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Token economy systems: Breakdown and control
Fkhav. Res. k Therapy,
1973. Vol. I I,
pp. 253
to 263. Ptrgaman
Press. Printed in England
TOKEN ECONOMY SYSTEMS : B~AKDOWN AND CONTROL* JOHN HALL
and
ROGER BAKER
Departments of Psychiatry and Psychology, University of Leeds, England
(Received 7 December 1972) Summary-Attention is drawn to the relatively high rate of breakdown of token economy programmes, and the reasons for this are considered. Reference is made to the results of a questionnaire circulated to British token economy programmes. Reasons for breakdown are considered in five categories, these being: nonexistent or poor patient selection; inadequate selection and training of nursing and ward staff; lack of definition of the functions of the supervising psychologist; poor co-operation from, and communication with, administrative staff; and active interference by the community. Solutions to these problems are suggested. The value of alternative or additional theoretical frameworks in promoting positive control of token systems is discussed.
TOMENEconomy programmes have been described by Krasner (1968) as “the most advanced type of social engineering currently in use”. It is an unfortunate fact that these forms of engineering seem especially prone to breakdown-in the engineering sense, of course. Tinkerings by psychologists, psychiatrists, and others have not prevented several of these advanced social engineering projects grinding to a halt. Token economy systems are essentially group applications of behaviour modification procedures, using tokens to reinforce new and more appropriate patterns of behaviour. The form of the token is not important, since it is only a medium of exchange, providing access to the ultimate reinforcers, which for chronic psychiatric patients typically include cigarettes and the opportunity to sit quietfy without being disturbed. Stenger and Peck (I970), in their review of twenty-seven active Veterans Administration programmes, noted that eight other programmes had been terminated. Paul (1969) mentioned two well-designed American token systems, those of Hughes, and of Hallsten and Fletcher, which had to be abandoned after early starts, even though Halisten and Ftetcher’s proposed scheme had won an award. There are now token economies in Britain that have been running continuously for up to four years, although some came to a halt, often for reasons unconnected with their therapeutic efficiency. It is curious to find, so soon after the general acceptance of token economy programmes, that articles are-appearing with such titles as “How to Make a Token System Fail” (Kuypers ef al., 1968) and “Problems and PitfaIls of Establishing an Operant Conditioning Token Economy Programme” (Montgomery and McBumey, 1970). It is equally confusing to read that “all staff involved in the token economy programme voted to discontinue the programme” (C. M. Bowdlear, personal commun., 1972.) Perhaps Krasner’s analogy of an engineering system is not so inappropriate after all. A token economy can be regarded as a machine which delivers the goods as required when the correct psychological button is pressed. After construction the machine needs periodical l We gratefully acknowledge the support of the MedicalResearch Council. the Mental Health Research Fund, and the Department of Health and Social Security.
I1.R.T.
I l/3--*
253
254
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HALL
and
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BAKER
maintenance and new parts. As the parts become more complex, it is necessary to have someone well trained in the wiles of such machines to keep a general eye on things. We want to inspect the mechanics of a token system to identify the main components. If these are not properly maintained, the whole machine is likely to break down. In the words of Miron (1966), these particular components may be endowed with considerable “sabotage potential”. This inspection is based in part on the present authors experience in initiating and maintaining two token economy programmes for chronic psychiatric patients: in part on the accounts that others have published of their difficulties with token and operant programmes: and in part on the results of a questionnaire which was circulated to the organisers of hospital-based token and ward operant regimes in the United Kingdom and Ireland in late 1972. Comments referring to present practice in Britain are made from an analysis of completed questionnaires from twenty-one separate institutions, covering twenty-eight programmes. Fourteen of these pro~ammes were in psychiatric hospitals, thirteen in hospitals for the mentally handicapped, and one in a comprehensive children’s hospital. The examples are derived from hospital-based programmes, but the discussion is relevant to schools for delinquents for example, with appropriate translations in terminology where necessary. There appear to be five components of token economies in hospitals that are IikeIy to lead to failure. There are the patients themselves, the subjects of the programme. Secondly, there are the nursing and ward staff, the personnel who constantly interact with and care for the patients.* Thirdly, there are the psychologists or psychiatrists, responsible for the direct organisation and supervision of the programme. Fourthly there are the administrators, removed from the direct therapeutic situation, yet capable of controlling major aspects of the programme. Lastly there is the community, the relatives of the patients and indeed anyone who can communicate directly with the patient. The pafients Peck and Thorpe (1971) have pointed out the high degree of stimulus control exerted by the ward environment, staff, and other patients on an individual patient, and the consequent desirability of commencing programmes with at least some change of staff or patients. AylIon and Azrin (1968) picked their patients by asking the ward staff of their hospital which patients they would like transferred out of their ward. This simple process resulted in the transfer of, in their own words, “the old, the idle, problem patients, the mute and the garrulous”. We have found that ward nursing staff are only too willing to suggest patients for another ward, though they have no idea of the purpose of the ward, or what type of patient is actually being sought. Other studies have also used groups of patients which are extremely heterogeneous. For example, the ages of patients in the study of MeReynolds and Coleman (1972) ranged between 18 and 83 years. The length of hospitalization of the patients in Heap et al’s. (1970) study, ranged between 5 days and 30 years. Lack of positive selection of patients may have several undesirable consequences. A considerable strain may be placed on the nursing staff by requiring them to cope simultaneously with a wide range of behavioural problems from patients with widely differing capacities to benefit from a token programme. In such a situation staff need to acquire and maintain a highly complex set of individual responses. The range of problems presented by l The proportion of nursing and ward staff that is trained is greater in British psychiatric hospitafs than in American hospitals. In the British programmes reviewed only 21% of all ward staff were untrained. 56% of staff were registered or enrolled nurses and 23 ‘A were trainee nurses.
TOKEN
ECONOMY
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SYSTEMS
unselected patients may require further sub-division or grouping of the patients. It may require the development of assessment procedures capable of being sensitive to change for all levels of patient. Such heterogeneous groups of patients also make it difficult to establish meaningful statements about the type of patients likely to derive most benefit from token programmes. Some positive criteria for the selection of patients should therefore be sought if possible. Although positive criteria appear desirable, less than half of British programmes have had free choice of patients (see Table 1 (i)). TABLE
I. CHARACI-ERISTICS
OF BRITISH TOKEN
(All figures are
ECONOMY
AND
OPERANTLY
BASED
WARD
percentages)
PROGRAMMFS
%
N
(i) Degree of selection of patients in programmer
No choice of patients possible Limited choice possible Free choice possible
33 22 45
27
(ii) Degree of selection of ward staff by supervisory staff
Selection of Staff possible Selection not possible
24 76 1
25
(iii) Degree of supervision of programme by psychologists
Psychologist has full-time or major responsibility for programme Psychologist has only part-time responsibility for programme No psychologist associated with normal operation of programme
53
(iv) Degree of control of ward staff
(v) Adequacy of communication and co-operation with administrators, as viewed by supervisory staff
29
Medical administrators Nursing administrators LaY administrators
Satisfactory
1
Yes
No
55
45
22
46
54
24
Ward staff may relieve on other wards Ward staff may be allocated to other wards without consultation Good
28
18
Poor
Uncertain
69
23
8
0
26
50
34
12
4
26
38
27
31
4
26
Apart from these general problems posed by heterogeneous samples of patients, unresponsive patients pose a more specific problem. Many studies note the existence of groups of patients who fail to respond even to the most stringent contingencies. It has been suggested that this group of non-responders includes, for example, the catatonically withdrawn (Atthowe and Krasner, 1968), and the paranoid (Liberman, 1968). Cotter (1967), in his report of the use of operant conditioning in a Vietnamese hospital, found that after twenty electro-convulsive shock treatments, delivered as negative reinforcement, there were still non-responders. He found that three days total starvation produced one-hundred per cent response rate. Perhaps even these patients wouldn’t have responded if they had known that discharge to the community was, for them, work in an Army-defended farm, surrounded by
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HALL
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BAKER
the Viet-Cong! Kazdin (1972), from a different viewpoint, has stressed the value of individualized contingencies and specialized procedures to reduce. non-responsiveness, but there is a practical limit beyond which such procedures are incompatible with a programme suitable for more responsive patients. Both the general and specific ptobiems are illustrated by Allen and Magaro’s (1971) analysis of changes in a token economy programme. Thirty-nine unselected patients were subjects for a study examining the effects of different contingencies. Nine patients (23%) responded very quickly with no token contingency at all. Another nine patients responded later at a slower rate, but still in the absence of a positive token contingency. So 46 % of the patients produced the desired target behaviour without any positive token reinforcement. Only five patients responded at the next stage, when payment by tokens was introduced. Sixteen patients, or 41% of the group, never responded at all. It is clear from these results that only 13% of the group of patients responded uniquely to the token contingency. A deduction that could be drawn from this is that the use of tokens as reinforcers may be most appropriate for some intermediate group of patients. Tokens may be less relevant for other groups, in this case for very rapid responders or very slow responders. Apart from this relatively passive form of sabotage, patients can influence a token programme in more subtle ways, Bye and Bernal (1968) have shown that the affective components of a patient’s response to a nurse influence the way in which that nurse rates the patient behaviourally, so that a “warm” response to the nurses is associated with a rating of more positive and adaptive behaviour. Patients can “play the system”, by exploiting gaps in the operant conditioning regime. In Aylion and Azrin’s (1965) experiment patients spending exceeded earnings in individual cases by over 80 per cent during the first twenty days of their third experiment. In that experiment the eight patients with the highest earnings earned in total 10,846 tokens, but spent 12,715 tokens. The eight patients with the lowest earnings earned 349, and spent only 150. Ayllon and Azrin noted that lending and borrowing of tokens between patients could occur. When it does happen on such a large scale, relative to the earnings of some patients, it becomes difficult to relate token earnings and spending to the actual performance of the patient. A patient in our own first study, in which only tokens circulated as ward currency, regularly bought bottles of Lucozade (a proprietary glucose drink} from the ward shop. Having drunk the contents, he took the empty bottle to the cash-based hospital shop and collected the deposit on the bottle. A second patient removed gift vouchers from the packets of cigarettes which he bought at the ward shop, and exchanged the vouchers for more cigarettes with a nurse on another ward. Another patient, a high-level token earner, was able to become a minor “lobacco baron”, and we had considerable trouble in keeping patients from other wards from trading with him in his bed before he got up in the morning. Events such as these led us to evaluate carefully any deviations from the system, as apparent violations of the programme may actually indicate the emergence of adaptive behaviour. Nursing and ward staff
Miron, to quote him again, thinks that “ward nursing staff, and especially the ward charge nurses, are the most crucial personnel involved in any treatment programme”. We agree with him. Nurses, aides, and other ward staff who are not favourably disposed to particular treatment regimes can completely disrupt them. Montgomery and McBurney “were af3icted with one overtly hostile employee, who regularly expressed her dislikes of the programme. Another technician was untruthful, unreliable, and a violator of all precepts
TOKEN
ECONOMY
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257
of operant conditioning”. Thesetwostaff membersmanaged to hamper thewhole programme until they were replaced. Suchotliff, et al. (1970) set up token economy programmes in two different wards. In one ward the patients improved, in the other they did not. They attributed this to differences in the attitudes of the two sets of staff involved: the staff on the ward where the programme failed had significantly more custodial care attitudes than ‘he other staff. These results suggest that at least some selection of staff is advisable, yet threequarters of British programmes have had no choice in the staff allocated to the programme (see Table 1 (ii)). There is increasing evidence that, left to their own devices, ward staff do not interact with patients in a way that is therapeutic, viewed from a behavioural standpoint. They may interact with their patients so that a considerable proportion of deviant behaviour is positively reinforced (Gelfand ez al., 1967), they may just ignore the patients (Katz el al., 1972), or they may positively reinforce dependent, rather than independent, behaviour (Mikulic, 1971). Unless these staff are trained carefully they may therefore fail to carry out an operant programme appropriately. Most British training programmes are based on talks by psychologists, the use of handouts and literature, and demonstration and practical sessions. The content of these programmes emphasizes the application of operant procedures, appropriately enough, but it is easy to neglect other factors. Since individual contingencies for specific deviant acts may still leave the patient inactive for most of the day, provision of a structured activity programme is important in maintaining therapeutic potential. The poor reliability of rating scales may obscure any real change in the patient, so accurate recording of observed behaviour is important in providing reliable data. Training in these areas may together be as important as training in operant conditioning. Often staff training is intensive at the beginning of a programme, but falls off later. Nursing staff, even after careful training in behavioural procedures, may not fully understand the implication of their own observations in planning further changes in treatment regimes. Bok (1971) for example, showed that nursing staff did not recognise the relationship between their ratings of the activity of patients, and the patient’s preparedness for discharge. Nursing staff may also come to apply procedures rigidly, so that, for example, “some staff members became quite rigid and soon saw the patient not as a person but as a number of categories” (Wild, 1969). Nurses probably need in most situations a degree of guidance and supervision from someone more sophisticated psychologically. The supervising psychologist
Most token programmes in Britain are supervised by clinical psychologists, though a number have little, if any, contact with psychologists (see Table 1 (iii)). British psychologists have not historically been closely involved in central hospital administration, but running a token economy programme is quaranteed to increase such involvement. Closer involvement between psychologists and nursing staff is a further consequence of these programmes. This probably contributes to one of the most commonly reported findings of a token programme, which is that staff morale shows marked improvement (e.g. McReynolds and Coleman, 1972). Indeed, one of the returned questionnaires stated that the amount of time spent by the psychologist on the ward was the main factor in the success of the programme. If the psychologist reduces or eliminates this time, staff morale is likely to suffer, thereby threatening the efficiency of the programme. Nurses need reinforcing too! In a token system, the exact nature of the responsibilities of various members of the
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and
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BAKER
treatment team may not be clear. Responsibility for reallocation of patients to different groups, for regular analysis of data, for planning the activity programme for the patient, all need to be defined. Arran (1971) found that data collection unfortunately ceased for eight days in the middle of his second experiment, his many other duties preventing him from being able to check that ‘data was being collected appropriately. It may be unreasonable to expect nurses to take full responsibility for treatments and procedures whose full implications they do not appreciate. Psychologists in Britain have only recently begun to clarify the legal nature of the responsibilities they have acquired. In delegating these responsibilities they may be helped by the British Royal College of Nursing (1970) booklet concerning the legal position of the nurse with respect to new treatments. The administrators
Problems arise when anyone outside the ward situation can make an administrative decision directly bearing on the token programme. In the British hospital situation the administrative staff concerned fall into three groups. The first group is the senior nurses, whose decisions can have a major effect on the functioning of a programme. Ellsworth and Ellsworth (1970) suffered a significant drop in the therapeutic effectiveness of their programme when the nursing administration made unexpected changes which affected staffing levels. Torpy (1972) has suggested that in longstay wards deviations in actual staffing, either upwards or downwards, from average staffing levels increase the level of disturbance of the patients. Planned movement of trained staff admittedly helps in increasing acceptance within a hospital of operant and token economy procedures. Unplanned movement places a strain on the staff who remain, and also on the effectiveness of staff training. At least a year is needed, in our experience, for ward staff to acquire an adequate understanding of these procedures. The most frequent comment offered by those returning the questionnaire was that close co-operation with the nursing administration is essential for the success of a programme. In practice, however, in half the British programmes nursing staff may relieve other wards, and may be allocated to other wards without adequate warning (see Table 1 (iv)). The second type of administrator is the doctor. Medically qualified staff often retain the right of admission, transfer, and discharge to and from long-stay wards, even though they have little therapeutic contact with the ward. Bowdlear’s (1971) programme was sabotaged by the referral of inappropriate patients to his programme, whom he was powerless to refuse. The usual system of medical cover means that at certain times of the day or week junior medical staff, unfamiliar with the main ward programme, may order medical treatments or procedures to be carried out. Some treatments, such as changes in psychotropic drugs, may interfere fundamentally with the adjustment of a.patient to a token programme. It is essential to clarify the role of medical staff in relation to the programme, and to ensure a system of medical coverage so that unforeseen treatment changes are at least minimized. The third group of administrators includes Hospital Secretaries, Supply Officers, Laundry Managers, em-the lay administrators, in other words. Basic to a token economy is ready availability and control of reinforcers. For psychiatric and mentally handicapped patients, young and old, such reinforcers in the hospital setting typically include cigarettes, food, sweets, and small amounts of cash. Unfortunately it is precisely these things, which must be controlled for a token economy to be efficient, that in Britain are under the control of lay administrators. It is a paradox that this advanced form of management for patients relies to a considerable extent upon the co-operation of staff least fitted by experience to
TOKEN
ECONOMY
SYSTEMS
259
understand it. Such a restriction on the effective control of reinforcers in the programme may be especially important for those patients who are less sensitive to social reinforcement, and are therefore most reliant on material reinforcers. It may be significant that while most British programmes have had good or satisfactory relationships with medical and nursing administrators, communication and co-operation with lay administrators has been worse (see Table 1 (v)). The outside community The problems presented to an operant programme by an antagonistic community have been described most vividly by Henderson (1969). In attempting to set up a communitybased programme he found himself besieged by local government inspectors. There were two different sets of inspectors, each with differing requirements, since the exact status in the regulations of a community operant programme was not clear. The inspectors were most conscientious in examining the plumbing and wiring: the fire alarm system had to be reinstalled three times before both sets of inspectors were satisfied. It later emerged that local residents with influence on city councillors had initiated these thorough visits. Apart from the obvious difficulties posed by such opposition, staff became apprehensive even of the telephone, fearing a complaint, and patients attempted to control the staff by threatening to behave psychotically in the local streets. Such problems that we have faced seem minor by comparison, but we have had continuing difficulty with the relatives of patients smuggling in goods, although we explained to all of them that we would prefer this not to happen. The brother of one of our patients regularly enticed him out for week-end drinking sessions, which were invariably followed by nocturnal incontinence on the part of the patient. The part played by other nursing staff in a hospital should not be neglected. Student nurses regularly arrive on our ward for their three month spell already primed by the reactionary charge nurse of their previous ward. The delusional system of one of our patients was fanned into verbal flame by one member of the staff who told him “I wouldn’t trust ‘em if I were you, they’re trying to control your mind.” Another patient, following his usual adequate meal, complained to a nurse supervising an off-ward assignment that his recent disturbance of behaviour, and lack of sleep, was due to him missing a meal. The nurse thereupon expressed his own hostile attitudes towards the token system, increasing the patient’s disturbance even more. DISCUSSION Five components of a token system which are considered to be potentially major factors in breakdown of the system have been examined. This examination leads to three conclusions. No investigator has attributed breakdown of a token system to the inappropriateness of operant conditioning theory, or to the inadequacy of the specific derived procedures. In other words, the merit of operant methods as a basis for the remotivation of the chronic mentally ill and handicapped has not been questioned. Technical problems, such as difficulty in obtaining reliable data, or the failure of equipment, have apparently not been the main causes of breakdown. The last conclusion to be drawn from this examination is that breakdown has occurred because of human failure, for reasons unconnected with operant conditioning. These failures have mainly concerned an inability to control the central operant conditioning process, and the factors affecting it. Improved control would involve both a reduction of the problems already discussed, and a positive attempt to integrate
260
JOHNHALL
and ROGERBAKER
these factors into the therapeutic programme. The problems already mentioned have a parallel set of solutions. Unsuitable patients should be eliminated by appropriate selection at all stages of the programme. StafTrunning the programme should have the right to select patients, and ought to be able to define the characteristics of patients considered suitable. Several selection criteria have been suggested, including the use of verbal conditioning tests (Krasner, 1968), pre-runs of token programmes on potential patients (Allen and Magaro, 1971), and clinical assessments of the liklihood of response by individual patients (Nevin 1970). Strain on the nursing staff is further minimized by keeping groups of patients relatively homogeneous. If any patients continue to avoid some contingencies, the ultimate consequences of their actions need to be identified, and modifications made accordingly. Ward staff should preferably be specifically chosen for the work on the basis of interest, ability, and attitudes. Personality and attitudinal criteria for the selection of nursing staff for behaviour modification assignments have been suggested by Loy (1969) and Hall (1971) respectively. An additional approach to ensuring effective staff-patient interaction is to reinforce staff performance systematically (Katz et al.) Reinforcers can be material, such as extra pay or free time, or by means of providing feedback, via charts and other means, to show that patients are changing. Staff who are not keen on token regimes should at least be given an opportunity to change wards. Thorough training should be given to all ward staff involved, and this training needs to continue over a considerable period of time. While most psychologists are used to teaching students of high ability, psychologists teaching nurses need to adapt the presentation of their material to the more practical concerns of student nurses, avoiding an approach that may be too academic and theoretical (Ellsworth and Ellsworth, 1970). Outlines of effective training programmes incorporating use of videotapes, the analysis of the behaviour of individual patients, and the completion of programmed texts are increasingly available (Epling et al., 1972). Psychologists or psychiatrists supervising token programmes need to clarify their own responsibilities to ward staff, and the reciprocal responsibilities of the nurses. Regular and effective communication with all ward staff preserves staff morale, and ensures that procedures are correctly carried out. Establishment of a minimum acceptable level of staffing, and the reduction of unanticipated staff changes, are two of the most effective steps that can be taken to ensure the maintenance of a programme. Solutions to the problem of under-staffing include the use of a “flying-squad” of specially trained staff (Gripp and Magaro, 1971), and the use of students or voluntary workers, but neither of these are real substitutes in the long-term for inadequate staffing. Collaboration with medical staff is necessary to clarify admission and discharge procedures from the programme, and to prevent unnecessary treatment changes. Lay administrators need a full introduction to the rationale of the token system, and may require assurance that adequate safeguards exist if control of cash or food is sought. Both patients and staff on a programme are likely to encounter ambiguous or hostile comment from people outside the programme. Ambiguity may result from ignorance, and can be tackled by disseminating information about the programme. The Minnesota Guidelines for behaviour modification projects (Vail, 1970) recommend that such projects should be as open as possible to public inspection. The problems and solutions so far identified have been concerned with people. The identification of these people was carried out by analysing our own and other people’s experience, so the remedies suggested are essentially pragmatic. We have not attempted to
TOKEN ECONOMY SYSTEMS
261
co-ordinate in a systematic manner the actions of these people with the central therapeutic process. If such a co-ordination were carried out, certain requirements would need to be met for the co-ordination to be satisfactory. These would be the further identification of all people and events that influence the central process: a comprehensive examination of the token economy in context would be required. Further, these people and events must be specified in such a way that analysis of their interaction is possible. Lastly, this identification and specification must generate procedures which can be put into practice. These requirements might be met by using an alternative, or additional, frame of reference for examining behaviour modification programmes. Winkler (1971) has already suggested and elaborated the use of a model taken from economic theory. An economic model encompasses certain facets of token systems, such as the nature of inflation and the relationship between earning levels and spending, which are not so readily explained in the language of operant conditioning. The economic model has been further developed (Kagel and Winkler, 1972) to the point where specific practical procedures have been generated which increase the effectiveness of a token system (Winkler, 1972). Tenbrunsel (1969), to use his own words “developed a programme which combined the positive aspects of both the operant and cognitive paradigms”. O’Keefe (1971) examined this approach and developed it further, though not to the same degree as the development of the economic approach. A further alternative framework that appears promising is systems theory. The theory essentially is concerned with the principles governing processes of mutual interaction, irrespective of the nature or content of these processes. This type of approach would permit an examination of the network of phenomena and interactions surrounding the central operant conditioning process, without necessarily investigating that process itself. Hibbert and Henderson (1971) introduced the idea of systems theory in their analysis of changes in an individual patient under a token economy regime. Caste11 (1970) has examined the relevance of systems theory methodology to behaviour therapy in some detail, and he pointed to the advantages that could be obtained from such a methodology. The introduction of alternative theoretical frameworks and languages such as these might well enable satisfactory co-ordination between external factors and the central process to occur. There is a danger that operant conditioning, in its application to human problems, may become, a “closed system”, in systems theory language, which is isolated from other areas of psychological enquiry. Krantz (1971) drew attention to this danger in his analysis of the number of self-citations of reference sources given in two operantlyoriented journals, the “Journal of the Experimental Analysis of Behaviour”, and the “Journal of Applied Behaviour Analysis”. By an increasing degree of self-reference, these journals are less able to draw from psychological knowledge in other areas. Similarly, ignoring factors outside the conditioning process is likely to impair the efficiency with which the process is implemented. Introducing other approaches would encourage the development of an “open system”, where continual transactions with the environment in an adaptive, self-regulatory fashion could occur. Short of Walden II becoming a reality, with the fundamental social revolution implied by that reality, a controlled environment ultimately has bounds. While some contingencies for patients within the environment can be controlled, contingencies for the controllers of the environment cannot. But it is beyond the bounds of that environment that key components of a token system lie, as far as the risk of breakdown is concerned. An expansion of Krasner’s
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and ROGER BAKER
engineering analogy, or the introduction of other paradigms, may suggest further aids to positive control of operant conditioning programmes without any loss of psychological rigour or precision. As in engineering a machine needs a framework as well as components, so in human engineering we may need to consider psychological frameworks. REFERENCES ALLEN
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MIRON N. B. (1966)Behaviour shaping and group nursing with severely retarded patients. In: reinforcement
theory in psychological treatment-a symposium. (Eds. FISHERJ. and HARRLYR. E.). Research Monograph No. 8, Dept. of Mental Hygiene, State of California. MONTC~OMERY J. and MCBURNEYR. D. (1970) Problems and pitfalls of establishing an operant conditioning token economy programme. Mental Hygiene 54, 382-387. NEMN D. A. (1970) Prediction of response to a token economy treatment programme in a mental hospital. Dissert. Abstracts 2999-B. O’KEEFE R. L. (1971) A behavioural model for chronic mental patients. Unpublished Ph.D. Thesis, St. Louis University. PAUL G. L. (1969) Chronic mental patient: current status-future directions. Psychol. Bull. 71, 81-94. PECK D. F. and THORPEG. L. (1971) Experimental foundations of token economies: a critique. Paper presented at 3rd Behaviour Modification Conference, Wexford. ROYALCOLLEGEOF NURSING(I 970) 7&e duties and position of rhe nurse. London. STENGER C. A. and PECK C. P. (1970) Token economy programmes in the veterans administration. Hosp. & Comm. Psychiatry 21, 371-375. SUCHOTL~FFZ L., GREAVE~S.. STECKERH. and BERKE R. (1970) Critical variables in the token economy. Paper presented at 78th A.P.A. Convention. TENBRUNSELT. W. (1969) A group coupon programme in treating mental illness. Unpublished Ph.D. dissertation, St. Louis University. TORPY D. M. (1972) The individual and the clinical psychologist. Bull. Br. Psycho/. Sot. 25, 309-310. Van. D. J. (1970) Revised guidelines for learning-theory based training and therapy programmes in Minnesota State Hospitals. Office Memorandum, Minnesota State Department of Public Welfare. WILD W. F. (1969) Behaviour modification: a therapeutic milieu for chronic schizophrenics. Hawaii Med. J. 29. 20-26.
WINKLERR. C. (1971) The relevance of economic theory and technology Behav. Res. & Therapy 9, 81-88.
WINKLERR. C. (1972) A theory of equilibrium
in token economies.
to token reinforcement
systems.
J. Abnorm. Psychol. 79, 169-173.
1973. Vol. I I,
pp. 253
to 263. Ptrgaman
Press. Printed in England
TOKEN ECONOMY SYSTEMS : B~AKDOWN AND CONTROL* JOHN HALL
and
ROGER BAKER
Departments of Psychiatry and Psychology, University of Leeds, England
(Received 7 December 1972) Summary-Attention is drawn to the relatively high rate of breakdown of token economy programmes, and the reasons for this are considered. Reference is made to the results of a questionnaire circulated to British token economy programmes. Reasons for breakdown are considered in five categories, these being: nonexistent or poor patient selection; inadequate selection and training of nursing and ward staff; lack of definition of the functions of the supervising psychologist; poor co-operation from, and communication with, administrative staff; and active interference by the community. Solutions to these problems are suggested. The value of alternative or additional theoretical frameworks in promoting positive control of token systems is discussed.
TOMENEconomy programmes have been described by Krasner (1968) as “the most advanced type of social engineering currently in use”. It is an unfortunate fact that these forms of engineering seem especially prone to breakdown-in the engineering sense, of course. Tinkerings by psychologists, psychiatrists, and others have not prevented several of these advanced social engineering projects grinding to a halt. Token economy systems are essentially group applications of behaviour modification procedures, using tokens to reinforce new and more appropriate patterns of behaviour. The form of the token is not important, since it is only a medium of exchange, providing access to the ultimate reinforcers, which for chronic psychiatric patients typically include cigarettes and the opportunity to sit quietfy without being disturbed. Stenger and Peck (I970), in their review of twenty-seven active Veterans Administration programmes, noted that eight other programmes had been terminated. Paul (1969) mentioned two well-designed American token systems, those of Hughes, and of Hallsten and Fletcher, which had to be abandoned after early starts, even though Halisten and Ftetcher’s proposed scheme had won an award. There are now token economies in Britain that have been running continuously for up to four years, although some came to a halt, often for reasons unconnected with their therapeutic efficiency. It is curious to find, so soon after the general acceptance of token economy programmes, that articles are-appearing with such titles as “How to Make a Token System Fail” (Kuypers ef al., 1968) and “Problems and PitfaIls of Establishing an Operant Conditioning Token Economy Programme” (Montgomery and McBumey, 1970). It is equally confusing to read that “all staff involved in the token economy programme voted to discontinue the programme” (C. M. Bowdlear, personal commun., 1972.) Perhaps Krasner’s analogy of an engineering system is not so inappropriate after all. A token economy can be regarded as a machine which delivers the goods as required when the correct psychological button is pressed. After construction the machine needs periodical l We gratefully acknowledge the support of the MedicalResearch Council. the Mental Health Research Fund, and the Department of Health and Social Security.
I1.R.T.
I l/3--*
253
254
JOHN
HALL
and
ROGER
BAKER
maintenance and new parts. As the parts become more complex, it is necessary to have someone well trained in the wiles of such machines to keep a general eye on things. We want to inspect the mechanics of a token system to identify the main components. If these are not properly maintained, the whole machine is likely to break down. In the words of Miron (1966), these particular components may be endowed with considerable “sabotage potential”. This inspection is based in part on the present authors experience in initiating and maintaining two token economy programmes for chronic psychiatric patients: in part on the accounts that others have published of their difficulties with token and operant programmes: and in part on the results of a questionnaire which was circulated to the organisers of hospital-based token and ward operant regimes in the United Kingdom and Ireland in late 1972. Comments referring to present practice in Britain are made from an analysis of completed questionnaires from twenty-one separate institutions, covering twenty-eight programmes. Fourteen of these pro~ammes were in psychiatric hospitals, thirteen in hospitals for the mentally handicapped, and one in a comprehensive children’s hospital. The examples are derived from hospital-based programmes, but the discussion is relevant to schools for delinquents for example, with appropriate translations in terminology where necessary. There appear to be five components of token economies in hospitals that are IikeIy to lead to failure. There are the patients themselves, the subjects of the programme. Secondly, there are the nursing and ward staff, the personnel who constantly interact with and care for the patients.* Thirdly, there are the psychologists or psychiatrists, responsible for the direct organisation and supervision of the programme. Fourthly there are the administrators, removed from the direct therapeutic situation, yet capable of controlling major aspects of the programme. Lastly there is the community, the relatives of the patients and indeed anyone who can communicate directly with the patient. The pafients Peck and Thorpe (1971) have pointed out the high degree of stimulus control exerted by the ward environment, staff, and other patients on an individual patient, and the consequent desirability of commencing programmes with at least some change of staff or patients. AylIon and Azrin (1968) picked their patients by asking the ward staff of their hospital which patients they would like transferred out of their ward. This simple process resulted in the transfer of, in their own words, “the old, the idle, problem patients, the mute and the garrulous”. We have found that ward nursing staff are only too willing to suggest patients for another ward, though they have no idea of the purpose of the ward, or what type of patient is actually being sought. Other studies have also used groups of patients which are extremely heterogeneous. For example, the ages of patients in the study of MeReynolds and Coleman (1972) ranged between 18 and 83 years. The length of hospitalization of the patients in Heap et al’s. (1970) study, ranged between 5 days and 30 years. Lack of positive selection of patients may have several undesirable consequences. A considerable strain may be placed on the nursing staff by requiring them to cope simultaneously with a wide range of behavioural problems from patients with widely differing capacities to benefit from a token programme. In such a situation staff need to acquire and maintain a highly complex set of individual responses. The range of problems presented by l The proportion of nursing and ward staff that is trained is greater in British psychiatric hospitafs than in American hospitals. In the British programmes reviewed only 21% of all ward staff were untrained. 56% of staff were registered or enrolled nurses and 23 ‘A were trainee nurses.
TOKEN
ECONOMY
255
SYSTEMS
unselected patients may require further sub-division or grouping of the patients. It may require the development of assessment procedures capable of being sensitive to change for all levels of patient. Such heterogeneous groups of patients also make it difficult to establish meaningful statements about the type of patients likely to derive most benefit from token programmes. Some positive criteria for the selection of patients should therefore be sought if possible. Although positive criteria appear desirable, less than half of British programmes have had free choice of patients (see Table 1 (i)). TABLE
I. CHARACI-ERISTICS
OF BRITISH TOKEN
(All figures are
ECONOMY
AND
OPERANTLY
BASED
WARD
percentages)
PROGRAMMFS
%
N
(i) Degree of selection of patients in programmer
No choice of patients possible Limited choice possible Free choice possible
33 22 45
27
(ii) Degree of selection of ward staff by supervisory staff
Selection of Staff possible Selection not possible
24 76 1
25
(iii) Degree of supervision of programme by psychologists
Psychologist has full-time or major responsibility for programme Psychologist has only part-time responsibility for programme No psychologist associated with normal operation of programme
53
(iv) Degree of control of ward staff
(v) Adequacy of communication and co-operation with administrators, as viewed by supervisory staff
29
Medical administrators Nursing administrators LaY administrators
Satisfactory
1
Yes
No
55
45
22
46
54
24
Ward staff may relieve on other wards Ward staff may be allocated to other wards without consultation Good
28
18
Poor
Uncertain
69
23
8
0
26
50
34
12
4
26
38
27
31
4
26
Apart from these general problems posed by heterogeneous samples of patients, unresponsive patients pose a more specific problem. Many studies note the existence of groups of patients who fail to respond even to the most stringent contingencies. It has been suggested that this group of non-responders includes, for example, the catatonically withdrawn (Atthowe and Krasner, 1968), and the paranoid (Liberman, 1968). Cotter (1967), in his report of the use of operant conditioning in a Vietnamese hospital, found that after twenty electro-convulsive shock treatments, delivered as negative reinforcement, there were still non-responders. He found that three days total starvation produced one-hundred per cent response rate. Perhaps even these patients wouldn’t have responded if they had known that discharge to the community was, for them, work in an Army-defended farm, surrounded by
256
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HALL
and
ROGER
BAKER
the Viet-Cong! Kazdin (1972), from a different viewpoint, has stressed the value of individualized contingencies and specialized procedures to reduce. non-responsiveness, but there is a practical limit beyond which such procedures are incompatible with a programme suitable for more responsive patients. Both the general and specific ptobiems are illustrated by Allen and Magaro’s (1971) analysis of changes in a token economy programme. Thirty-nine unselected patients were subjects for a study examining the effects of different contingencies. Nine patients (23%) responded very quickly with no token contingency at all. Another nine patients responded later at a slower rate, but still in the absence of a positive token contingency. So 46 % of the patients produced the desired target behaviour without any positive token reinforcement. Only five patients responded at the next stage, when payment by tokens was introduced. Sixteen patients, or 41% of the group, never responded at all. It is clear from these results that only 13% of the group of patients responded uniquely to the token contingency. A deduction that could be drawn from this is that the use of tokens as reinforcers may be most appropriate for some intermediate group of patients. Tokens may be less relevant for other groups, in this case for very rapid responders or very slow responders. Apart from this relatively passive form of sabotage, patients can influence a token programme in more subtle ways, Bye and Bernal (1968) have shown that the affective components of a patient’s response to a nurse influence the way in which that nurse rates the patient behaviourally, so that a “warm” response to the nurses is associated with a rating of more positive and adaptive behaviour. Patients can “play the system”, by exploiting gaps in the operant conditioning regime. In Aylion and Azrin’s (1965) experiment patients spending exceeded earnings in individual cases by over 80 per cent during the first twenty days of their third experiment. In that experiment the eight patients with the highest earnings earned in total 10,846 tokens, but spent 12,715 tokens. The eight patients with the lowest earnings earned 349, and spent only 150. Ayllon and Azrin noted that lending and borrowing of tokens between patients could occur. When it does happen on such a large scale, relative to the earnings of some patients, it becomes difficult to relate token earnings and spending to the actual performance of the patient. A patient in our own first study, in which only tokens circulated as ward currency, regularly bought bottles of Lucozade (a proprietary glucose drink} from the ward shop. Having drunk the contents, he took the empty bottle to the cash-based hospital shop and collected the deposit on the bottle. A second patient removed gift vouchers from the packets of cigarettes which he bought at the ward shop, and exchanged the vouchers for more cigarettes with a nurse on another ward. Another patient, a high-level token earner, was able to become a minor “lobacco baron”, and we had considerable trouble in keeping patients from other wards from trading with him in his bed before he got up in the morning. Events such as these led us to evaluate carefully any deviations from the system, as apparent violations of the programme may actually indicate the emergence of adaptive behaviour. Nursing and ward staff
Miron, to quote him again, thinks that “ward nursing staff, and especially the ward charge nurses, are the most crucial personnel involved in any treatment programme”. We agree with him. Nurses, aides, and other ward staff who are not favourably disposed to particular treatment regimes can completely disrupt them. Montgomery and McBurney “were af3icted with one overtly hostile employee, who regularly expressed her dislikes of the programme. Another technician was untruthful, unreliable, and a violator of all precepts
TOKEN
ECONOMY
SYSTEMS
257
of operant conditioning”. Thesetwostaff membersmanaged to hamper thewhole programme until they were replaced. Suchotliff, et al. (1970) set up token economy programmes in two different wards. In one ward the patients improved, in the other they did not. They attributed this to differences in the attitudes of the two sets of staff involved: the staff on the ward where the programme failed had significantly more custodial care attitudes than ‘he other staff. These results suggest that at least some selection of staff is advisable, yet threequarters of British programmes have had no choice in the staff allocated to the programme (see Table 1 (ii)). There is increasing evidence that, left to their own devices, ward staff do not interact with patients in a way that is therapeutic, viewed from a behavioural standpoint. They may interact with their patients so that a considerable proportion of deviant behaviour is positively reinforced (Gelfand ez al., 1967), they may just ignore the patients (Katz el al., 1972), or they may positively reinforce dependent, rather than independent, behaviour (Mikulic, 1971). Unless these staff are trained carefully they may therefore fail to carry out an operant programme appropriately. Most British training programmes are based on talks by psychologists, the use of handouts and literature, and demonstration and practical sessions. The content of these programmes emphasizes the application of operant procedures, appropriately enough, but it is easy to neglect other factors. Since individual contingencies for specific deviant acts may still leave the patient inactive for most of the day, provision of a structured activity programme is important in maintaining therapeutic potential. The poor reliability of rating scales may obscure any real change in the patient, so accurate recording of observed behaviour is important in providing reliable data. Training in these areas may together be as important as training in operant conditioning. Often staff training is intensive at the beginning of a programme, but falls off later. Nursing staff, even after careful training in behavioural procedures, may not fully understand the implication of their own observations in planning further changes in treatment regimes. Bok (1971) for example, showed that nursing staff did not recognise the relationship between their ratings of the activity of patients, and the patient’s preparedness for discharge. Nursing staff may also come to apply procedures rigidly, so that, for example, “some staff members became quite rigid and soon saw the patient not as a person but as a number of categories” (Wild, 1969). Nurses probably need in most situations a degree of guidance and supervision from someone more sophisticated psychologically. The supervising psychologist
Most token programmes in Britain are supervised by clinical psychologists, though a number have little, if any, contact with psychologists (see Table 1 (iii)). British psychologists have not historically been closely involved in central hospital administration, but running a token economy programme is quaranteed to increase such involvement. Closer involvement between psychologists and nursing staff is a further consequence of these programmes. This probably contributes to one of the most commonly reported findings of a token programme, which is that staff morale shows marked improvement (e.g. McReynolds and Coleman, 1972). Indeed, one of the returned questionnaires stated that the amount of time spent by the psychologist on the ward was the main factor in the success of the programme. If the psychologist reduces or eliminates this time, staff morale is likely to suffer, thereby threatening the efficiency of the programme. Nurses need reinforcing too! In a token system, the exact nature of the responsibilities of various members of the
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and
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BAKER
treatment team may not be clear. Responsibility for reallocation of patients to different groups, for regular analysis of data, for planning the activity programme for the patient, all need to be defined. Arran (1971) found that data collection unfortunately ceased for eight days in the middle of his second experiment, his many other duties preventing him from being able to check that ‘data was being collected appropriately. It may be unreasonable to expect nurses to take full responsibility for treatments and procedures whose full implications they do not appreciate. Psychologists in Britain have only recently begun to clarify the legal nature of the responsibilities they have acquired. In delegating these responsibilities they may be helped by the British Royal College of Nursing (1970) booklet concerning the legal position of the nurse with respect to new treatments. The administrators
Problems arise when anyone outside the ward situation can make an administrative decision directly bearing on the token programme. In the British hospital situation the administrative staff concerned fall into three groups. The first group is the senior nurses, whose decisions can have a major effect on the functioning of a programme. Ellsworth and Ellsworth (1970) suffered a significant drop in the therapeutic effectiveness of their programme when the nursing administration made unexpected changes which affected staffing levels. Torpy (1972) has suggested that in longstay wards deviations in actual staffing, either upwards or downwards, from average staffing levels increase the level of disturbance of the patients. Planned movement of trained staff admittedly helps in increasing acceptance within a hospital of operant and token economy procedures. Unplanned movement places a strain on the staff who remain, and also on the effectiveness of staff training. At least a year is needed, in our experience, for ward staff to acquire an adequate understanding of these procedures. The most frequent comment offered by those returning the questionnaire was that close co-operation with the nursing administration is essential for the success of a programme. In practice, however, in half the British programmes nursing staff may relieve other wards, and may be allocated to other wards without adequate warning (see Table 1 (iv)). The second type of administrator is the doctor. Medically qualified staff often retain the right of admission, transfer, and discharge to and from long-stay wards, even though they have little therapeutic contact with the ward. Bowdlear’s (1971) programme was sabotaged by the referral of inappropriate patients to his programme, whom he was powerless to refuse. The usual system of medical cover means that at certain times of the day or week junior medical staff, unfamiliar with the main ward programme, may order medical treatments or procedures to be carried out. Some treatments, such as changes in psychotropic drugs, may interfere fundamentally with the adjustment of a.patient to a token programme. It is essential to clarify the role of medical staff in relation to the programme, and to ensure a system of medical coverage so that unforeseen treatment changes are at least minimized. The third group of administrators includes Hospital Secretaries, Supply Officers, Laundry Managers, em-the lay administrators, in other words. Basic to a token economy is ready availability and control of reinforcers. For psychiatric and mentally handicapped patients, young and old, such reinforcers in the hospital setting typically include cigarettes, food, sweets, and small amounts of cash. Unfortunately it is precisely these things, which must be controlled for a token economy to be efficient, that in Britain are under the control of lay administrators. It is a paradox that this advanced form of management for patients relies to a considerable extent upon the co-operation of staff least fitted by experience to
TOKEN
ECONOMY
SYSTEMS
259
understand it. Such a restriction on the effective control of reinforcers in the programme may be especially important for those patients who are less sensitive to social reinforcement, and are therefore most reliant on material reinforcers. It may be significant that while most British programmes have had good or satisfactory relationships with medical and nursing administrators, communication and co-operation with lay administrators has been worse (see Table 1 (v)). The outside community The problems presented to an operant programme by an antagonistic community have been described most vividly by Henderson (1969). In attempting to set up a communitybased programme he found himself besieged by local government inspectors. There were two different sets of inspectors, each with differing requirements, since the exact status in the regulations of a community operant programme was not clear. The inspectors were most conscientious in examining the plumbing and wiring: the fire alarm system had to be reinstalled three times before both sets of inspectors were satisfied. It later emerged that local residents with influence on city councillors had initiated these thorough visits. Apart from the obvious difficulties posed by such opposition, staff became apprehensive even of the telephone, fearing a complaint, and patients attempted to control the staff by threatening to behave psychotically in the local streets. Such problems that we have faced seem minor by comparison, but we have had continuing difficulty with the relatives of patients smuggling in goods, although we explained to all of them that we would prefer this not to happen. The brother of one of our patients regularly enticed him out for week-end drinking sessions, which were invariably followed by nocturnal incontinence on the part of the patient. The part played by other nursing staff in a hospital should not be neglected. Student nurses regularly arrive on our ward for their three month spell already primed by the reactionary charge nurse of their previous ward. The delusional system of one of our patients was fanned into verbal flame by one member of the staff who told him “I wouldn’t trust ‘em if I were you, they’re trying to control your mind.” Another patient, following his usual adequate meal, complained to a nurse supervising an off-ward assignment that his recent disturbance of behaviour, and lack of sleep, was due to him missing a meal. The nurse thereupon expressed his own hostile attitudes towards the token system, increasing the patient’s disturbance even more. DISCUSSION Five components of a token system which are considered to be potentially major factors in breakdown of the system have been examined. This examination leads to three conclusions. No investigator has attributed breakdown of a token system to the inappropriateness of operant conditioning theory, or to the inadequacy of the specific derived procedures. In other words, the merit of operant methods as a basis for the remotivation of the chronic mentally ill and handicapped has not been questioned. Technical problems, such as difficulty in obtaining reliable data, or the failure of equipment, have apparently not been the main causes of breakdown. The last conclusion to be drawn from this examination is that breakdown has occurred because of human failure, for reasons unconnected with operant conditioning. These failures have mainly concerned an inability to control the central operant conditioning process, and the factors affecting it. Improved control would involve both a reduction of the problems already discussed, and a positive attempt to integrate
260
JOHNHALL
and ROGERBAKER
these factors into the therapeutic programme. The problems already mentioned have a parallel set of solutions. Unsuitable patients should be eliminated by appropriate selection at all stages of the programme. StafTrunning the programme should have the right to select patients, and ought to be able to define the characteristics of patients considered suitable. Several selection criteria have been suggested, including the use of verbal conditioning tests (Krasner, 1968), pre-runs of token programmes on potential patients (Allen and Magaro, 1971), and clinical assessments of the liklihood of response by individual patients (Nevin 1970). Strain on the nursing staff is further minimized by keeping groups of patients relatively homogeneous. If any patients continue to avoid some contingencies, the ultimate consequences of their actions need to be identified, and modifications made accordingly. Ward staff should preferably be specifically chosen for the work on the basis of interest, ability, and attitudes. Personality and attitudinal criteria for the selection of nursing staff for behaviour modification assignments have been suggested by Loy (1969) and Hall (1971) respectively. An additional approach to ensuring effective staff-patient interaction is to reinforce staff performance systematically (Katz et al.) Reinforcers can be material, such as extra pay or free time, or by means of providing feedback, via charts and other means, to show that patients are changing. Staff who are not keen on token regimes should at least be given an opportunity to change wards. Thorough training should be given to all ward staff involved, and this training needs to continue over a considerable period of time. While most psychologists are used to teaching students of high ability, psychologists teaching nurses need to adapt the presentation of their material to the more practical concerns of student nurses, avoiding an approach that may be too academic and theoretical (Ellsworth and Ellsworth, 1970). Outlines of effective training programmes incorporating use of videotapes, the analysis of the behaviour of individual patients, and the completion of programmed texts are increasingly available (Epling et al., 1972). Psychologists or psychiatrists supervising token programmes need to clarify their own responsibilities to ward staff, and the reciprocal responsibilities of the nurses. Regular and effective communication with all ward staff preserves staff morale, and ensures that procedures are correctly carried out. Establishment of a minimum acceptable level of staffing, and the reduction of unanticipated staff changes, are two of the most effective steps that can be taken to ensure the maintenance of a programme. Solutions to the problem of under-staffing include the use of a “flying-squad” of specially trained staff (Gripp and Magaro, 1971), and the use of students or voluntary workers, but neither of these are real substitutes in the long-term for inadequate staffing. Collaboration with medical staff is necessary to clarify admission and discharge procedures from the programme, and to prevent unnecessary treatment changes. Lay administrators need a full introduction to the rationale of the token system, and may require assurance that adequate safeguards exist if control of cash or food is sought. Both patients and staff on a programme are likely to encounter ambiguous or hostile comment from people outside the programme. Ambiguity may result from ignorance, and can be tackled by disseminating information about the programme. The Minnesota Guidelines for behaviour modification projects (Vail, 1970) recommend that such projects should be as open as possible to public inspection. The problems and solutions so far identified have been concerned with people. The identification of these people was carried out by analysing our own and other people’s experience, so the remedies suggested are essentially pragmatic. We have not attempted to
TOKEN ECONOMY SYSTEMS
261
co-ordinate in a systematic manner the actions of these people with the central therapeutic process. If such a co-ordination were carried out, certain requirements would need to be met for the co-ordination to be satisfactory. These would be the further identification of all people and events that influence the central process: a comprehensive examination of the token economy in context would be required. Further, these people and events must be specified in such a way that analysis of their interaction is possible. Lastly, this identification and specification must generate procedures which can be put into practice. These requirements might be met by using an alternative, or additional, frame of reference for examining behaviour modification programmes. Winkler (1971) has already suggested and elaborated the use of a model taken from economic theory. An economic model encompasses certain facets of token systems, such as the nature of inflation and the relationship between earning levels and spending, which are not so readily explained in the language of operant conditioning. The economic model has been further developed (Kagel and Winkler, 1972) to the point where specific practical procedures have been generated which increase the effectiveness of a token system (Winkler, 1972). Tenbrunsel (1969), to use his own words “developed a programme which combined the positive aspects of both the operant and cognitive paradigms”. O’Keefe (1971) examined this approach and developed it further, though not to the same degree as the development of the economic approach. A further alternative framework that appears promising is systems theory. The theory essentially is concerned with the principles governing processes of mutual interaction, irrespective of the nature or content of these processes. This type of approach would permit an examination of the network of phenomena and interactions surrounding the central operant conditioning process, without necessarily investigating that process itself. Hibbert and Henderson (1971) introduced the idea of systems theory in their analysis of changes in an individual patient under a token economy regime. Caste11 (1970) has examined the relevance of systems theory methodology to behaviour therapy in some detail, and he pointed to the advantages that could be obtained from such a methodology. The introduction of alternative theoretical frameworks and languages such as these might well enable satisfactory co-ordination between external factors and the central process to occur. There is a danger that operant conditioning, in its application to human problems, may become, a “closed system”, in systems theory language, which is isolated from other areas of psychological enquiry. Krantz (1971) drew attention to this danger in his analysis of the number of self-citations of reference sources given in two operantlyoriented journals, the “Journal of the Experimental Analysis of Behaviour”, and the “Journal of Applied Behaviour Analysis”. By an increasing degree of self-reference, these journals are less able to draw from psychological knowledge in other areas. Similarly, ignoring factors outside the conditioning process is likely to impair the efficiency with which the process is implemented. Introducing other approaches would encourage the development of an “open system”, where continual transactions with the environment in an adaptive, self-regulatory fashion could occur. Short of Walden II becoming a reality, with the fundamental social revolution implied by that reality, a controlled environment ultimately has bounds. While some contingencies for patients within the environment can be controlled, contingencies for the controllers of the environment cannot. But it is beyond the bounds of that environment that key components of a token system lie, as far as the risk of breakdown is concerned. An expansion of Krasner’s
JOHN HALL
262
and ROGER BAKER
engineering analogy, or the introduction of other paradigms, may suggest further aids to positive control of operant conditioning programmes without any loss of psychological rigour or precision. As in engineering a machine needs a framework as well as components, so in human engineering we may need to consider psychological frameworks. REFERENCES ALLEN
D. J. and MAGAROP. A. (1971) Measures of change in token-economy programmes. Behuc. Res. & 771erapy 9, 311-318. ARRAN L. (1971) Operant tactics applied to patient behaviours on an open psychiatric ward. DiFserr. Absrrucis 31B, 7586. A-ITHOWE J. M. and KRASNERL. (1968) Preliminary Report on the application of contingent reinforcement procedures (token economy) on a “chronic” psychiatric ward. /. Abnorm. Psychol. 73, 37-43. AYLLON T. and AZRIN N. H. (1965) The measurement and reinforcement of behaviourof psychotics. J. Exp. Anal. Behau. 8, 357-383.
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