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Performance on a token economy psychiatric ward: A two year summary
Be&v.
Ra.
& Tbcrrpy.
1970.
Vol.
8, PP. 1 to 9.
FuGma
Plus.
Rdcd
in Endand
PERFORMANCE ON A TOKEN ECONOMY PSYCHIATRIC WARD: A TWO YEAR SUMMARY KENNETH E. LLOYD and LEONARD ABEL Washington State University, Pullman, Washington and State Hospital North, Orofino, Idaho (Received 20 June 1969) Summary-A token economy psychiatric hospital ward for chronic schizophrenic male and fema!e patients is described in detail. After two years, 13 patients had been discharged, 6 were hospital employees, 12 had earned many privilegas on the token ward, 12 had earned very few privileges and 9 had been removed from the ward. The patients in these five terminal positions were compared on age, years-in-hospital, prescribed drugs and diagnosis. The median years-in-hospital for discharged patients was lower than the median for the other four terminal positions. Otherwise comparisons of these variables revealed no consistent trends. The proportion of time the patients spent out of the hospital was greater after entering the token ward than before entering it. The two-thirds of patient movements from one of the five positions to another were in the direction of improvement of socially acceptable behavior.
A RECIZNTdescription of “hard-core” chronic mental patients cited them as one of the most difficult problems facing the mental health field today (Paul, 1969). Mental hospitals in the United States have become “two hospitals”-one for acute short-term, quickly discharged, younger patients, and one for chronic, static, custodial, older patients (Brown, 1960; Honigfeld and Gillis, 1967; Paul, 1969). Paul’s reiriew notes that one, among very few, treatment programs for the chronic patient is the token economy psychiatric ward. A token economy psychiatric ward is an application of an experimental analysis of hhavior to a between responses and group of patients living together on a hospital ward. Contingencies reinforcing stimuli are planned for a number of different responses in a number of different patients who behave in a variety of hospital environments. The contingencies are in effect 24 hr a day, 7 days a week. Several rules about how the wards are organized or about how behavior is modified on a ward have been formulated (Ayllon and Azrin, 1968). The fundamental rule is that behavior which occurs with a low frequency (like social interaction, personal care or working) is linked by a token with a high frequency behavior (like eating, sitting or smoking). This rule has been labeled the probability of behavior rule (Ayllon and Azrin, 1968, p. 60) or the Premack principle (Premack, 1959). On a token ward, in order to perform a high frequency response, the patient must first earn a token by performing a low frequency response. Technically, the token is first a generalized conditioned reinforcing stimulus for the low frequency response which precedes it in time, and second a discriminative stimulus which occasions a subsequent high frequency response. Descriptions of token economy psychiatric wards have been published (e.g. Atthowe and Krasner, 1968 ; Ayllon and Azrin, 1968; Lloyd and Garlington, 1968 ; Schaefer and Martin, 1969). In these articles’ the effects of manipulating reinforcement contingencies on 1
Bchaviour
Res.
& Therapy
Vol.
8 No.
I-A
KENNETHE. LLOYD and
2
LEONARD
ABEL
a few selected behaviors were presented. In the present paper data describing long term changes in the behavior of patients during the first 27 months of a token economy ward program are presented. METHOD The token economy program at State Hospital North, Orofino, I&ho, was initiated through the cooperative efforts of the hospital staB and the financial support of the U.S. Public Health Service.* Patients were selected for the program from different wards in the hospital. The criterion for their selection was the opinion of the hospital staff that they would do well on a token ward. The rules of behavior for the ward were established on the basis of what was known about token wards at Palo Alto Veterans Administration Hospital (Atthowe and Krasner, 1968) and at Anna State Hospital (AylIon and Azrin, 1968). Adjustments in the rules were frequently made. Some adjustments were evaluated empirically and some were not. Records were kept of all token transactions between the ward staff and the patients. In the following sections of this paper descriptions of the patients, of the ward rules, of the recording of responses and of behavior changes of the patients will be presented. PATIENTS Table 1 contains a description of the 39 male and 13 female patients who were on the ward. The ages in Table 1 are those at the end of this report period. The third column in Table 1, years-in-hospital, is not the same as years-since-first-admission which would be a longer period if the patient had ever been released from the hospital. The drugs listed are the predominant drugs given to that patient. During the first 27 months of the program five medical doctors successively serviced the ward and drugs were often changed. The Diagnosis listed in Table 1 is the last diagnosis assigned to the patient. This diagnosis could have been assigned on first admission or at a later date. The program began with only male patients. The female patients entered the program 12 months later. TABLE1. AGE, DRUGS,DIAGNOSIS PATIENTS
AND RANKED
TERMINAL BY YEARS
POSITION
FOR THE MALE
AND
FEMALE
IN HOSPITAL
YearSin
Male
patients
Age
hospital
1
62
39-8
Sparine
SU”
2
54
30.5
None
su
3
56
29.8
Phenothiazine
su
A
4
59
29.2
None
su
B
Drug
Diagnosis
Terminal position C Removed
* The support from USPHS Grant MH 0227-01 is gratefully acknowledged. Many persons have contributed to the token economy. Especially appreciated is the help of Myrick W. Pullen, M.D., Idaho Director of Mental Health, William V. Van Duyne, M.D., Superintendent, Kay Anderson, Herman Androes, Verle Bjur, Doris Brackelsberg, Warren K. Garlington, Mary Hall, Ronald Kleinkneck, Jacob Panzerella, Charles L. Preuninger, Thomas Samuels and Betty Vogel.
PERFORMANCE ON A TOKEN ECONOMY PSYCHIATRIC
WARD:
A TWO YEAFt SUMMARY
TABLE1. Continued
Male
YearSill Drug
Diagnosis
Terminal
Age
hospital
5
55
28.9
Phenothiazine
su
Temporary
6
52
27.9
None
su
B
7
58
27,3
Phenothiazine
SPb
A
8
56
26.8
No record
SU
9
50
26.8
No record
su
B
10
54
26.5
Phenothiazine
su
Discharged
II
53
26.5
Phenothiazine
su
B
12
55
26.1
Phenothiazine
SP
A
13
61
24.8
Phenothiazine
su
B
14
53
23-2
None
SH=
15
53
22.1
Phenothiazine
MDd
16
59
20.4
Phenothiazine
su
Temporary
17
49
17.7
Phenothiazine
su
Removed
18
62
16.9
No record
su
Removed
19
63
16.6
Phenothiazine
SP
Temporary
20
37
16-5
Phenothiazine
see
C
21
59
14.8
No record
SP
B
22
46
12.8
Phenothiazine
su
Discharged
23
43
12.7
No record
SH
C
24
33
12.2
Phenothiazine
su
C
25
34
10.6
Phenothiazine
su
A
26
64
9.7
Phenothiazine
su
Discharged
27
28
7.9
Phenothiazine
su
c
28
53
6.9
Phenothiazine
SP
A
29
47
5.8
Phenothiazine
MMD’
30
27
4.7
Phenothiazine
SP
31
56
4.0
Phenothiazine
SP
32
27
3.0
Phenothiazine
CBSS
Patients
position visit
Removed
Removed C visit
visit
Removed C Temporary visit A
3
4
KENNETH
and LEONARD
E.LLoYD TAsLE
1.
ABEL
&hUMd
Male patients
Age
Years in hospital
33
45
2.9
Phenothiazine
SP
Discharged
34
34
2.4
Phenothiazine
SP
B
35
21
1.1
Phenothiazine
CBS
C
36
34
0.5
Phenothiazine
su
Temporary visit
37
33
0.3
Phenothiazine
su
Discharged
38
24
0.3
Trilafon
SU
B
39
39
0.2
None
SP
Removed
53
18.0
1
57
36.4
Phenothiazine
SP
Removed
2
62
35.7
Phenothiazine
su
B
3
56
28.1
Compazine
su
C
4
51
24.9
No record
su
C
5
52
22.6
No record
SH
Family care
6
55
20.2
Phenothiazine
su
B
7
51
19.0
Phenothiazine
su
B
8
55
12.2
No record
su
C
9
51
12.2
Phenothiazine
su
10
63
9.7
Phenothiazine
Uncertain
B
11
30
2.0
Artane
SP
C
12
47
1.4
Phenothiazine
su
Discharged
13
46
1,2
Phenothiazine
SP
Discharged
Median
53
18.0
Median
Drug
Diagnosis
Terminal position
Female patients
a Schizophrenic,
undifferentiated.
b Schzophrenic,
paranoid.
CSchizophrenic,
hebephrenic.
* Severe mental deficiency with psychosis. e Schizophrenic,
catatonic.
f Mild mental deficiency. g Chronic brain syndrome with psychosis.
Removed
PEXFORMANCE
ON A TOKEN ECOMONY
PSYCHIATRIC
WARD:
A TWO YEAR SU?dMARY
5
WARD RULES During the first month of the program all patients (only males) lived by the same rules. After the first month the patients were divided into three groups on the basis of their behavior. There were different rules for the different groups. Group A patients functioned at the highest level. They were off the token program, usually lived in private rooms in another building, were employees of the hospital, ate with the other employees and were expected to make plans to leave the hospital. They were returned to Group C if they failed to perform the expected activities. Group B patients lived on the token ward and earned tokens. They had ground and town privileges, could make home visits, could sleep in individual rooms and could attend all hospital recreational functions. They worked off the ward in the hospital kitchen, laundry and maintainance building. They could move to Group A if they earned 10,000 tokens within any 1l-week period. They were returned to Group C if they failed to earn 700 tokens per week for 2 consecutive weeks. Group C patients lived and earned tokens on the ward. They were restricted to the ward except for meals (which were served in a central patient dining-room), for special hourly work assignments and for special recreational functions. They could move to Group B if they earned 2000 tokens in any 3-week period. Tokens were paid to the patients at three daily pay stations. At the 7 a.m. Pay Station they could earn 5 tokens for having brushed their teeth, 5 for being shaved (or wearing appropriate makeup), 5 for having combed their hair, 5 for wearing neat clean clothes and 5 for being on time at the pay station. At the 11 a.m. Pay Station patients could earn 15 tokens for their behavior at breakfast. Meal time eating behavior was scored in three categories (5 tokens each): (1) eating quietly, not gulping food and spending at least 15 min in the dining hall, (2) tray tidy at end of meal and (3) clothing and face not soiled. They were also paid for making their bed (5 tokens) and for any occupational or industrial (work) therapy (10 tokens per hour) they had completed during the morning at the 11 a.m. Pay Station. At the 4 p.m. Pay Station patients could earn 15 tokens for lunch eating behavior, and 10 tokens per hr for afternoon work. At an 8:30 p.m. bed check, patients could earn 5 tokens for having bathed and another 5 for changing clothing. Patients in Group B were paid 10 tokens for being dressed and out of bed at 8 :30 p.m. ; patients in Group C could earn 15 tokens depending upon the condition of their bed, their personal appearance and their being out of bed at 8 :30 p.m. During the evening patients were periodically observed and paid immediately for engaging in conversation or other social behavior. They could earn 10 tokens each time they were observed in social interaction. From time to time individual patients were placed on special shaping programs for which they were paid immediately. Sometimes cigarettes or soft drinks were also given with the tokens on these shaping programs. A particular behavior would be subdivided into smaller response units and the patient would gradually be required to perform more and more of these response units as the shaping program continued. Shaping tokens were never counted towards moving from one group to another. Medications were dispensed three times daily. Patients were paid 10 tokens each time for taking medications. A patient could always be paid less than the allowed tokens for a given activity. For example, although he could earn 5 tokens for brushing teeth a patient could receive fewer tokens if he had not used toothpaste or a brush.
6
KENNETHE.
LLOYD
and LEONARD
ABEL
At the pay stations the patients also paid for those activities in which they wished to engage. They purchased their meals (20 tokens for breakfast, 40 for lunch and 30 for supper), they paid room rent (30 per week) and they paid any fines for refusing to comply with requests. They paid for elective behavior (c.,.0 10 tokens to sit in a favorite chair for-J hour or to lie on the floor for f hr) and for recreational activities (e.g. 10 tokens per hr to watch television). Tobacco, clothing and other personal items were purchased during scheduled office hours. Excess tokens could be placed in a bank account. All token transactions were recorded on a daily pay station form. Total earnings minus fines and shaping tokens were computed for each patient each day. These totals were summed each week to obtain a weekly earnings score. This score was plotted on each patient’s graph which was displayed on the ward. These weekly scores were the basis for moving patients from group to group. RESULTS Three response measures will be reported. These are: (1) the relationship between terminal position and age, years-in-hospital, drug and diagnosis; (2) time out of hospital and (3) movement patterns from one ward status to another. TERMINAL
WARD
STATUS
The last column in Table 1 indicates the position of each patient after 27 months. There were five possible terminal positions, that is, a patient could be out of the hospital, in Group A, Group B or Group C or could have been removed from the program. The median age for all patients was 53 yr. The median ages for the five terminal positions was 53, 53, 53,41 and 53 respectively. The median years-in-hospital for all patients was 18 yr. The median years-in-hospital for the five terminal positions was 8, 18,21,13 and 18 respectively. The number of patients (both male and female) in these five positions was 13 discharged, 6 in Group A, 12 in Group B, 12 in Group C and 9 removed from the ward. Two-thirds (35) of all patients were taking a phenothiazine derivative drug and one-fourth (13) were taking none (or no record). These 48 patients were distributed proportionally across all five status categories (13, 6, 11, 9 and 9, respectively). Eighty-four per cent (44) of all patients were diagnosed undifferentiated or paranoid schizophrenia. These patients were also distributed proportionally across all five status categories (12, 5, 12, 8 and 7, respectively). There were only two discernible trends in these comparisons: first, patients in Group C were younger and had been in the hospital a shorter period of time and, second, discharged patients had been in the hospital a shorter period of time. However, although the median years-in-hospital for Group C and for discharged patients was lowest, these patients varied continuously from O-3 of a yr to over 30 yr in the hospital. TIME
OUT-OF-HOSPITAL
Time out of the hospital on temporary visit, family care, or discharge is another measure of patient performance. The rules of the token economy ward clearly specified how a patient could leave the hospital. The rules for leaving the hospital on other wards were less specific. This means that time out of hospital before the program began and time out of hospital during the token program did not necessarily measure the same behavior changes. For the males 7 had been out of the hospita1 prior to entering the token ward. After entering the
PERFORMANCE
ON A TOKEN
ECOMONY
PSYCHIATRIC
WARD:
A TWO YEAR
SUMMARY
7
token ward 12 males (including 5 of the 7 who had been out before) were released. The proportions of time (during which all males were out of the hospital) were 0.09 before and 0.16 after entering the token economy. For the females, 3 had been out before and 4 after yielding proportions of O-04 and 0.11, respectively.
MOVEMENT
PATTERNS
Patients could move up or down within the program in six possible patterns. They could move upward from Group C to Group B, from B to Group A, from Group A to Discharge and they could move downward from Discharge, or from Group A or from Group B to Group C. There were 113 male moves and 38 female moves. Of all the male moves, 63 per cent were upward moves and 37 per cent were downward moves. Of the female moves 71 per cent were upward moves and 29 per cent were downward ones. The majority of moves (103) were from Group C to Group B (60) and from Group B to Group C (43). The upward moves from Group B to Group A and from Group A to Discharge, 21 and 18, respectively, were similar in frequency. The downward moves from Group A to Group C and from Discharge to Group C, 6 and 3 respectively, were also similar in frequency. Inspection of the movement patterns of individual patients indicated that they could be grouped into four categories based on how they moved from group to group. These movement patterns are illustrated in Fig. 1. Patients 30M and 4F (cf. Table 1, Column 1) in Fig. 1 were typical of a group of 7 males (1, 20, 23, 24, 27, 30, 35) and 3 females (3, 4, 8) who were predominantly in Group C although they did move to Group B for short periods of time. Patients 4M and 6F represent a group of 7 males (4, 9, 1 I, 13, 21, 34, 38) and 3 females (2, 6, 10) respectively, who were predominantly in Group B although they did fall to Group C occasionally. Patients 33M and 13F were in a group of 9 males (3, 7, 16, 19, 22, 25, 26, 33, 36) and 3 females (5, 12, 13) who progressed rapidly through the token ward into Group A and then either left the hospital (5 of 9 males and all 3 females) or remained in Group A. Patients 12M and 7F represent 5 males (6, 12, 15, 28, 32) and 2 females (7, 11) who progressed to Group A or out of the hospital (2 males and 1 female) and later returned to Group C. These groupings of patients account for 28 males and 11 females. Of the remaining 13 patients, 7 males and 2 females were removed from the ward because of illness or severe behavioral disturbances and 4 males (5, 10, 31, 37) had been originally placed in Group A and subsequently discharged from the hospital without ever being in Groups B or C.
DISCUSSION The rules of a token economy ward were discussed, the patients living in it were described and three response measures were presented. No relationship was observed between a patient’s terminal position and his drug prescription or psychiatric diagnosis. Patients with fewer years in the hospital tended to be in Group C or Discharged. The proportion of time the patients were released from the hospital increased after they were on the token ward even though the criteria for release were more stringent than before the token economy was initiated. Two-thirds of all changes in ward position represented an increase in socially acceptable behavior. The lack of a consistent relationship between terminal position and age, time in hospital, drugs or diagnosis may indicate that such traditional variables are simply not closely
KENNETHE.
and
LLOYD
LEONARD
4M
0
10
ABEL
33
20
30
45
M
12 M
50
Weeks
4F
FIG. 1. Tokens earned each week for one typical male (M) and female (F) patient from each of four categories of patient movement patterns. If a patient remained within a given group for a long period of time rhen that portion of his data is omitted as noted. Patient numbers refer to the numbers in the first column of Table 1. The horizontal lines drawn in each graph indicate the dividing line between Groups C and B and Groups B and A.
related to the day to day behavior of patients. The changes in ward status during the program were equivalent to number of tokens earned and were directly related to the day to day behaviors of the patients. These changes indicated an overall improvement in patient performance. The number of tokens earned has been shown to be directly related to the manner in which the rules of the token ward have been established (Lloyd and Garlington, 1968). Although the data presented here were in support of a token economy ward many features of the program need to be evaluated. Many rules of the ward were established in an arbitrary manner. Dividing patients into groups may not be necessary. The individual shaping programs could perhaps be eliminated if the overall rules were more appropriate. This would be especially true in the case of fines. Sometimes ward personnel would attempt unsuccessfully to rely on tines rather than adequately shape performance. The program described here stressed personal appearance and work habits. It may be important to weigh verbal behavior and social interaction more heavily. The present program also tended to emphasize leaving the hospital as contrasted with simply maintaining a high level of behavior on the ward. With patients as old as these finding employment outside the hospital is difficult. More important than discharge may be identifying the variables that contribute to the bigb frequency of movements between Groups C and B.
PERFORMANCE
ON A TOKEN
ECONOMY PSYCHIATRIC W*D:
A TWO YEAR SUMXUY
9
Much of the traditional behavior between ward attendants and patients was altered on the token ward. Attendants learned to talk in terms of changing behavior rather than speculating about the etiology of behavior. They discussed the relationship of environmental events to behavior rather than the relationship of mental events to behavior. They became as conscientious in recording behavioral data as they had been in recording medical data. Finally, the establishment of explicit rules relating what a patient may do if he behaves in a specified way removes many of the ambiguities often associated with a patient’s position in the hospital or with the possibilities of his being released from the hospital. REFERENCES I. M. and KUSNER L. (1968) Preliminary report on the application of contingent reinforcement procedures (token economy) on a “chronic” psychiatric ward. J. abnorm. Psychol. 73, 37-43. AYLLON T. and AZRIN N. (1968) The Token Economy. Appleton-Century-Crofts; New York. BROWN G. W. (1960) Lenah of hosDita1 stay and schizoohrenia: A review of statistical studies. Acta ATTHOWE
Psychiat. N&rol:
&and. 35, 41G30.
_
HONIGFELDG. and GILU R. (1967) The role of institutionalization
in the natural history of schizophrenia.
Dis. New. Syst. 28, 660-663.
LLOYD K. E. and GARLINGTONW. K. (1968) Weekly variations in performance on a token economy psychiatric ward. Behav. Res. & Therapy 6,407AlO. PAUL G. L. (1969) Chronic mental patient: Current status-future directionsdq&ol. Bull. 71, 81-94. PREMACKD. (1959) Toward empirical behavior laws: 1. Positive reinforcement. Psychol. Rev. 66,219-233. SCHAEFFERH. H. and MARTINP. L. (1969) Behaviornl Therapy. McGraw-Hill, New York.
Ra.
& Tbcrrpy.
1970.
Vol.
8, PP. 1 to 9.
FuGma
Plus.
Rdcd
in Endand
PERFORMANCE ON A TOKEN ECONOMY PSYCHIATRIC WARD: A TWO YEAR SUMMARY KENNETH E. LLOYD and LEONARD ABEL Washington State University, Pullman, Washington and State Hospital North, Orofino, Idaho (Received 20 June 1969) Summary-A token economy psychiatric hospital ward for chronic schizophrenic male and fema!e patients is described in detail. After two years, 13 patients had been discharged, 6 were hospital employees, 12 had earned many privilegas on the token ward, 12 had earned very few privileges and 9 had been removed from the ward. The patients in these five terminal positions were compared on age, years-in-hospital, prescribed drugs and diagnosis. The median years-in-hospital for discharged patients was lower than the median for the other four terminal positions. Otherwise comparisons of these variables revealed no consistent trends. The proportion of time the patients spent out of the hospital was greater after entering the token ward than before entering it. The two-thirds of patient movements from one of the five positions to another were in the direction of improvement of socially acceptable behavior.
A RECIZNTdescription of “hard-core” chronic mental patients cited them as one of the most difficult problems facing the mental health field today (Paul, 1969). Mental hospitals in the United States have become “two hospitals”-one for acute short-term, quickly discharged, younger patients, and one for chronic, static, custodial, older patients (Brown, 1960; Honigfeld and Gillis, 1967; Paul, 1969). Paul’s reiriew notes that one, among very few, treatment programs for the chronic patient is the token economy psychiatric ward. A token economy psychiatric ward is an application of an experimental analysis of hhavior to a between responses and group of patients living together on a hospital ward. Contingencies reinforcing stimuli are planned for a number of different responses in a number of different patients who behave in a variety of hospital environments. The contingencies are in effect 24 hr a day, 7 days a week. Several rules about how the wards are organized or about how behavior is modified on a ward have been formulated (Ayllon and Azrin, 1968). The fundamental rule is that behavior which occurs with a low frequency (like social interaction, personal care or working) is linked by a token with a high frequency behavior (like eating, sitting or smoking). This rule has been labeled the probability of behavior rule (Ayllon and Azrin, 1968, p. 60) or the Premack principle (Premack, 1959). On a token ward, in order to perform a high frequency response, the patient must first earn a token by performing a low frequency response. Technically, the token is first a generalized conditioned reinforcing stimulus for the low frequency response which precedes it in time, and second a discriminative stimulus which occasions a subsequent high frequency response. Descriptions of token economy psychiatric wards have been published (e.g. Atthowe and Krasner, 1968 ; Ayllon and Azrin, 1968; Lloyd and Garlington, 1968 ; Schaefer and Martin, 1969). In these articles’ the effects of manipulating reinforcement contingencies on 1
Bchaviour
Res.
& Therapy
Vol.
8 No.
I-A
KENNETHE. LLOYD and
2
LEONARD
ABEL
a few selected behaviors were presented. In the present paper data describing long term changes in the behavior of patients during the first 27 months of a token economy ward program are presented. METHOD The token economy program at State Hospital North, Orofino, I&ho, was initiated through the cooperative efforts of the hospital staB and the financial support of the U.S. Public Health Service.* Patients were selected for the program from different wards in the hospital. The criterion for their selection was the opinion of the hospital staff that they would do well on a token ward. The rules of behavior for the ward were established on the basis of what was known about token wards at Palo Alto Veterans Administration Hospital (Atthowe and Krasner, 1968) and at Anna State Hospital (AylIon and Azrin, 1968). Adjustments in the rules were frequently made. Some adjustments were evaluated empirically and some were not. Records were kept of all token transactions between the ward staff and the patients. In the following sections of this paper descriptions of the patients, of the ward rules, of the recording of responses and of behavior changes of the patients will be presented. PATIENTS Table 1 contains a description of the 39 male and 13 female patients who were on the ward. The ages in Table 1 are those at the end of this report period. The third column in Table 1, years-in-hospital, is not the same as years-since-first-admission which would be a longer period if the patient had ever been released from the hospital. The drugs listed are the predominant drugs given to that patient. During the first 27 months of the program five medical doctors successively serviced the ward and drugs were often changed. The Diagnosis listed in Table 1 is the last diagnosis assigned to the patient. This diagnosis could have been assigned on first admission or at a later date. The program began with only male patients. The female patients entered the program 12 months later. TABLE1. AGE, DRUGS,DIAGNOSIS PATIENTS
AND RANKED
TERMINAL BY YEARS
POSITION
FOR THE MALE
AND
FEMALE
IN HOSPITAL
YearSin
Male
patients
Age
hospital
1
62
39-8
Sparine
SU”
2
54
30.5
None
su
3
56
29.8
Phenothiazine
su
A
4
59
29.2
None
su
B
Drug
Diagnosis
Terminal position C Removed
* The support from USPHS Grant MH 0227-01 is gratefully acknowledged. Many persons have contributed to the token economy. Especially appreciated is the help of Myrick W. Pullen, M.D., Idaho Director of Mental Health, William V. Van Duyne, M.D., Superintendent, Kay Anderson, Herman Androes, Verle Bjur, Doris Brackelsberg, Warren K. Garlington, Mary Hall, Ronald Kleinkneck, Jacob Panzerella, Charles L. Preuninger, Thomas Samuels and Betty Vogel.
PERFORMANCE ON A TOKEN ECONOMY PSYCHIATRIC
WARD:
A TWO YEAFt SUMMARY
TABLE1. Continued
Male
YearSill Drug
Diagnosis
Terminal
Age
hospital
5
55
28.9
Phenothiazine
su
Temporary
6
52
27.9
None
su
B
7
58
27,3
Phenothiazine
SPb
A
8
56
26.8
No record
SU
9
50
26.8
No record
su
B
10
54
26.5
Phenothiazine
su
Discharged
II
53
26.5
Phenothiazine
su
B
12
55
26.1
Phenothiazine
SP
A
13
61
24.8
Phenothiazine
su
B
14
53
23-2
None
SH=
15
53
22.1
Phenothiazine
MDd
16
59
20.4
Phenothiazine
su
Temporary
17
49
17.7
Phenothiazine
su
Removed
18
62
16.9
No record
su
Removed
19
63
16.6
Phenothiazine
SP
Temporary
20
37
16-5
Phenothiazine
see
C
21
59
14.8
No record
SP
B
22
46
12.8
Phenothiazine
su
Discharged
23
43
12.7
No record
SH
C
24
33
12.2
Phenothiazine
su
C
25
34
10.6
Phenothiazine
su
A
26
64
9.7
Phenothiazine
su
Discharged
27
28
7.9
Phenothiazine
su
c
28
53
6.9
Phenothiazine
SP
A
29
47
5.8
Phenothiazine
MMD’
30
27
4.7
Phenothiazine
SP
31
56
4.0
Phenothiazine
SP
32
27
3.0
Phenothiazine
CBSS
Patients
position visit
Removed
Removed C visit
visit
Removed C Temporary visit A
3
4
KENNETH
and LEONARD
E.LLoYD TAsLE
1.
ABEL
&hUMd
Male patients
Age
Years in hospital
33
45
2.9
Phenothiazine
SP
Discharged
34
34
2.4
Phenothiazine
SP
B
35
21
1.1
Phenothiazine
CBS
C
36
34
0.5
Phenothiazine
su
Temporary visit
37
33
0.3
Phenothiazine
su
Discharged
38
24
0.3
Trilafon
SU
B
39
39
0.2
None
SP
Removed
53
18.0
1
57
36.4
Phenothiazine
SP
Removed
2
62
35.7
Phenothiazine
su
B
3
56
28.1
Compazine
su
C
4
51
24.9
No record
su
C
5
52
22.6
No record
SH
Family care
6
55
20.2
Phenothiazine
su
B
7
51
19.0
Phenothiazine
su
B
8
55
12.2
No record
su
C
9
51
12.2
Phenothiazine
su
10
63
9.7
Phenothiazine
Uncertain
B
11
30
2.0
Artane
SP
C
12
47
1.4
Phenothiazine
su
Discharged
13
46
1,2
Phenothiazine
SP
Discharged
Median
53
18.0
Median
Drug
Diagnosis
Terminal position
Female patients
a Schizophrenic,
undifferentiated.
b Schzophrenic,
paranoid.
CSchizophrenic,
hebephrenic.
* Severe mental deficiency with psychosis. e Schizophrenic,
catatonic.
f Mild mental deficiency. g Chronic brain syndrome with psychosis.
Removed
PEXFORMANCE
ON A TOKEN ECOMONY
PSYCHIATRIC
WARD:
A TWO YEAR SU?dMARY
5
WARD RULES During the first month of the program all patients (only males) lived by the same rules. After the first month the patients were divided into three groups on the basis of their behavior. There were different rules for the different groups. Group A patients functioned at the highest level. They were off the token program, usually lived in private rooms in another building, were employees of the hospital, ate with the other employees and were expected to make plans to leave the hospital. They were returned to Group C if they failed to perform the expected activities. Group B patients lived on the token ward and earned tokens. They had ground and town privileges, could make home visits, could sleep in individual rooms and could attend all hospital recreational functions. They worked off the ward in the hospital kitchen, laundry and maintainance building. They could move to Group A if they earned 10,000 tokens within any 1l-week period. They were returned to Group C if they failed to earn 700 tokens per week for 2 consecutive weeks. Group C patients lived and earned tokens on the ward. They were restricted to the ward except for meals (which were served in a central patient dining-room), for special hourly work assignments and for special recreational functions. They could move to Group B if they earned 2000 tokens in any 3-week period. Tokens were paid to the patients at three daily pay stations. At the 7 a.m. Pay Station they could earn 5 tokens for having brushed their teeth, 5 for being shaved (or wearing appropriate makeup), 5 for having combed their hair, 5 for wearing neat clean clothes and 5 for being on time at the pay station. At the 11 a.m. Pay Station patients could earn 15 tokens for their behavior at breakfast. Meal time eating behavior was scored in three categories (5 tokens each): (1) eating quietly, not gulping food and spending at least 15 min in the dining hall, (2) tray tidy at end of meal and (3) clothing and face not soiled. They were also paid for making their bed (5 tokens) and for any occupational or industrial (work) therapy (10 tokens per hour) they had completed during the morning at the 11 a.m. Pay Station. At the 4 p.m. Pay Station patients could earn 15 tokens for lunch eating behavior, and 10 tokens per hr for afternoon work. At an 8:30 p.m. bed check, patients could earn 5 tokens for having bathed and another 5 for changing clothing. Patients in Group B were paid 10 tokens for being dressed and out of bed at 8 :30 p.m. ; patients in Group C could earn 15 tokens depending upon the condition of their bed, their personal appearance and their being out of bed at 8 :30 p.m. During the evening patients were periodically observed and paid immediately for engaging in conversation or other social behavior. They could earn 10 tokens each time they were observed in social interaction. From time to time individual patients were placed on special shaping programs for which they were paid immediately. Sometimes cigarettes or soft drinks were also given with the tokens on these shaping programs. A particular behavior would be subdivided into smaller response units and the patient would gradually be required to perform more and more of these response units as the shaping program continued. Shaping tokens were never counted towards moving from one group to another. Medications were dispensed three times daily. Patients were paid 10 tokens each time for taking medications. A patient could always be paid less than the allowed tokens for a given activity. For example, although he could earn 5 tokens for brushing teeth a patient could receive fewer tokens if he had not used toothpaste or a brush.
6
KENNETHE.
LLOYD
and LEONARD
ABEL
At the pay stations the patients also paid for those activities in which they wished to engage. They purchased their meals (20 tokens for breakfast, 40 for lunch and 30 for supper), they paid room rent (30 per week) and they paid any fines for refusing to comply with requests. They paid for elective behavior (c.,.0 10 tokens to sit in a favorite chair for-J hour or to lie on the floor for f hr) and for recreational activities (e.g. 10 tokens per hr to watch television). Tobacco, clothing and other personal items were purchased during scheduled office hours. Excess tokens could be placed in a bank account. All token transactions were recorded on a daily pay station form. Total earnings minus fines and shaping tokens were computed for each patient each day. These totals were summed each week to obtain a weekly earnings score. This score was plotted on each patient’s graph which was displayed on the ward. These weekly scores were the basis for moving patients from group to group. RESULTS Three response measures will be reported. These are: (1) the relationship between terminal position and age, years-in-hospital, drug and diagnosis; (2) time out of hospital and (3) movement patterns from one ward status to another. TERMINAL
WARD
STATUS
The last column in Table 1 indicates the position of each patient after 27 months. There were five possible terminal positions, that is, a patient could be out of the hospital, in Group A, Group B or Group C or could have been removed from the program. The median age for all patients was 53 yr. The median ages for the five terminal positions was 53, 53, 53,41 and 53 respectively. The median years-in-hospital for all patients was 18 yr. The median years-in-hospital for the five terminal positions was 8, 18,21,13 and 18 respectively. The number of patients (both male and female) in these five positions was 13 discharged, 6 in Group A, 12 in Group B, 12 in Group C and 9 removed from the ward. Two-thirds (35) of all patients were taking a phenothiazine derivative drug and one-fourth (13) were taking none (or no record). These 48 patients were distributed proportionally across all five status categories (13, 6, 11, 9 and 9, respectively). Eighty-four per cent (44) of all patients were diagnosed undifferentiated or paranoid schizophrenia. These patients were also distributed proportionally across all five status categories (12, 5, 12, 8 and 7, respectively). There were only two discernible trends in these comparisons: first, patients in Group C were younger and had been in the hospital a shorter period of time and, second, discharged patients had been in the hospital a shorter period of time. However, although the median years-in-hospital for Group C and for discharged patients was lowest, these patients varied continuously from O-3 of a yr to over 30 yr in the hospital. TIME
OUT-OF-HOSPITAL
Time out of the hospital on temporary visit, family care, or discharge is another measure of patient performance. The rules of the token economy ward clearly specified how a patient could leave the hospital. The rules for leaving the hospital on other wards were less specific. This means that time out of hospital before the program began and time out of hospital during the token program did not necessarily measure the same behavior changes. For the males 7 had been out of the hospita1 prior to entering the token ward. After entering the
PERFORMANCE
ON A TOKEN
ECOMONY
PSYCHIATRIC
WARD:
A TWO YEAR
SUMMARY
7
token ward 12 males (including 5 of the 7 who had been out before) were released. The proportions of time (during which all males were out of the hospital) were 0.09 before and 0.16 after entering the token economy. For the females, 3 had been out before and 4 after yielding proportions of O-04 and 0.11, respectively.
MOVEMENT
PATTERNS
Patients could move up or down within the program in six possible patterns. They could move upward from Group C to Group B, from B to Group A, from Group A to Discharge and they could move downward from Discharge, or from Group A or from Group B to Group C. There were 113 male moves and 38 female moves. Of all the male moves, 63 per cent were upward moves and 37 per cent were downward moves. Of the female moves 71 per cent were upward moves and 29 per cent were downward ones. The majority of moves (103) were from Group C to Group B (60) and from Group B to Group C (43). The upward moves from Group B to Group A and from Group A to Discharge, 21 and 18, respectively, were similar in frequency. The downward moves from Group A to Group C and from Discharge to Group C, 6 and 3 respectively, were also similar in frequency. Inspection of the movement patterns of individual patients indicated that they could be grouped into four categories based on how they moved from group to group. These movement patterns are illustrated in Fig. 1. Patients 30M and 4F (cf. Table 1, Column 1) in Fig. 1 were typical of a group of 7 males (1, 20, 23, 24, 27, 30, 35) and 3 females (3, 4, 8) who were predominantly in Group C although they did move to Group B for short periods of time. Patients 4M and 6F represent a group of 7 males (4, 9, 1 I, 13, 21, 34, 38) and 3 females (2, 6, 10) respectively, who were predominantly in Group B although they did fall to Group C occasionally. Patients 33M and 13F were in a group of 9 males (3, 7, 16, 19, 22, 25, 26, 33, 36) and 3 females (5, 12, 13) who progressed rapidly through the token ward into Group A and then either left the hospital (5 of 9 males and all 3 females) or remained in Group A. Patients 12M and 7F represent 5 males (6, 12, 15, 28, 32) and 2 females (7, 11) who progressed to Group A or out of the hospital (2 males and 1 female) and later returned to Group C. These groupings of patients account for 28 males and 11 females. Of the remaining 13 patients, 7 males and 2 females were removed from the ward because of illness or severe behavioral disturbances and 4 males (5, 10, 31, 37) had been originally placed in Group A and subsequently discharged from the hospital without ever being in Groups B or C.
DISCUSSION The rules of a token economy ward were discussed, the patients living in it were described and three response measures were presented. No relationship was observed between a patient’s terminal position and his drug prescription or psychiatric diagnosis. Patients with fewer years in the hospital tended to be in Group C or Discharged. The proportion of time the patients were released from the hospital increased after they were on the token ward even though the criteria for release were more stringent than before the token economy was initiated. Two-thirds of all changes in ward position represented an increase in socially acceptable behavior. The lack of a consistent relationship between terminal position and age, time in hospital, drugs or diagnosis may indicate that such traditional variables are simply not closely
KENNETHE.
and
LLOYD
LEONARD
4M
0
10
ABEL
33
20
30
45
M
12 M
50
Weeks
4F
FIG. 1. Tokens earned each week for one typical male (M) and female (F) patient from each of four categories of patient movement patterns. If a patient remained within a given group for a long period of time rhen that portion of his data is omitted as noted. Patient numbers refer to the numbers in the first column of Table 1. The horizontal lines drawn in each graph indicate the dividing line between Groups C and B and Groups B and A.
related to the day to day behavior of patients. The changes in ward status during the program were equivalent to number of tokens earned and were directly related to the day to day behaviors of the patients. These changes indicated an overall improvement in patient performance. The number of tokens earned has been shown to be directly related to the manner in which the rules of the token ward have been established (Lloyd and Garlington, 1968). Although the data presented here were in support of a token economy ward many features of the program need to be evaluated. Many rules of the ward were established in an arbitrary manner. Dividing patients into groups may not be necessary. The individual shaping programs could perhaps be eliminated if the overall rules were more appropriate. This would be especially true in the case of fines. Sometimes ward personnel would attempt unsuccessfully to rely on tines rather than adequately shape performance. The program described here stressed personal appearance and work habits. It may be important to weigh verbal behavior and social interaction more heavily. The present program also tended to emphasize leaving the hospital as contrasted with simply maintaining a high level of behavior on the ward. With patients as old as these finding employment outside the hospital is difficult. More important than discharge may be identifying the variables that contribute to the bigb frequency of movements between Groups C and B.
PERFORMANCE
ON A TOKEN
ECONOMY PSYCHIATRIC W*D:
A TWO YEAR SUMXUY
9
Much of the traditional behavior between ward attendants and patients was altered on the token ward. Attendants learned to talk in terms of changing behavior rather than speculating about the etiology of behavior. They discussed the relationship of environmental events to behavior rather than the relationship of mental events to behavior. They became as conscientious in recording behavioral data as they had been in recording medical data. Finally, the establishment of explicit rules relating what a patient may do if he behaves in a specified way removes many of the ambiguities often associated with a patient’s position in the hospital or with the possibilities of his being released from the hospital. REFERENCES I. M. and KUSNER L. (1968) Preliminary report on the application of contingent reinforcement procedures (token economy) on a “chronic” psychiatric ward. J. abnorm. Psychol. 73, 37-43. AYLLON T. and AZRIN N. (1968) The Token Economy. Appleton-Century-Crofts; New York. BROWN G. W. (1960) Lenah of hosDita1 stay and schizoohrenia: A review of statistical studies. Acta ATTHOWE
Psychiat. N&rol:
&and. 35, 41G30.
_
HONIGFELDG. and GILU R. (1967) The role of institutionalization
in the natural history of schizophrenia.
Dis. New. Syst. 28, 660-663.
LLOYD K. E. and GARLINGTONW. K. (1968) Weekly variations in performance on a token economy psychiatric ward. Behav. Res. & Therapy 6,407AlO. PAUL G. L. (1969) Chronic mental patient: Current status-future directionsdq&ol. Bull. 71, 81-94. PREMACKD. (1959) Toward empirical behavior laws: 1. Positive reinforcement. Psychol. Rev. 66,219-233. SCHAEFFERH. H. and MARTINP. L. (1969) Behaviornl Therapy. McGraw-Hill, New York.