Econmy Token

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PERFOMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

SUBMITTED BY :

MS.SREEJA.P.A

1ST

YEAR M.Sc (Nursing)

MENTAL HEALTH NURSING,2011-2013 BATCH,

ORIENTAL COLLEGE OF

NURSINGBANGALORE-560044


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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA,BANGALORE,

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1. NAME OF THE CANDIDATE AND

ADRESS

MS.SREEJA.P.A

SREEBHAVAN, ELAKOLLOOR.P.O, KONNIPATHANAMTHITTA- 689703, KERALA

2. NAME OF THE INSTITUTION Oriental college of nursing,Bangalore560044.

3. COURSE OF STUDY AND SUBJECT 1ST Year M.Sc Nursing,

Mental Health Nursing

4. DATE OF ADMISSION OF THE COURSE 15-10-2011

5. TITLE OF THE TOPIC A quasi- experimental study to assess

the effectiveness of token economy program on

behaviour modification among institutionalized

mentally ill patients in selected mental hospitals in

Bangalore

6. BRIEF RESUME OF THE WORK6.0 INTRODUCTION

6.1 NEED FOR THE STUDY6.1.1 STATEMENT OF TH STUDY6.2 REVIEW OF LITERATURE6.3 OBJECTIVES OF THE STUDY6.3.1 OPERATIONAL DEFENITIONS

6.3.2 ASSUMPTION6.3.3 HYPOTHESIS6.3.4 SAMPLING CRITERIA

Enclosed

EnclosedEnclosedEnclosedEnclosedEnclosed

EnclosedEnclosedEnclosed

7. MATERIALS AND METHODS

7.1 SOURCES OF DATA

7.2 METHOD OF DATA COLLECTION7.3 Does the study require any investigationsof interventions to be conducted on the patients

or other human being or animals?7.4 Has ethical clearance been obtained fromyour institution?

Data will be collected from mentally ill patients inselected hospital in BangaloreEvaluative Approach

YesYes. Ethical committees report is here with enclosed


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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BENGALURU, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 NAME OF THE CANDIDATE

AND ADDRESS

Miss. SREEJA P A

SREE BHAVAN,

ELAKOLLOOR P O,KONNI, PATHANAMTHITTA (Dist.),

KERALA- 689703

2 NAME OF THE INSTITUTION ORIENTAL COLLEGE OF NURSING

BANGALORE- 560-010

3 COURSE OF THE STUDY AND

SUBJECT

FIRST YEAR M.Sc NURSING

MENTAL HEALTH NURSING

4 DATE OF ADMISSION 15 -10-2011

5 TITLE OF THE STUDY:

A QUASI-EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OFTOKEN ECONOMY PROGRAM ON BEHAVIORAL MODIFICATION AMONG

INSTITUTIONALISED MENTALLY ILL PATIENTS IN SELECTED MENTALHOSPITALS IN BANGALORE.


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6. BRIEF RESUME OF THE INTENDED WORK

6.0. INTRODUCTION:

People's behaviour makes sense if you think about it in terms of their goals,

needs, and motives.

-- Thomas Mann

Human mind can be defined as a fantabulous device which is natural but rather very

complicated. It is an abstruct, abstruse, and an imaginative device which determines the character

and thereby the behaviour of a person. As a coin own two faces, humans also have two attitudes

in behaviour. They may be positive or negative. Situations and environment plays a vital role in

developing either positive or negative behaviour in a person. The positive behaviour of a person

can be modified by some reinforcement techniques such as appreciation, giving gifts in the form

of tokens etc. Based on this concept researcher have adopted the token economy program.

Anything that is visible and countable can be used as a token. Tokens should preferably

be attractive, easy to carry and dispense, and difficult to counterfeit. Commonly used items

include poker chips, stickers, point tallies, or play money. When an individual displays desirable

behaviour, he or she is immediately given a designated number of tokens. Tokens have no value

of their own. They are collected and later exchanged for meaningful objects, privileges or

activities. Individuals can also lose tokens (response cost) for displaying undesirable behaviour.

Individuals participating in a token economy need to know exactly what they must do in order to


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receive tokens. Desirable and undesirable behaviour is explained ahead of time in simple,

specific terms.

A token economy is a behavioural therapy technique in which the desired change

is achieved by means of tokens administered for the performance of predefined behaviours

according to a program. Though token economy programmes were widespread in the 1970s they

became largely restricted to wards where long-stay patients from institutions are prepared for

transfer into the community and were particularly aimed at changing negative symptoms of

schizophrenia - poor motivation, poor attention and social withdrawal.

The token economy is a treatment intervention based on principles of operant

conditioning and social learning. Developed in the 1950s and 1960s for long-stay hospital

patients, the token economy has fallen out of favour since that time.

"In the token economy, the full range of self-care, social, and work behaviours could be

modified by systematic and pre-planned use of antecedents (e.g., prompts) and consequences

(e.g., reinforces) of these behaviours. The 'psychopathological' behaviour of the mentally ill was

conceptualized as being subject to the same 'laws of learning' that influenced normal behaviour.

Tokens could be conveniently dispensed to patientscontingent ontheir exhibiting improvements

in their behaviour. The tokens were then subsequently exchanged for apanoplyof rewards."

Primary reinforcers are the meaningful objects, privileges, or activities that individuals

receive in exchange for their tokens. Examples include food items, toys, extra free time, or
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outings. The success of a token economy depends on the appeal of the primary reinforcers.

Initially tokens are awarded frequently and in higher amounts, but as individuals learn the

desirable behaviour, opportunities to earn tokens decrease.

Ideally, individuals will use the skills learned in a token economy in their everyday

surroundings. They will display the undesirable behaviour less frequently or not at all. They will

also engage in positive, adaptive behaviours more often. If the token economy was ineffective or

time spent in the token economy was limited, individuals may show no changes or actual

increases in the undesirable behaviour.

Risks involved in token economies are similar to those in other forms of Behaviour

Modification. Staff members implementing the therapy may intentionally or unintentionally

neglect the rights of individuals receiving treatment. Token Economies should never deprive

individuals of their basic needs, such as sufficient food, comfortable bedding, or reasonable

opportunities for leisure. If staff members are inadequately trained or there is a shortage of staff,

desirable behaviours may not be rewarded or undesirable behaviours may be inadvertently

rewarded, resulting in an increase of undesirable behaviour

6.1. NEED FOR THE STUDY:

A token economy is a form of behaviour modificationdesigned to increase desirable

behaviour and decrease undesirable behaviour with the use of tokens. Individuals receive tokens

immediately after displaying desirable behaviour. The tokens are collected and later exchanged


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for a meaningful object or privilege. The primary goal of a token economy is to increase

desirable behaviour and decrease undesirable behaviour. Often token economies are used in

institutional settings (such as psychiatric hospitals or correctional facilities) to manage the

behaviour of individuals who may be aggressive or unpredictable. However, the larger goal of

token economies is to teach appropriate behaviour and social skills that can be used in one's

natural environment. Special education (for children with developmental or learning disabilities,

hyperactivity, attention deficit, or behavioural disorders), regular education, colleges, various

types of group homes, military divisions, nursing homes, addictiontreatment programs,

occupational settings, family homes (for marital or parenting difficulties), and hospitals may also

use token economies. Token economies can be used individually or in groups.

A token economy system is an approach in which students are given a mark for reward

redeemable at a later time (Lovitt, 1978). Target behaviours to be used in the token economy

(Mueller, Sterling-Turner, & Scattone, 2001). Token economy systems can at times be time

consuming and costly (Lovitt, 1978). A separate aspect of a token economy system is response

cost. Taking away token or points for disobeying rules is an example of response cost (Lovitt,

1978).

From 1960 to 1970, the token economy has been extended widely across populations and

behaviours in treatment, rehabilitation, educational, and community settings. The current review

was undertaken as a part of the 2003 update of the schizophrenia treatment recommendation of

Patient Outcome Research Team (PORT). A total of uncontrolled studies of the token economy

were reviewed. These studies provide evidence of the token economy programs effectiveness in


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increasing the desirable or adaptive behaviours of patients with mental illness. The token

economy has been shown to reduce violence in various treatment situations, such as for patients

in alcohol treatment, chronic psychiatric patients, and those with severe head injuries.

The researcher observed that although there are studies on the effects of a token economy

program, there are seem to indicate with a need for an extended study. The recent research lacks

the needed intervention time for reliable results. The effects of this research will extend the

intervention phase to attain more reliable results. Hence the researcher selected to research on A

quasi- experimental study to assess the effectiveness of token economy program on behaviour

modification among institutionalized mentally ill patients in selected mental hospitals in

Bangalore

6.1.1. STATEMENT OF THE PROBLEM

A quasi- experimental study to assess the effectiveness of token economy program

on behaviour modification among institutionalized mentally ill patients in selected mental

hospitals in Bangalore

6.2 REVIEW OF LITERATURE:

The review of literature is defined as a broad, comprehensive, in depth, systematic and

critical review of scholarly publications, unpublished scholarly print materials, audio visual


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materials and personal communications. It aids in the identification of relevant theoretical or

conceptual frame work for a research problem, identification of suitable designs and data

collection methods for the study3.

A study conducted in India assessed the effectiveness of token economy in bringing up

adaptive behaviour of schizophrenic patient admitted in Vidyasagar hospital, Amritsar. The

observation method used to assess 50 schizophrenic patients randomly selected for this study.

The researcher followed the patients for three months and assessed behaviour including

maintenance of personal hygiene, grooming etc. The result indicates a wide range improvement

in patients adaptive behaviour, and they suggest the implementation of token economy in

improving the adaptive behaviour of psychiatric ill patients4.

A study conducted in Iran investigated effect of social and token economy reinforcements

on academic achievement of 9th grade boy students with intellectual disabilities in an

experimental science class in Tehran Province.The method used for this study was experimental

by pre-test, post- test with a control group. The boy students with intellectual disabilities from

three junior high schools participated in this study. The sample consisted of thirty, 9th grade boy

students with intellectual disabilities in the selected schools. The results showed that there was a

significant increase in academic achievement of students with intellectual disabilities when using

token economy than using social reinforcements compared with the control group. Also, when

using social reinforcements, the academic achievement of students was more than the control

group5

.


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A study conducted in US to investigate the effects of a token economy system in

comparison to social praise on the manifest behaviors of learning disabled students at an

elementary school in West Virginia. Ten learning disabled students from an elementary school

tested using the Conners Teacher Rating Scale-Revised to obtain the manifest behaviors of the

Control and Experimental Groups. The results of this study found that there was no significant

difference between a token economy system in comparison to social praise on the manifest

behaviors of elementary learning disabled students. This may have been caused by the

similarities of the learning disabled students. Furthermore, these findings do not support the

related literature which stated there was a positive relationship between a token economy system

and manifest behaviors of learning6

.

A study on mentally retarded African American students was conducted on four boys and

three girls. The students received cents contingent upon a correct response. Cents were then used

to buy backup reinforcers such as sweets or access to a video or listening to music. The token

economy was established in order to increase appropriate responses, and decrease verbal

outbursts. The results of the study indicated a positive outcome with the use of a token economy

as well as self-monitoring techniques to be useful with mild mentally retarded students7.

A study was conducted in Ireland to review the effects of token economies for people

with schizophrenia, or other serious or chronic mental illnesses, compared with standard care.

Randomized studies comparing a token economy regime to standard care for those with

schizophrenia or any other similar chronic or serious mental illness were used for the study.

Studies were reliably selected, quality rated and data extracted. For dichotomous data relative


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risk with 95% confidence intervals was estimated. Where possible, the number needed to treat

statistic was also calculated. Results indicate that the token economy approach may have effects

on negative symptoms but it is unclear if these results are reproducible, clinically meaningful and

are maintained beyond the treatment program. Token economy remains worthy of careful

evaluation in well designed conducted and reported randomized trials8.

A review was undertaken as part of the 2003 update of the schizophrenia treatment

recommendations of the Patient Outcomes Research Team (PORT). A total of 13 controlled

studies of the token economy were reviewed. As a group, the studies provide evidence of the

token economy's effectiveness in increasing the adaptive behaviors of patients with

schizophrenia. Most of the studies are limited, however, by methodological shortcomings and by

the historical context in which they were performed. More research is needed to determine the

specific benefits of the token economy when administered in combination with contemporary

psychosocial and psychopharmacological treatments9

.

A study was conducted reviewed outcome studies of token economy programs for

psychiatric inpatients. Only studies that employed some control procedures in their evaluation

were included. Token economies were most effective in modifying in hospital work, personal

care, and some psychotic behaviour. Studies that assessed token programs to prepare patients for

community living and reduce recidivism generally affirmed the effectiveness

of token procedures, but the studies were poorly designed, and they lacked systematic follow-up

data. Almost all studies failed to examine possible interactions between chemotherapy and


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the token economies. The author suggests the need for studies using token economies with

psychiatric patients other than chronic schizophrenics, who have been studied almost exclusively

to date10

.

A two-part systematic review was undertaken to assess the effectiveness

of token economies in increasing rates of appropriate classroom behaviour for students

demonstrating behavioural difficulties. The first part of the review utilized the recently published

What Works Clearinghouse (WWC) standards for evaluating single-subject research to

determine the extent to which eligible studies demonstrated sufficient evidence to classify the

token economy as an evidence-based practice. The second part of the review employed meta-

analytic techniques across four different types of effect sizes to evaluate the quantitative strength

of the findings. Methodological strengths and weaknesses across the studies were systematically

investigated. Results indicated that the extant research on token economies does not provide

sufficient evidence to be deemed best-practice based on the WWC criteria.11

A study was conducted in the US reveals that the token economy is among the most well-

validated and effective behavioral treatments for schizophrenia and other serious psychiatric

disorders, its use in clinical and research settings has declined from a peak in the early 1970s.

Reasons for this decrease in use include staff resistance, reduced length of inpatient admissions,

greater emphasis on community based treatments, economic constraints, and legal and ethical

challenges. Nevertheless, a small but enthusiastic group of proponents still conducts token

economy research and treatment. Important topics pertaining to the token economy remain to be

addressed, including specifying its remediative components, developing strategies to promote


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generalization and maintenance of treatment gains, and creating better methods to identify

patients who would most benefit from participating in these programs.12

6.3 THE OBJECTIVE OF THE STUDY

To assess the pre-intervention level of behaviour modification of mentally ill patients.

To design and develop a token economy program for mentally illpatients.

To assess the post-intervention level ofbehaviour modification of mentally ill

patients.

To determine the effectiveness of token economy on behaviour modification of

mentally ill patients

To find out the association between the pre test and post test level ofbehaviour

modification of mentally ill patients.

To determine the association between the selected demographic variables such as age,

sex, education, period of stay in the hospital, use of other behavior techniques, etc. and

behaviourmodification of mentally ill patients.

6.3.1. OPERATIONAL DEFINITIONS:

1. Assess: - It refers to the process used to estimate the behaviour modification of mentally

ill patients with the help of an observation check list.


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2. Effectiveness: - refers to the improvement in patient behaviouras determined by

significant difference between pre and post test level ofbehaviour.

3 Token economy program: - A token economy is a behavioural therapy

technique in which the desired change is achieved by means of tokens

administered for the positive performance of predefined behaviours according to a

program.

4 Behaviour modification: - An observable change in the behaviour of a patient

which the society accepted as a desirable behaviour.

5 Mentally ill patients: - individual with a common debilitating mental weakness,

and is associated with the psychiatric signs and symptoms which will be

diagnosed by the professional qualified person

6. 3.2 ASSUMPTIONS:

1. Mentally ill patients may have some behavioural difficulties.

2. Mentally ill patients may need some behaviour modification.

3. Token economy is an ideal behaviour modification technique


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6 .3.3 HYPOTHESIS

H1. There will be significant improvement between pre and post test level of

behaviour modification of mentally ill patients.

H2. There will be significant association between pre test levels of behaviour

modification of mentally ill patients with their selected demographic variables

6. 3.4 SAMPLING CRITERIA:

INCLUSION CRITERIA:

1. The mentally ill patients who are willing to participate in the study.

2. Mentally ill patients who are available during the study period.

3. In-patients who are admitted for a period of six week.

EXCLUSION CRITERIA:

1. Mentally ill patients who have already benefited by token economy.

2. Chronically ill patients with poor prognosis

6. 3.5 LIMITATION

The study is limited to

Mentally ill patients who are admitted in a selected mental hospital in Bangalore.

6 week period of data collection


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7. MATERIALS AND METHODS:

Data will be collected from mentally ill patients who admitted in a selected mental hospital in

Bangalore.

7.2 METHOD OF DATA COLLECTION

For the present study the data will be collected by using a structured observation check

list. The tool for the present study will be developed by the investigator based on the objectives,

review of literature and the suggestion of the experts regarding token economy and behaviour

modification.

Research Approach : Evaluative approach

Research Design : Quasi experimental design

Research Setting : Selected mental hospital in Bangalore

Population : All mentally ill patients in selected hospital

Sample size : 40

Sampling technique : Simple Random Technique


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Method of data collection :

Phase 1: conducting pre-test to assess the behaviour modification

of mentally ill patients with the help of an observation check list.

Phase 2: administering token economy program on behavior

modification to the selected mentally ill patients.

Phase 3: Conducting post-test to assess the behaviour modification

of mentally ill patients with the help of an observation check list

Tool fordata collection : Observation check list

Method of data analysis :

The data will be analyzed by using descriptive and inferential statistics

DESCRIPTIVE STATSTICS:

Descriptive statistics such as mean, median, percentage

distribution, frequency, paired t-test, correlation and standard deviation

will be used for assessing demographic data.

INFERENTIAL STATISTICS:

Chi- square test will be used to determine the association between

the selected demographic variables and the pre test score.


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Duration of study : 6 weeks

Research variables

Dependent Variables : Behavior modification of the mentally ill

patients.

Independent Variables : Is the token economy.

Demographic Variables : Age, Sex, Education, Occupation, Type of

Family, Period of stay in hospital,

Use of other behavior therapies, Previous

Knowledge about token economy program

Projected Outcomes : This study will enable mentally ill patients

to improve their behavior as a desirable

one which is accepted by the society

7.3. Does the study require any investigation or any intervention on patient or

human/animals?

Yes. Token economy program

7.4. Has the ethical clearance been obtained from your institution?

Yes. Administrative permission and ethical clearance to the study will be obtained

from the research committee of Oriental college of Nursing, Bangalore, prior to

conducting the study.


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8. LISTS OF REFERENCES:

1. Brunner and Suddharth, Text book of Medical Surgical Nursing, 10th

edition, Elsevier

Publications 2007.p525-9

2. Joyce m Black, medical surgical nursing 8th

edition, Elsevier India 2006 p820-7

3. Walid and leech NL. Writing narrative literature reviews. 5(3)2005p101-114

4. Amith Chopra. : Effects of token economy in Schizophrenic patient in the Journ

Psychol June 2010..(52)24: 124-128.

5. Seyed-Mahmood Mirzamani, Mohammad Ashoori, Narges Adib Sereshki. Iranian

Journal of Psychiatry >Vol 6, No 1 (2011)>Mirzamani

6. Kimberly Waggy The effectsof a token economysystem in comparison to social

praise. The American journal June 2002- (1-28).

7. Akande A.; The role of reinforcement in self-monitoring; Education; 1997; 118,

275- 82.

8. . Faith B. Dickerson,Wendy N. Tenhula,Lisa D. Green-Paden; The token economy

for schizophrenia: review of the literature and recommendations for future

research; Schizophrenia Research,Volume 75, Issue 2 , Pages 405-416, 15

June 2005

9. Milby JB; A review of token economy treatment programs for psychiatric

inpatients;Hosp Community Psychiatry.1975 Oct;26(10):651-8.

10. Maggin DM,Chafouleas SM,Goddard KM,Johnson AH; A systematic evaluation

token economies as a classroom management tool for students with challenging

behavior;J Sch Psychol.2011 Oct;49(5):529-54. Epub 2011 Jun 28.
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11. Shirley M. Glynn; Token Economy Approaches for Psychiatric Patients Progress and

Pitfalls Over 25 Years; psychiatric service; 1995 dec; 46(12): 1258-63.

12.McMonagle T,Sultana A; Token economy for schizophrenia;Cochrane Database

Syst Rev.2000;(3):CD001473.

.
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9SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE

11NAME AND DESIGNATION OF:

11.1GUIDE

11.2SIGNATURE

11.3CO-GUIDE

11.4SIGNATURE

11.5HEAD OF THE DEPARTMENT

11.6SIGNATURE

12.1 REMARKS OF THE PRINCIPAL

12.2SIGNATURE

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