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Token economy interventions.

The Problem

You work in a state hospital-like setting, and token economy interventions are developed for the treatment of patients with schizophrenia and other serious mental illnesses.

The Question

Are the principles of token economy effective in strengthening adaptive behaviors, or weakening non-adaptive behaviors, in this patient population?

The Analysis

Our Medline search combined "token economy" and "schizophrenia, schizoaffective, or mental illness." We located review articles in the Cochrane Library (Cochrane Database Syst. Rev. 2000;CD001473; and in Schizophrenia Research (2005;75:405-16).

The Evidence

Broadly based on B.F. Skinner's principles of operant conditioning, the token economy was created in the 1960s as a way to treat the large numbers of seriously ill patients who were then living in mental hospitals.

"In the token economy, the full range of self-care, social, and work behaviors could be modified by systematic and preplanned use of antecedents (e.g., prompts) and consequences (e.g., reinforcers) of these behaviors. The 'psychopathological' behavior of the mentally ill was conceptualized as being subject to the same 'laws of learning' that influenced normal behavior.... Tokens could be conveniently dispensed to patients contingent on their exhibiting improvements in their behavior. The tokens were then subsequently exchanged for a panoply of rewards," noted Dr. Robert Paul Liberman, professor of psychiatry at the University of California, Los Angeles (Am. J. Psychiatry 2000;157:1398).

Each of the review articles that we found in our search reached different conclusions.

The Cochrane review considered all relevant randomized, controlled trials. Quasi-randomized studies were excluded. Studies using block randomization, such as those using whole wards of patients, were excluded. Where patients were given additional treatments within a token-economy trial, data were included only if this treatment was evenly distributed and it was only the token economy that was randomized. A double-blind assessment is not possible for token economy.

Given that most token economies are applied in long-term facilities, studies with attrition rates greater than 30% were excluded. Fourteen studies were excluded and three included for this review, with a total of 110 patients. The reviewers concluded that data from such small studies are not meaningful for clinical care. However, one study was cited as showing improvement in negative symptoms at 3 months.

The investigators in the Schizophrenia Research review included studies that had a comparison condition with random assignment by individual or group, or a comparison with matched controls. Unlike the Cochrane review, studies using block randomization of whole wards were not excluded. Quasi-randomized studies were explicitly included. The 13 studies included in the review involved approximately 1,000 patients, of whom 600 were enrolled in a single outpatient study. Eleven of these studies were conducted in the 1960s or 1970s.

The most common type of outcome measure was ward rating scales, such as the Nurse Observation Scale for Inpatient Evaluation or the Wing Ward Behavior Scale. The investigators found that all but two studies showed significant benefits of the token economy on target behaviors of self-care, social interaction, treatment participation, and other activities of daily living.

The Conclusion

Is token economy efficacious for schizophrenia treatment? The Cochrane review excluded studies using block randomization, or randomization of entire wards. We question the necessity of this exclusion, as we cannot see any other way of conducting such a study in a meaningful way.

The Cochrane review also excluded studies using quasi-randomization. If sufficient patient numbers are available, randomization is the best way to avoid allocation bias. True randomization involves selecting patients by processes such as random-number tables. Quasi-randomization--such as sorting by birth dates or medical-record numbers--is reasonable in most cases, although investigators need to test for any bias that might result, so excluding quasi-randomization studies may be unnecessarily strict.

This leaves us, then, with the more inclusive review published in Schizophrenia Research, which found token economy effective for treating patients with schizophrenia when targeting negative symptoms, such as asocialization, amotivation, and poor activities of daily living. However, token economy for treatment of the severely mentally ill requires further study, in larger numbers, when applied with current knowledge of psychosocial and psychopharmacologic therapy.

DR. LEARD-HANSSON is a forensic psychiatrist affiliated with Atascadero (Calif.) State Hospital. DR. GUTTMACHER is chief of psychiatry at the Rochester (N.Y.) Psychiatric Center. They can be reached at


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Author:Leard-Hansson, Jan; Guttmacher, Laurence
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:May 1, 2006
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