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Behavior Management Quarterly Vol. 6, No.4, Fall 1990

TOKEN SYSTEM: A PSYCHIATRIC CASE STUDY

M. Kay Fortin, R.N.C. and D. L. Hayter, MA.

Clinton Valley Center

The purpose of this article is to present the effect of a token economy program upon a long-term resident of an extended-care ward. Graphic changes in target behavior and basic daily living skills are also presented. It is believed by the authors that the token economy program has had a major impact upon the subsequent stabilization and discharge of this resident into the community.

Providing effective treatment for the individual with a psychiatric disorder can be a challenging endeavor, whether within a hospital or a community setting. In spite of the current armaments available such as counseling and psychotropic medication for psychiatric disorders, at times it still remains difficult to achieve stabilization.

Perhaps one of the most striking features of the psychiatric population is in terms of their aberrant behavior (i.e., withdrawal, impulsiveness, aggression). Their behavior represents one of the primary bases for most psychiatric admissions to an inpatient hospital setting. Therefore, focusing our attention upon their behavior seems to be the first logical approach for treatment. We are proposing that a token economy system can be used effectively in reinforcing the individuals' desired behavior and providing consistency and structure to a ward setting.

The effectiveness of a token economy program for the chronic psychiatric populations has been extensively examined by (Atthowe & Krasner, 1968; Ayllon & Azrin, 1964, 1968; Baker, Hall, Hutchinson, & Bridge 1977; Davidson, 1970; Elliott, 1977; Liberman, 1970; McCreadie, Main, & Dunlop, 1978; Schaefer & Martin, 1969; Wincze, Leitenberg, & Agras, 1972; Nelson & Cone, 1979; Gericke, 1965; Stenger & Peck, 1970; Chase, 1970). Token systems with the dually diagnosed (Beard & Hayter, 1987; Stoneman, Munk, & Bowden, 1988).

Probably one of the most important components of the token program on Meadowview II is targeting behavior (apathy, non-compliance, and aggression), which has resulted in this highly restrictive inpatient setting. Our primary goals focus upon the improvement of adaptive skills, as well as the reinforcement of improved adaptive coping behavior. In spite of the cause of their emotional or mental disturbance or, in fact, the multitude of symptoms which might be considered secondary to the disturbance, (e.g., Advance Daily Living Skills), the behavior which is either dangerous to self or others is the primary reason for admission. This constitutes a continuum of both behaviors and reactions to behaviors by others. Thus, addressing these behaviors represents one of the primary objectives within the hospital system. With these goals in mind, it follows that a behavior plan will be two-fold in nature. First, it is directed towards the elimination of the behaviors which have contributed to the individuals hospitalization and secondly, the enhancement of behaviors which are more adaptable to life within the community.

The Token Economy Program offers the practitioner a unique opportunity to address both issues within a systematic approach. By the establishing of target behaviors to both eliminate and reinforce, the token system provides a medium of immediate feedback and direct interaction with staff members in a spontaneous yet structured manner. Any type of target behavior can be integrated within the token system, thus aberrant behavior was only one aspect of the overall token system, which also emphasized advance daily living skills, socialization, etc. Furthermore, the token system itself was only a portion of the overall ward milieu, which was all focused upon the re-integration of the individual back within the community.


Case History:

George was a 36 year-old Caucasian male with a long history of inpatient hospitalization ranging twenty years. The severity of his behaviors resulted in him residing on a difficult to manage male ward for approximately 15 years. The treatment George received through his 15 years in the hospital consisted of various psychotropic medications in the form of polypharmacy, individual and group therapy, work therapy, milieu activities, occupational therapy, and recreational therapy. Minimal improvement was seen in that he continued to experience a poor frustration tolerance, poor comprehension, short attention span, minimal interaction with others, bed wetting, poor hygiene, and an increase in aggressive behavior (i.e., threatening, cursing, and assaulting others) in response to the auditory hallucinations. The voices remained continuous in nature from the time of his admission to discharge.

As a result of his assaultive behavior, George was in and out of seclusion or restraints 2-3 times a month for several years. In November of 1986 he was placed on Mellaril and remained on the same medication and dosage until his eventual discharge. As a result of this psychotropic medication, George was able to reduce his violent episodes and required seclusion and/or restraints 1-2 times every 2-3 months.

In August of 1988, the Token Economy Program was initiated by the Eastern Michigan University project. It was at this time we began to slowly observe some improvement in George�s behavior. As a result of our assessment, we identified target behaviors, which were both global as well as specific in nature. In the global realm, we had observed a need to increase in George�s personal self-care and socialization skills.

Treatment globally included self-care skills groups, which focus upon bathing, hygiene, grooming, dressing, clothing care, and eating skills program. In addition to the self-care skills, he was engaged in socialization groups and activity groups focusing on his strengths. His participation and achievements within these groups were reinforced through the Token Economy Program in terms of points earned. Upon completion of each task he received points and individual time with staff, which verbally praised his specific accomplishments.

Specifically, we targeted his violent aggressive episodes in response to his auditory hallucinations, which represented a major barrier to community placement. George would curse at and threaten peers and staff alike, yell out while rapidly pacing, and swinging his arms out in an aggressive manner. Although, it should be noted, that he could not verbalize his feelings in any other relevant fashion.

One of the more prominent features of a Token Economy Program is its flexibility to address specific target behaviors. The effectiveness of the Token Economy Program was initially explored for the treatment of delusional behavior in studies by (Teodoro, Ayllon & Michael, 1959; Richard, Dignam, & Horner, 1960). Furthermore, Redd, Porterfield, and Anderson (1979), stated that �since these early investigations, a host of reports have appeared in which, overt delusional and/or hallucinatory behaviors have been met with extinction or response costs (such as time out, a loss of tokens or privileges), while rational behavior was differentially reinforced (Ayllon & Haughton, 1964; Haynes & Geddy, 1973; Liberman, 1972; Liberman, Teigen, Patterson, & Baker, 1973; Richardson, Karkalas, & Lal, 1972; Wincze, Leitenberg, & Agras, 1972)" (p. 391). Although, in our token program, response cost was not used. Furthermore, it should be appreciated that using response costs runs the risk of the program losing its reinforcement value. Thus, response cost should not be used unless the program is well established and has a rich source of reinforcement. Ignoring the client�s inappropriate behavior while actively reinforcing more adaptive behaviors used extinction.

Our plan for treatment was that George would be able to carry on a conversation in a relevant manner free from his identified target behavior. George was given two opportunities per shift: once in the morning and another opportunity in the afternoon to exhibit his adaptive behavior. He received 1:1 time with staff, verbal praise and his token points, when he was able to converse with others in a friendly and relevant manner as well as controlling his physical aggressiveness. Progress in global and specific behavior skills are reflected in the graph below.


Series 1: Incident Free Conversation

Series 2: Total Points X 10 Per Day

Series 3: Personal Hygien

This graph represents a correlation between the amount of tokens earned and increases in both personal hygiene and incident free conversation. These would be expected, since tokens are awarded for these specific target behaviors. It also seems to indicate the relative effectiveness of reinforcers in this particular case, which provided assistance to the individual to learn more adaptive behaviors during treatment. During the follow-up period, the graph reflects the continuation of a relatively high level of adaptive skills while being placed in the community. The token system was at this point no longer reinforcing these skills, but was undoubtedly being maintained by other social reinforcers within the community setting. Finally, the overall effect from the baseline period till follow-up seems dramatic, thus seeming to warrant continuation of a structural token program in at least a few specific cases of psychiatric disturbances. A larger study of the effectiveness of the token system with psychiatric cases awaits further research.

In conclusion, the Token Economy Program has been found to be an effective strategy for working with the long-term psychiatric individual. Its main advantages is its systematic approach for addressing more global needs such as ADL skills and its flexibility which allows for remediation of the more specific target behaviors. It is well accepted that for behavioral modification programs to be most effective, the target behavior must occur consistently under specific circumstances or in a frequent manner. Thus, the practitioner should be aware of these conditions when utilizing a Token Economy System. Furthermore, based on our clinical interview, the auditory hallucinations were not eliminated, but the treatment was successful in that the individual was able to control his responses to the hallucinations. Thus, resulting in the subsequent placement of a long-term psychiatric patient who is currently being maintained in a community setting.



REFERENCES


Ayllon. T., & Haughton, E. (1964). Modification of Symptomatic Verbal Behavior of Mental Patients. Behavior Research and Therapy, 2, 87-97.

Ayllon, T., & Michael, J. (1959). The Psychiatric Nurse as a Behavioral Engineer. Journal of Experimental Analysis of Behavior, 2, 323-334.

Baker, R., Hall, J. N., Hutchinson, K., & Bridge, G. (1977). Symptom Changes in Chronic Schizophrenic Patients on a Token Economy: A Controlled Experiment. British Journal of Psychiatry, 131, 381-393.

Bandura, A. (1967, March). Behavioral Psychotherapy. Scientific American, 216, (pp. 78-86).

Beard, J. P. & Hayter, D. L. (1987). Negaunee Center: A Community Based Program Dually Diagnosed. Behavioral Management Quarterly, 3, 10-17.

Chase, J. D. (1970). Token Economy Programs in the Veterans Administration (Report of Survey conducted Nov.-Dec. 1969). Veterans Administration, Washington, D. C., 1970.

Foreyt, J. P. (1975). Behavior Modification in Mental Institutions. In W. D. Gentry (Ed.), Applied Behavior Modification. (pp. 61-83), Saint Louis, MO: Mosby Comp.

Gericke, O. L. (1965). Practical Use of Operant Conditioning Procedures in a Mental Hospital. Psychiatric Studies and Projects, 3, 2-10.

Haynes, S. N., & Geddy, P. (1973). Suppression of Psychotic Hallucinations Through Time Out. Behavior Therapy, 4, 123-1127.

Liberman, R. P. (1971). Behavior Modification with Chronic Mental Patients. Journal of Chronic Disease, 23, 803-812.

Liberman, R. P. (1972). Behavior Modification of Schizophrenia: A Review. Schizophrenia Bulletin, 6, 37-48.

Liberman, R. P., Teigen, J., Patterson, R., & Baker, V. (1973). Reducing Delusional Speech in Chronic Paranoid Schizophrenics. Journal of Applied Behavior Analysis, 6. 57-64.

Martin, G., & Pear, J. (1978). Behavior modification: What it is and how to do it. (PP. 333- 349), Englewood Cliffs, NJ: Prentice-Hall.

McCreadie, R. G., Main, C. J., & Dunlop, R.A. (1978). Token Economy, Pimozide and Chronic Schizophrenia. British Journal of Psychiatry, 133, 179-181.

Nelson, G. L., Cone, J. D. (1979). Multiple-baseline Analysis of a Token Economy for Psychiatric Inpatients. Journal of Applied Behavior Analysis, 12, 255-271.

Redd. W. H., Porterfield, A. L., & Andersen, B. L. (1979). Behavior Modification. New York: Random House.

Richardson, R., Karkalas, Y., & Lal, H. In Treatment of Hallucinations in Chronic Patients. In R. D. Rubin, H. Fensterheim, J. D. Henderson, & L. P. Ullmann (Eds.), Advances in Behavior Therapy. New York: Academic Press.

Rickard, H.C., Dignam, P. J., & Horner, R. F. (1960) Verbal Manipulations in a Psychotherapeutic Relationship. Journal of Clinical Psychology, 16, 364-367.

Stenger, C. A., & Peck, C. P. (1970). Token-Economy Programs in the Veterans Administration. Hospital and Community Psychiatry, 21, 39-43.

Wincze, J. P.Leitenberg, H., & Agras, W. 8. (1972). The Effects of Token Reinforcement and Feedback on the Delusional Verbal Behavior of Chronic Paranoid schizophrenics. Journal of Applied Behavior Analysis, 5, 247-262.

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