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119© NAPICU 2016

Journal of PsychiatricIntensive Care

Journal of Psychiatric Intensive Care, 12 (2): 119–127doi:10.20299/jpi.2016.009Received 15 July 2015 | Accepted 28 January 2016© NAPICU 2016

REVIEW ARTICLE

The use of a token economy for

behaviour and symptom management

in adult psychiatric inpatients: a critical

review of the literature

Krista Glowacki, Grace Warner, Cathy White

School of Occupational Therapy, Dalhousie University, CanadaCorrespondence to: Krista Glowacki, School of Occupational Therapy, ForrestBuilding, PO Box 15000 Halifax, Nova Scotia, B3H 4R2, Canada;krista.glowacki@dal.ca

Background: A token economy is a behavioural modification and rewardbased intervention in which tokens are given for predefined terms. Thisreview aims to answer the question: What is the effectiveness of the use ofa token economy for the reduction of negative behaviours and symptomsin adult psychiatric inpatients?Method: A systematic review of studies using a token economy for adultswith mental illness, within an inpatient setting was undertaken for theperiod 1999–2013. References cited in relevant literature were alsoexamined.Results: The Oxford CEBM Levels of evidence was used to determinequality. Grade A and B recommended studies were included in the review.A total of seven studies were included in the analysis. All of the studiesshowed the effectiveness of a token economy for reducing negativebehaviours and symptoms in the short-term.Conclusions: The use of a token economy, on the basis of reward andencouragement, should be considered within inpatient psychiatric settings.The literature shows the effectiveness on behavioural changes in reductionof violence and aggression. The literature on negative symptom reductionis scarce and cannot be generalised. There is no evidence to support thetransfer outside of an inpatient/secure setting.

Key words: token economy; psychiatric inpatient; symptom manage-ment; behaviour management

Financial support: This research received no specific grant from any funding agency,commercial or not-for-profit sectors.Declaration of interest: None.

120 © NAPICU 2016

GLOWACKI ET AL.

Introduction

With the shift toward community-based mental healthcare, inpatient psychiatry units are seeing an increase inacuity of the patients who come through their doors (Bow-ers, 2005). Common reasons for admission include dangerto self or others, severe mental disorder such as psychosis,and extreme behaviours such as agitation, mania,unpredictability, confusion, disorientation, emotionallability, distress/tears, acting out and delusions (Bowers,2005). Patients may exhibit negative symptoms such asslow and superficial responses, social withdrawal, andlack of energy (Hopko et al. 2003; Gholipour et al. 2012),or negative behaviours, including agitation and aggres-sion particularly toward staff members (Lepage et al.2003; Park & Lee, 2012). Thus, the creation of a safe andsecure environment becomes paramount.

As Bowers (2005) discussed, ongoing risk assessmentand monitoring and observation of the patients are routineaspects of the care, which may lead to the need to employskills in negotiation, persuasion, coaxing, distraction andde-escalation. When patients do escalate, disrupting themilieu and placing themselves and/or others at risk, be-haviour management strategies such as exerting physicalcontrol, restraints and coercive use of medications may beemployed to mediate the behaviour. One approach tobehaviour modification that has received limited recentattention in the literature is the use of a token economy.

Background

A token economy, developed for use within inpatientpsychiatry settings, is a behaviour modification interven-tion that can be used to shape behaviours including acquir-ing new skills, reducing undesired behaviours, increasingtreatment compliance, and improving overall manage-ment of patients on psychiatry units (LePage et al. 2003;McMonagle & Sultana, 2000). This intervention is basedon operant conditioning. Patients can earn ‘tokens’ whichhave no innate value, and can exchange them for some-thing that does have value to them, such as goods, servicesor privileges in the facility when they exhibit a desiredbehaviour (Seegert, 2003; McMonagle & Sultana, 2000).The first principle of the token economy is the law of causeand effect based on the idea that reinforcement is the mosteffective means in changing behaviour. The second princi-ple is the law of contiguity association, in that two eventswill be associated with one another if they happen together(Dickerson et al. 2005; McMonagle & Sultana, 2000). Inthe original economy, both reward and punishment tech-niques could be implemented (Kreyenbuhl et al. 2010).Punishment is now viewed as inappropriate within ahealthcare setting, causing the decline of this intervention.Punishment is considered a negative consequence, includ-

ing the removal of tokens. There are common mis-conceptions about all token economies, including thebelief that the intervention is abusive, it does not fosterindividual treatment, and does not generalise. These mis-conceptions prevail among health care practitioners andfurther contribute to its lack of use (LePage et al. 2003).

A token economy can facilitate improvement in behav-iour and function. It is an economically friendlyintervention, and can be beneficial in facilities with lim-ited resources (LePage, 1999; Seegert, 2003; Coelho et al.2008; Comaty et al. 2001; McMonagle & Sultana, 2000;Kreyenbuhl et al. 2010). It is relatively simple in its overallconceptualisation for those involved, and is beneficial forreducing challenging or disruptive behaviours (LePage,1999; Coelho et al. 2008). Token economies can be used toincrease functioning and to foster recovery, a key focus oftoday’s mental health care (Hassell, 2009).

A systematic review of the use of token economies waspublished in 2000, analysing literature up to 1999(McMonagle & Sultana, 2000). McMonagle & Sultana(2000) concluded by recommending the token economyas a cost-effective alternative to psychosocial interven-tions in institutions with financial struggles. The articlealso recommends further in-depth research in a controlledsetting using randomised trials to further explore effec-tiveness. This systematic review of the literature examinescurrent research (1999–2013) on the use of a current tokeneconomy in adult inpatient psychiatric settings. The ques-tion guiding the review is: What is the effectiveness of theuse of a token economy for the reduction of negativebehaviours and symptoms in adult psychiatric inpatients?

Method

Inclusion criteria

Types of studies. Peer reviewed articles including:randomised controlled trials, prospective cohort studies,retrospective cohort studies and pre–post design.

Types of participants. Adults ages 18 and older admittedto a psychiatric facility as an inpatient in a forensic, acute,or rehabilitation unit, with a mental health disorder asidentified in the Diagnostic Statistical Manual of MentalDisorder, 5th Edition (DSMV).

Types of interventions. Intervention included a tokeneconomy in which tokens or vouchers are given as rewardsfor behaviour specified prior to entering the programme/economy. Rewards may be given for positive behaviour orabstinence of negative behaviour. The goal is to achievebehavioural change by means of use of non-monetary andnon-consumable tokens, which can be exchanged for avariety of goods, privileges or services in the facility.

121© NAPICU 2016

A TOKEN ECONOMY

Types of outcome measures. To determine if the therapy iseffective, there must be a reduction in one of the twoidentified outcomes after the implementation of the inter-vention. The identified outcomes are negative behavioursor negative symptoms. Negative behaviours include: vio-lence, aggression, and drug abuse. Negative symptomsinclude: flat affect, lack of pleasure in life, lack of partici-pation, lack of ability to begin and sustain activities, andlack of socialisation and interaction with others. Out-comes can be measured by observation data, frequencydata, incident reports, patient charts, group participationnumbers/percentages and number of positive urine sam-ples. Statistical information was extracted from each studyinclusive of average test scores and standard deviation,statistical significance and effect size in changes or differ-ences.

Search strategy

Electronic searches were undertaken, limiting results tothe English language and publication in the period 1999–2013 (due to the McMonagle & Sultana (2000) reviewincluding research prior to 1999). The databases CINAHL,EMBASE, OTseeker, PubMed, PsycInfo and GoogleScholar were used. The search terms used in CINAHL(EBSCOhost) were: (1) “token economy” OR (tokens ORvouchers) and psychiatric OR (mental* N2 (health OR ill*

OR disorder*)) and inpatient* OR hospital* OR ward*OR unit OR patient* OR forensic*; (2) “token economy”OR tokens OR vouchers and psychiatric OR mental*NEAR/2 (health OR ill* OR disorder*) and inpatient* ORhospital* OR ward* OR unit OR patient* OR forensic* andbehavi* OR violen* OR aggressi* OR negative; (3) “To-ken economy” and adult; (4) “Token economy” andpsychiatric OR (mental* N2 (health OR ill* OR disor-der*)); (5) Voucher-based and mental health. Other similarsearch terms were used in the other databases. An exami-nation of references cited in relevant literature was alsoundertaken.

Exclusion criteria

Research done before 1999, participants under the age of18, outpatient settings, and diagnoses not in the DSMVwere excluded. Specific study types not included were:systematic reviews, open forum blogs, hospital unit re-views and descriptive articles of intervention without ameasureable outcome (see Fig. 1).

Data extraction & quality review

Articles were identified through electronic searches andabstracts were reviewed. Those that did not meet theinclusion criteria were then excluded. Of the abstractreviews, 20 articles were identified and the full manuscripts

Identified through

searching database:

n = 342

Identified through

examination of

references:

n = 3

Excluded after

abstract review:

n = 325

Full-text articles assessed

for eligibility:

n = 20

Included after

manuscript review:

n = 7

Excluded after manuscript review: n = 13

Reasons: Population not inpatients: n = 4

Study design: n = 7

Outcome measured not negative behaviour change: n = 1

Full text not accessible: n = 1

Fig. 1. Articles included and excluded.

122 © NAPICU 2016

GLOWACKI ET AL.

of the papers were read and assessed for quality andeligibility. The Oxford Centre for Evidence-Based Medi-cine Levels of Evidence was used to determine quality,and only grade A and B studies were included in the review(OCEBM, 2009). Grade A studies are considered thehighest quality and grade B studies are the second highestquality. After the full manuscript reviews, 13 were ex-cluded, leaving 7 studies to be included in the systematicreview. Figure 1 indicates reasons why studies were ex-cluded.

Results

Data were extracted from seven studies and compared todetermine the effectiveness of a token economy (Table 1).Each study included a rewards and incentive based tokeneconomy for adults within an inpatient psychiatry setting.Of the seven studies, three were randomised controlledtrials, one was a prospective cohort, two were pre–postdesigns and one was a retrospective cohort. All of thesestudies were categorised using the OCEBM (2009) todetermine study quality.

The studies classified as grade A of the OCEBM (2009)were the three randomised controlled trials (Hopko et al.2003; Gholipour et al. 2012; Park & Lee, 2012).Randomisation methods were difficult to assess as entireinpatient units were used. Two of the studies looked only atmale units and were done outside of North America(Gholipour et al. 2012; Park & Lee, 2012), and in one, allmales on the unit were diagnosed with schizophrenia(Gholipour et al. 2012). Thus, cultural and gender differ-ences should be considered and the results be used withcaution to generalise to North American culture and prac-tice, and to mixed units. Two of the studies had smallsample sizes (Hopko et al. 2003; Gholipour et al. 2012).The next grade of studies, level B of the OCEBM (2009),were pre–post designs and prospective cohorts (LePage,1999; Comaty et al. 2001; LePage et al. 2003). Two of thestudies only analysed one unit of a hospital, limiting thegeneralisation, and there was no control group as all patientsin the unit participated in the token economy (LePage,1999; LePage et al. 2003). Lastly, a retrospective study,also grade B of the OCEBM (2009) was used (Hassell,2009). This included an analysis of medical records and nopower analysis was used to determine if sample size wasadequate. In the same study various healthcare profession-als implemented the token economy and no informationwas given on inter-relater reliability or training. It shouldalso be noted that in all of the studies the intervention wascombined with individualised pharmacological treatment.

The effect of interventions on outcomes

The effectiveness of the intervention being analysed willbe reported as a narrative synthesis. This part will be

separated into two sections. The first will describe theeffectiveness of the intervention on negative behaviours,and the second will describe the effectiveness on negativesymptoms.

Behaviour. Behavioural change was an outcome meas-ured in five of the studies (LePage, 1999; Comaty et al.2001; LePage et al. 2003; Hassell, 2009; Park & Lee,2012). These studies included violent and aggressive be-haviour in a physical or non-physical manner that couldharm or threaten other individuals or themselves, mainlyreported as ‘incidents’. All of the studies’ findings supportthe efficacy of the token economy for reducing negativebehaviours and unit incidents related to these behaviourson inpatient psychiatric units. It should be noted that onestudy did not have a control, so improvements in behav-iour and function cannot be attributed to the token economyalone (Hassell, 2009). Further, one study and its resultsprovides data to support the positive long-term impact atoken economy can have on the safety and function of anacute care unit (LePage et al. 2003).

Negative symptoms. The effect of the intervention onnegative symptoms was examined in two studies (Hopkoet al. 2003; Gholipour et al. 2012). The findings from bothstudies support the efficacy of the token economy fornegative symptom reduction in an inpatient setting. How-ever, the study by Hopko et al. (2003) only includedinpatients diagnosed with depression, and the study byGholipour et al. (2012) only included males with schizo-phrenia. See Table 1 for a summary of the outcomes,results, and the statistical data from each study.

Discussion

This systematic review supports the efficacy of a tokeneconomy for reducing negative behaviours in adults withmental health illness in an inpatient psychiatry setting. Allfive of the studies analysing behavioural change showedstatistical significance in the reduction of negative behav-iours. While the literature reviewed on the efficacy of theeconomy for reducing negative symptoms supported theuse of the intervention, the number of studies was limited,providing insufficient evidence to support its use. Further,the symptom reduction studies only targeted one diagno-sis, not representative of most psychiatric inpatient units.The research on symptom reduction alone is scarce, andthis outcome measure needs to be explored further. All ofthe studies looked at the effects within an inpatient setting,and the regime of hospital units is important to con-sider. This includes structure, schedules, expectations andstaff. None of the studies were able to look at the directeffects on behaviour or symptoms outside of an inpatientsetting, so this is an important caution if considering use of

123© NAPICU 2016

A TOKEN ECONOMYTa

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Contin

ued

124 © NAPICU 2016

GLOWACKI ET AL.

Tab

le 1

.C

on

tinu

ed Co

maty

et

al. 2

001

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olip

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r et

al. 2

012

Hassell, 2

009

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pko

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Inte

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the form

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The thera

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ctiv

ities

with

ain

cluded a

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ssro

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lved r

ece

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gpart

icip

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were

giv

en to p

atie

nts

for

behavi

our

thera

py

form

of poin

ts for

the

train

ed thera

pis

t. A

train

ing s

ess

ion a

nd a

stam

ps

on a

daily

tim

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iven p

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tive

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in-

posi

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was

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ance

of

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ug

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ehavi

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g w

as

kept and

base

d e

conom

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aff.

Patie

nts

earn

ed

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kers

as

toke

ns.

pers

onal h

ygie

ne,

gro

up for

2-h

our

AD

Ls,

medic

atio

npatie

nts

would

meet

Toke

ns

were

pri

mari

lyst

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ps

for

behavi

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hey

were

giv

en fo

rcl

eanin

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bedro

om

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ssio

ns,

3 d

ays

aco

mplia

nce

and g

roup

with

a c

linic

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tim

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giv

en a

s re

info

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ent

ours

that fa

cilit

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dth

e a

bst

inence

of

bein

g o

n tim

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tc.

week

for

3 m

onth

s.attendance

. Po

ints

per

week

for

20

for

posi

tive b

ehavi

ours

treatm

ent or

were

aggre

ssiv

e b

ehavi

our

Toke

ns

were

sto

red in

were

rem

ove

d fo

rm

inute

s to

meet and

e.g

. gro

up p

art

icip

atio

nuse

ful f

or

rem

ain

ing

for

a 2

4-h

our

day.

a ‘b

ank’

for

each

patie

nt

unacc

epta

ble

or

in-

adju

st g

oals

. To

ken

sand k

eepin

g a

room

in the c

om

munity

Toke

ns

could

be r

e-

at th

e n

urs

ing s

tatio

n.

appro

pri

ate

behavi

our.

were

pro

vided fo

rcl

ean. T

oke

ns

could

e.g

. part

icip

atin

g in

deem

ed fo

r re

ward

sF

ines

or

penalti

es

were

Poin

ts c

ould

be r

e-

ach

ievi

ng

BAT

D g

oa

ls,

be lo

st fo

r m

ajo

r sa

fety

gro

up thera

py,

medic

-e.g

. coffee, fr

ied

giv

en a

nd toke

ns

deem

ed fo

r ite

ms

in the

wh

ich

co

uld

be

ex-

viola

tions

e.g

. vio

lence

,atio

n a

dhere

nce

and

chic

ken, outd

oor

rem

ove

d for

mal-

PIP

sto

re e

.g. c

loth

ing.

changed fo

r th

ings

thre

ats

or

dest

royi

ng

show

eri

ng. M

ajo

ract

iviti

es

or

sleepin

gadaptiv

e b

ehavi

ours

e.g

. off-g

rounds

pro

pert

y. T

oke

ns

could

viola

tion to s

afe

tyin

.div

ided in

to 3

cate

-pass

es,

phone c

ard

sbe e

xchanged for

rule

s re

sulte

d in

gori

es

of se

veri

ty. T

he

and s

nack

s.th

ings

e.g

. off-g

round

toke

ns

bein

g take

nhig

hest

fin

es

were

for

pass

es,

movi

es,

aw

ay.

To

kens

could

Majo

r M

ala

daptiv

esn

ack

s etc

.be u

sed in

a toke

nV

iola

tion

s (i

ncl

ud

ing

store

for

snack

s or

phys

ical a

ssault,

movi

es

or

exc

hanged

pro

pert

y dam

age,

for

a d

esi

rable

eve

nt

subst

ance

abuse

, etc

.).

e.g

. an o

ff-u

nit

pass

.

Ou

tco

mes

Ass

ess

ment w

as

done

Ass

ess

ment w

as

done

Data

were

analy

sed in

Ass

ess

ment w

as

done

Data

were

analy

sed in

Data

were

analy

sed

Data

were

an

aly

sed

at 3 w

eeks

and 3

2pre

– and 3

month

sth

e p

eriod o

f fo

ur

years

.at base

line p

rior

to the

a 1

23 d

ay

peri

od

12 m

onth

s pre

-and the e

xperi

menta

lw

eeks

into

the p

ro-

post

-inte

rventio

n.

Change in

psy

cho-

first

tre

atm

ent se

ssio

nbefo

re the toke

nin

terv

entio

n a

nd 2

4and c

ontr

ol g

roups

gra

mm

e. D

ata

at 32

Negativ

e s

ympto

ms

soci

al f

unct

ionin

gand a

t post

-inte

r-eco

nom

y and a

122

month

s post

-co

mpare

d b

efo

re a

nd

weeks

post

-inte

r-w

ere

measu

red u

sing

(few

er

mala

daptiv

eve

ntio

n o

n D

ay

14 o

rday

peri

od a

fter

the

inte

rventio

n. T

he

after

the 1

2 w

ee

kve

ntio

n is

rele

vant.

the s

cale

for

the

behavi

ours

and m

ore

at dis

charg

e if

earl

ier.

toke

n e

conom

yperc

enta

ge d

iffere

nce

toke

n e

conom

yN

um

ber

of to

tal f

ines

ass

ess

ment of

posi

tive b

ehavi

ours

)D

epre

ssiv

e s

ympto

ms

imple

menta

tion.

of th

e n

um

ber

of

peri

od. N

um

ber

of

giv

en fo

r m

ala

daptiv

enegativ

e s

ympto

ms

from

tim

e o

f adm

issi

on

ass

ess

ed u

sing the

1.

The p

erc

enta

ge

ass

aults

, defin

ed a

saggre

ssiv

e b

ehav-

behavi

ours

, num

ber

(SA

NS

).to

dis

charg

e m

easu

red

Be

ck D

epre

ssio

ndiff

ere

nce

of th

e tota

lst

aff in

juri

es

from

iours

incl

udin

g v

erb

al

of m

inor

fines,

and

by

the G

lobal A

ssess

-In

vento

ry (

BD

I).

num

ber

of negativ

epatie

nts

, patie

nt-

attack

, pro

pert

ynum

ber

of m

ajo

r fin

es

ment of F

unct

ionin

gin

cidents

on u

nit.

patie

nt in

juri

es

and

dam

age, phys

ical

com

pare

d b

etw

een

(GA

F)

score

.2.

The n

um

ber

of

self-

inju

ries

that

attack

again

st s

elf

and

the 3

gro

ups.

patie

nt and s

taff

required m

edic

al

phys

ical a

ttack

inju

ries.

attentio

n.

again

st o

ther.

125© NAPICU 2016

A TOKEN ECONOMY

Resu

lts

The n

on-c

om

ple

ters

The toke

n-b

ehavi

our

Both

the S

MI gro

up

The B

AT

D g

roup

Tota

l num

ber

of

Tota

l num

ber

of

Tota

l num

ber

of

show

ed

sig

nifi

can

tlyth

era

py g

roup s

how

ed

and the D

D g

roup

show

ed s

ignifi

cantly

inci

dents

reduce

din

cidents

reduce

daggr

ess

ive b

ehav

iours

more

fin

es

than b

oth

few

er

negativ

esh

ow

ed s

ignifi

cant

better

score

s on the

signifi

cantly

. This

wa

ssi

gnifi

cantly

after

use

for

the e

xperi

menta

lof th

e g

roups

that

sym

pto

ms

after

inte

r-im

pro

vem

ents

on the

BD

I in

dex

than the S

Pfr

om

129 tota

l inci

dents

of th

e toke

n e

conom

y.gro

up d

ecr

ease

d fr

om

finis

hed the toke

nve

ntio

n. T

he r

esu

ltsG

AF

after

hosp

italis

-gro

up (

usu

al i

npatie

nt

to 7

3 in

cidents

. The

The n

um

ber

of

178 to 1

41aft

er

the

eco

nom

y in

terv

entio

n,

were

sta

tistic

ally

atio

n a

nd the toke

ntr

eatm

ent)

, sh

ow

ing

num

ber

of st

aff a

nd

patie

nt–

patie

nt in

juries

inte

rventio

n. T

his

was

thus

show

ing h

igher

signifi

cant.

eco

nom

y pro

gra

mm

e.

negativ

e s

ympto

mpatie

nt in

juri

es

als

odecr

ease

d s

ignifi

c-a s

ignifi

cant d

ecr

ease

rate

s of m

ala

daptiv

eT

he im

pro

vem

ent is

an

reduct

ion. T

here

wa

ssi

gnifi

cantly

reduce

d.

antly

. The n

um

ber

of

as

com

pare

d to the

behavi

ours

while

inin

dic

atio

n o

f psy

cho-

als

o a

larg

e e

ffect

patie

nt–

staff a

nd s

elf-

contr

ol g

roup.

hosp

ital.

soci

al i

mpro

vem

ent,

size

.in

juri

es

reduce

d, but

meanin

g few

er

mal-

the r

esu

lts w

ere

not

ad

ap

tive

be

havi

ou

rs.

sta

tistic

ally

sig

nifi

can

t.

Sig

nif

ican

ce

Tota

l fin

es:

p <

0.0

01

p <

0.0

01.

Post

-inte

rventio

n a

nd

BAT

D g

roup:

After

toke

n e

conom

y:A

fter

toke

n e

conom

y:A

fter

toke

n e

conom

y:S

tatis

tical

Min

or

fines:

p <

0.0

06

Mean a

nd s

tandard

at dis

charg

e for

both

Mean a

nd s

tandard

Tota

l inci

dents

😛

atie

nt–

patie

nt

Ave

rage a

nd s

tandard

signifi

cance

Majo

r fin

es:

p <

0.0

02

dev

iatio

n:

gro

ups

p <

0.0

1. A

ndevi

atio

n:

43%

decr

ease

inju

ries:

48%

change

dev

iatio

n:

(p <

0.0

5)

Mean a

nd s

tandard

pre

– 77 ±

14

incr

ease

in the G

AF

pre

– 35.1

± 7

.4 a

nd

(p <

0.0

1)

(p <

0.0

5)

Exp

eri

menta

l gro

up:

devi

atio

n w

as

only

post

– 41 ±

11.

indic

ate

s im

pro

vem

ent.

post

– 19.1

± 1

3.1

.S

taff in

jury

: 54%

Self-

inju

ry: 1

7%

Pre

– 53.9

5 ±

3.1

2giv

en fo

r le

ngth

of

Mean a

nd s

tandard

This

was

signifi

cantly

decr

ease

(p

< 0

.01)

change (

not

Post

– 41.9

0 ±

2.3

4hosp

ital s

tay

whic

h is

devi

atio

n:

gre

ate

r th

an the

Patie

nt In

jury

: 45%

signifi

cant)

Contr

ol g

roup:

not th

e o

utc

om

eS

MI gro

up a

tch

ange o

f th

e S

Pdecr

ease

(p

< 0

.05).

Sta

ff in

juri

es:

21%

Pre

– 54.0

4 ±

1.5

5lo

oke

d a

t fo

r th

e p

ur-

adm

issi

on:

gro

up (

p <

0.0

5).

Mean a

nd s

tandard

change (

not

Post

– 56.2

2 ±

0.9

2pose

s of th

is p

aper.

35.6

8 ±

8.6

5 a

nd

Cohen E

ffect

siz

edevi

atio

n n

ot giv

en.

signifi

cant)

Gro

up d

iffere

nce

s:dis

charg

e:

larg

e (

d =

0.7

3).

Tota

l inju

ries:

33%

p <

0.0

01.

51.7

0 ±

8.5

4.

change (

p <

0.0

5).

DD

gro

up a

t adm

issi

on:

Mean a

nd s

tandard

35.3

5 ±

8.6

5 a

nd a

tdevi

atio

n n

ot g

iven.

dis

charg

e:

54.2

2 ±

7.0

8.

Co

nclu

sio

ns

The fin

din

gs

support

The fin

din

gs

support

The fin

din

gs

show

The fin

din

gs

support

The fin

din

gs

support

The fin

din

gs

support

The fin

din

gs

support

& Im

plicati

on

sth

e e

ffic

acy

of th

eth

e e

ffic

acy

of th

est

atis

tical s

ignifi

cance

the e

ffic

acy

of a toke

nth

e e

ffic

acy

of th

eth

e e

ffic

acy

of th

eth

e e

ffic

acy

of to

ken

toke

n e

conom

y fo

rto

ken e

conom

y fo

rfo

r im

pro

ving p

sych

o-

eco

nom

y fo

r sy

mpto

mto

ken e

conom

y fo

rto

ken e

conom

y fo

reco

nom

y use

for

red

uci

ng

ma

lad

ap

tive

red

uci

ng

ne

ga

tive

soci

al b

eh

avi

ou

r, b

ut

red

uct

ion

in in

pa

tien

tsre

duci

ng tota

l negativ

ere

duci

ng in

juri

es

and

reduci

ng a

ggre

ssiv

ebehavi

ours

short

-term

.sy

mpto

ms

short

-term

.th

is c

annot be

dia

gnose

d w

ithin

cidents

on a

n a

cute

negativ

e b

ehavi

ours

behavi

ours

. The

It a

lso s

how

s th

eT

he p

opula

tion w

as

attri

bute

d to the toke

ndepre

ssio

n, but it

unit

and for

reduci

ng

rela

ted to v

iole

nce

on

popula

tion w

as

limite

dbenefit

s fo

r 2 d

iffere

nt

limite

d to m

ale

s w

itheco

nom

y alo

ne s

ince

cannot be g

enera

lised

patie

nt/st

aff in

jury

.an in

patie

nt acu

teto

male

s in

an in

-cl

inic

al p

opula

tions.

schiz

ophre

nia

.th

ere

was

no c

ontr

ol

due to s

mall

sam

ple

psy

chia

tric

unit.

patie

nt psy

chia

try

gro

up to c

om

pare

.si

ze. T

he p

opula

tion

settin

g w

ith a

his

tory

was

limite

d to

of aggre

ssiv

ein

div

idu

als

with

MD

D.

be

havi

ou

r.

AD

L: a

ctiv

ities

of d

aily

livi

ng; B

AT

D: b

ehavi

oura

l act

ivatio

n tr

eatm

ent f

or d

epre

ssio

n; B

D: b

ehavi

oura

l dis

ord

er;

DD

: dual d

iagnosi

s M

DD

: majo

r depre

ssiv

e d

isord

er;

PD

: psy

chia

tric

dis

ord

er;

PIP

: poin

ts in

centiv

e p

rogra

mm

e; S

MI:

seri

ous

menta

l illn

ess

; SP

: support

ive p

sych

oth

era

py;

ST

TE

: short

-term

toke

n e

conom

y

126 © NAPICU 2016

GLOWACKI ET AL.

this intervention in a community setting. Comaty et al.(2001) looked at a three-year follow-up after dischargeand re-hospitalisation rates, but the data was not conclu-sive; thus the authors were unable to say whether a longerstay in the community was a result of the token economyitself.

Using a token economy may be a means of reducingviolence and aggression on inpatient units. Improved safetyin inpatient units for staff and patients may allow healthcarepractitioners to focus their attention on treatment andrehabilitation, and less on control of the unit. Behaviouralfocus could be less on the reduction of negative behav-iours, and more on the promotion of positive behaviour forrehabilitation and recovery. Further, reduction in negativesymptoms may also increase participation and collabora-tion of patients toward rehabilitation goals.

Healthcare practitioners should be cautious in using atoken economy. The token economies used in the studiesof this paper varied in rewards, desired behaviour andstructure. In saying this, the general concept of eacheconomy was the same, earning tokens for positive behav-iour towards rehabilitation that can be accumulated forpre-determined rewards. The economy has potential forabuse if implemented improperly, so programmes shouldlimit punishment and response costs for behaviour. This isinclusive of the removal of tokens for negative behaviour.Based on a recovery-oriented, patient-centred approach,the following recommendations derive from the literature:

1. Participants in the programme should be given theoption of enrolling at admission, and participationshould stay voluntary throughout (LePage et al. 2003;Park & Lee, 2012).

2. Staff and patients involved in the token economyshould collaborate to pre-determine rewards (Chiouet al. 2006; Dunn et al. 2008; Park & Lee, 2012).Rewards should also be individualised (Park & Lee,2012).

3. Thorough staff training should be done to ensureconsistency in programme implementation (LePage1999; LePage et al. 2003).

4. The token/voucher should be given immediately,thereby verifying positive behaviour (Chiou, et al.2006; LePage et al. 2003).

5. The economy should be used in congruence withindividualised treatment programmes (LePage, 1999;Gholipour et al. 2012; Park & Lee, 2012).

It is important to identify the limitations to this literaturereview. A small number of studies were analysed, asthere are limited recent research studies on this interven-tion. The quality is also limited by the fact that onlythree studies were randomised controlled trials. Further,this was a brief review of the literature available. The

research was only analysed by one person, and onlyEnglish studies were used.

Areas for future research have been identified from thisreview. The first is using a date after hospital discharge tofocus on psychosocial outcomes of participants and theirfunctioning in society outside of an institutional environ-ment. Usually hospitalisation is temporary, and it isimportant to find a transferable intervention for commu-nity care and living. Further, multiple units in one hospital,or comparison of multiple hospital studies could be donewith comparison of control and experimental groups.Research should also be done on symptom reduction for awider range of diagnoses within a hospital or inpatientunit. Research could also be done on the comparison ofdifferent types of rewards within the economies.

Conclusions

The findings of this literature review support the efficacyof a token economy for reducing negative behaviours in aninpatient psychiatric setting. This intervention should beconsidered by healthcare professionals working in aninpatient setting for reduction of negative behaviours, orincreased safety of the units. When implementing a tokeneconomy, the recommendations made on adapting theeconomy based on a recovery-oriented patient-centredpractice should also be considered. Few studies were doneon the efficacy of the economy for reducing negativesymptoms, but all that were done determined that the tokeneconomy was effective in symptom reduction. The use of atoken economy for symptom reduction should be usedwith caution until further research is done on the topic.

Since the overall number of research studies was lim-ited, the findings identify the need for further research onthis intervention and its effects on reducing negative be-haviours and symptoms. While more research is needed,the current findings should encourage healthcare practi-tioners to consider the use of a rewards-based tokeneconomy as a treatment intervention in an inpatient psy-chiatry setting.

Acknowledgements

School of Occupational Therapy at Dalhousie University.The Waterford Hospital in St. John’s Newfoundland, wherethe research first started based on a clinical need.

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Seegert, C.R. (2003) Token economies and incentive programs:behavioral improvement in mental health inmates housed instate prisons. The Behavior Therapist, 26(1): 208, 210–211.

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How it Works

  1. Clіck оn the “Place оrder tab at the tоp menu оr “Order Nоw” іcоn at the bоttоm, and a new page wіll appear wіth an оrder fоrm tо be fіlled.
  2. Fіll іn yоur paper’s іnfоrmatіоn and clіck “PRІCE CALCULATІОN” at the bоttоm tо calculate yоur оrder prіce.
  3. Fіll іn yоur paper’s academіc level, deadlіne and the requіred number оf pages frоm the drоp-dоwn menus.
  4. Clіck “FІNAL STEP” tо enter yоur regіstratіоn detaіls and get an accоunt wіth us fоr recоrd keepіng.
  5. Clіck оn “PRОCEED TО CHECKОUT” at the bоttоm оf the page.
  6. Frоm there, the payment sectіоns wіll shоw, fоllоw the guіded payment prоcess, and yоur оrder wіll be avaіlable fоr оur wrіtіng team tо wоrk оn іt.

Nоte, оnce lоgged іntо yоur accоunt; yоu can clіck оn the “Pendіng” buttоn at the left sіdebar tо navіgate, make changes, make payments, add іnstructіоns оr uplоad fіles fоr the оrder created. e.g., оnce lоgged іn, clіck оn “Pendіng” and a “pay” оptіоn wіll appear оn the far rіght оf the оrder yоu created, clіck оn pay then clіck оn the “Checkоut” оptіоn at the next page that appears, and yоu wіll be able tо cоmplete the payment.

Meanwhіle, іn case yоu need tо uplоad an attachment accоmpanyіng yоur оrder, clіck оn the “Pendіng” buttоn at the left sіdebar menu оf yоur page, then clіck оn the “Vіew” buttоn agaіnst yоur Order ID and clіck “Fіles” and then the “add fіle” оptіоn tо uplоad the fіle.

Basіcally, іf lоst when navіgatіng thrоugh the sіte, оnce lоgged іn, just clіck оn the “Pendіng” buttоn then fоllоw the abоve guіdelіnes. оtherwіse, cоntact suppоrt thrоugh оur chat at the bоttоm rіght cоrner

NB

Payment Prоcess

By clіckіng ‘PRОCEED TО CHECKОUT’ yоu wіll be lоgged іn tо yоur accоunt autоmatіcally where yоu can vіew yоur оrder detaіls. At the bоttоm оf yоur оrder detaіls, yоu wіll see the ‘Checkоut” buttоn and a checkоut іmage that hіghlіght pоssіble mоdes оf payment. Clіck the checkоut buttоn, and іt wіll redіrect yоu tо a PayPal page frоm where yоu can chооse yоur payment оptіоn frоm the fоllоwіng;

  1. Pay wіth my PayPal accоunt‘– select thіs оptіоn іf yоu have a PayPal accоunt.
  2. Pay wіth a debіt оr credіt card’ or ‘Guest Checkout’ – select thіs оptіоn tо pay usіng yоur debіt оr credіt card іf yоu dоn’t have a PayPal accоunt.
  3. Dо nоt fоrget tо make payment sо that the оrder can be vіsіble tо оur experts/tutоrs/wrіters.

Regards,

Custоmer Suppоrt

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