appropriate positive behavior/efforts through verbal praise and exchange of products for earned points. Simultaneously, the therapist accepts and encourages patient input /suggests as to supplies for stocking the store. The Occupational therapist also maintains the store upkeep and supervises a patient who cleans the store weekly (in exchange for additional points).

Third, the Occupational therapist restocks the token store by itemizing a supply list and organizing and outing for 3-4 Meadowview patients. This community trip consists of shopping and subsequently selecting products for the token store, purchasing, delivering and unpacking the necessary items required to maintain the token economy token store. Finally the interdisciplinary team formulates appropriate target behaviors for each individual patient participating in the token economy program.

The Meadowview currently has two patient workers assigned to assist in the point store. These patients are enrolled in the work therapy program and assist the therapist in the daily implementation of the Token store and in the weekly sorting and adding of patients� cards/points. Each week the patient�s points are added for compiling a �Top Point Earner� list. The top 10 patients point earners each week select and plan a special outing which serves as an additional reinforces.

One of the major advantages of the token system is that it is a structured system whereas the program content can be changed and measured with little disruption of the overall token system itself. The token system provides flexibility for the dynamic problems faced by the practitioner treating mental illness. Besides the token economy program�s flexibility and its inherent structure, the token system offers a consistency for the patients. It has been our clinical observation that a structured environment has provided an increasingly important role in the management, supervision, and eventual self-management of many psychiatric symptoms.

Furthermore, the token system offers the treatment teams an effective means for measuring progress. Token store also could, in the future, provide administration with an observable and objective method for evaluating and establishing criteria for placement, transfers, patient progress, and a systematic overview of treatment in general.

In addition to learn and controlled behaviors, the token system could be used as an external motivator for providing a patient with the incentive for assisting in their own treatment. In this regard, lack of motivation is perhaps one of the most prominent features exhibited by the individual after their psychiatric symptoms have been brought under control through the use of psychotropic medication. Thus, the token system could provide a means for motivating individuals to attend, participate in groups, tasks and activities. The token system provides potential secondary benefit for initial treatment objectives of improving self-esteem and self-worth through praise and positive reinforcement.

The program is staff intensive and demands resources and sufficient time to fully establish and use statistics. The patient�s become dependent upon receiving points to perform daily tasks is a probable disadvantage thus couple point reinforcers with secondary reinforcers such as praise and attention is essential. The lack of a graded program to advance patients when goals are achieved is a disadvantage in this regard having a step level program based upon achieving goals, i.e., self-care may have to be considered in the future. The token program requires continuous ongoing dedication, cooperation and scheduling of all disciplines on all three shifts which at times is not easy to consistently obtain.

The token economy program has many intrinsic benefits to both the patients and staff. For the patient, it provides a program which is directly dependent on the individual for its success. The patients are responsible both on an individual basis, (i.e., maintaining own cards and as group cooperating mutually so that the store runs smoothly). By learning to ask staff to award points after specific tasks is completed, the patient can learn and assume appropriate assertiveness thus in turn allows for a more positive goal oriented interaction between patients and staff.

For the staff, the point program offers a concrete method in which to remember to give positive reinforcement immediately whenever appropriate. The program rewards a large variety of positive behaviors ranging from general unit routine activities, (i.e., independently getting up each a.m. to participate in the structured group activities, OT, group therapy to individualized target behaviors). Implementing the token store five days a week allows the therapist time each day for contact with the patient participating in the program. This contact is valuable in providing consistent verbal praise, encouragement and also allows the therapist to assess the patient on a daily basis. Particularly in a large institutional setting this token economy program is exceptional in emphasis on the positive actions of our patients over the options of negative behavioral eliciting punitive responses.

A token economy/point program has been successfully implemented for twenty-one months on Meadowview, an all male, basic daily living/behavioral unit at Clinton Valley Center. It�s most prevalent strength has been its provision of a positive, structured program which encompasses and accentuates all other treatment modalities on the unit. The point system is flexible in its meeting of both group and individual needs within our specific population. The token economy program has been well-accepted by the patients and staff and has been maintained continuously since it�s initiation in August of 1988.