Bchav

Res. & Therapy.

1975. Vol

13. pp

I I!

A TOKEN

125. Pergamon

Press Prmtrd

m Great Bntam

ECONOMY TREATMENT DRUG ADDICTION*

OF

JAN H. ERIKSSON.K. GUNNARG~TESTAM. LENNARTMELIN? and LARS-GORAN&r: Psychiatric

Research

Center.

University of Uppsala. Uppsala. Sweden

(Rrcc~rrd

Ulleraker

Hospital.

I8 JUII~ 1974)

Summary-A token economy was introduced into a ward for drug addicts who were detoxified before entering the programme. The 52 subjects (amphetamine and opiate addicts) stayed on average I7 days in the programme. An ABABC-design. i.e. a reversal design with a non-contingent reinforcement phase at the end, was used. The patients’ activity increased from baseline to the treatment phase. During the reversal phase the-activity-level decreased. and it Increased again when the token economy was reintroduced. The non-reinforced activities. ward meetings and group therapy, were not influenced by the changes in contingencies for the reinforced activities. The proportion of intoxications on the ward was lower during treatment phases than during non-treatment phases.

In recent years the problem of drug addiction has attracted increasing interest from behavior therapists. Techniques such as aversion therapy (faradic. chemical and verbal). systematic desensitization, assertive training, extinction (classical and covert). covert conditioning, and behavior contracting have been used to treat addicts individually. The field has recently been reviewed by Droppa ( 1973) and Miller ( 1973). In the treatment of entire wards of patients the token economy (Ayllon and Azrin, 1968) has during its more than 10 yr of application proved to be an effective method to motivate, activate, and rehabilitate patients. It has been applied to chronic schizophrenics (Atthowe and Krasner, 1968), psychotic children (Knepler, Sewall and Boor, 1972), retarded adults (Thompson and Grabowski. 1972). retarded children (Birnbrauer rt al., 1964), delinquents (Phillips, 1968), psychopaths (Lawson rt al.. 1971). depressed patients (Hersen ~‘fal., 1973) and alcoholics (Narrol, 1967). There are also some attempts to use operant principles in the treatment of drug addicts. Glicksman, Ottomanelli and Cutler (1971) presented a study which they claim to be “one of the first applications of the token economy behavioral modification technique to a civilly committed addict population in a milieu treatment program” (p. 525). However, if one adhers to Krasner’s ( 197 1) definition of a token economy, the Glicksman er al. ( I97 1) study cannot be considered as one. Firstly. the specific types of behaviour to be reinforced were poorly defined. Secondly, there was a lack of continuous measurement of this behaviour, and thirdly, there were no back-up reinforcers. The only ‘reinforcer’ was a long-term reward, i.e. the involuntary patient could “buy his discharge from the institution” (p. 526) * This research was supported hy the Swedish Medical Research Council (grant No. B74-21X-3375-04). the Swedish National Board of Health and Welfare (grant from SN 4) and Anton and Dorotea Bexelius’ Foundation. t Present address: Psychological Department, Umverslty of Uppsala. Vasagatan 1 A, S-752 24 Uppsala. Sweden. $ Requests for reprints should be addressed to Lars-Giiran &t, Psychiatric Research Center, University of Uppsala. Ulleraker Hospital. S-750 17 Uppsala. Sweden. 113

114

J. H. ERIUSON, K. G. GBTESTAM. L. MELIK and L.-G. 6s~

when he had collected 936 points. Furthermore. as there was neither a baseline nor a control group, it is impossible to draw any conclusions from the result that it took 4 months during the token economy to gain approval for release “compared to 7.5 months for residents on other wards at the same time” (p. 528). O’Brien. Raynes and Patch (197 1) reported a controlled study including a baseline phase of two weeks and a treatment phase of 34 weeks. They treated 150 drug addicts who were to perform certain low frequency types of behaviour (e.g. up in the morning at 8.00. cleaning living area and following room rules) on the ward to get access to certain high frequency behaviours (reinforcers such as access to radio and TV. having visitors and passes). The day was divided into S-hr periods and the patient had to perform all low frequency behaviours during an 8-hr period to get access to all reinforcers. If he failed to perform one of them he lost one of the reinforcers and if he failed two he lost all reinforcers. These contingencies were in effect 24-hr a day and seven days a week. The result of this study was that the percentage of patients performing all low frequency behaviours increased from a baseline level of 20 to above 80 for the treatment phase. The first behavioural treatment programme for drug addicts in Sweden, using contingency management. was reported by Melin and Gotestam (1973). Subjects in this study were 16 female amphetamine addicts. The study had both a baseline phase and a control group (not randomly assigned however). The results showed a significant increase in the percentage of patients getting up and dressing in the morning and a significant decrease in the doses of prescribed psychotropic drugs. Furthermore, a significantly higher percentage of the treated patients had remained drug-free at the I-yr follow-up compared to the control group. The Melin and Gbtestam (1973) study consisted of two programmes, the first quite similar to that of O’Brien et ul. (1971). The disadvantage of this kind of programme was that the patient had to perform 100 per cent (or almost) of the low frequency behaviors to get access to any reinforcer at all. This made it difficult for the staff to carry out the programme consistently: “Should he lose all the privileges just because he was 10 minutes late this morning’.“’ When this kind of contingency management (Melin and Gotestam, 1973) had been in effect for 4 months it was changed to a point system to avoid the disadvantages mentioned above. The patients received a certain amount of points when they performed the low frequency behaviors. and they had to collect 25 points per week to get the privileges. With this system there was an increased flexibility in balancing low frequency behaviour and the reinforcers due to the quantification of the activities. The most pertinent disadvantage of the point system was that the reinforcers were of an all-or-none character rather than being proportional to the amount of target behaviour emitted. This disadvantage was partly eliminated in a similar behavioural programme dealing with opiate addicts in a methadone maintenance treatment program (Melin, Andersson and Giitestam, 1974). In this programme there was a stepwise access to the reinforcers and the patient could have all the privileges when he had collected 100 points. After that he had to reach 25 points/week to keep the privileges. which was rather easy as the maximum was 46 points/week. There were however two disadvantages in this programme. Firstly, the patients had no use for ‘surplus points’ (over 25). and secondly, there was a delay of the negative consequences (loss of privileges) for 1 week. The purpose of the present study was to design and evaluate a program that eliminated some of the disadvantages present in the former programmes. Firstly, it was attempted to achieve more flexibility by providing the patients with optional activities. Secondly, a

A token economy treatment of drug addiction

IiS

token economy system was applied in which the patients could use surplus points (above the daily criterion) to get access to different back-up reinforcers in addition to privileges. Thirdly, the delay of the negative consequences was shortened from 1 week to 1 day if the patient did not reach the criterion. Unfortunately. due to lack of funds it was not possible to include rehabilitative steps outside the ward into the array of target behavior, and the programme thus had to be limited to ward management behaviour such as getting up in the morning, bed making. physical exercises etc. METHODS

The ward accepted both male and female drug addicts, and during the S-months programme period 52 patients entered the treatment programme. Of these patients. 37 were men and 15 women. Their median age was 22 yr (range: 16-41). These patients had started to use opiates or central stimulants at a median age of 17 (range: 12-X). The median time of treatment for the patients was 17 days (males 15 days and females 31 days). This difference, however. was not statisticaify signi‘ficant. At the start of treatment 56 per cent (29) of the patients said that they used either opiates (25 per cent) or central stimulants (31 per cent) exclusively. Fourteen per cent mixed opiates and central stimulants. 4 per cent opiates and hallucinogens, I7 per cent opiates. central stimulants and hailucino~ens and 4 per cent mixed central stimulants and hallucinogens. There were no differences between males and females regarding their preference for certain types of drugs. The ward consisted of two units. one for detoxi~cation (1 I beds) and one for tr~atrnent (1 I beds). Before a patient could enter the treatment unit he had to be detoxified. defined as having no traces of illegal drugs in his urine. (The patients had to leave a urine sample every day.) The physical milieu on the detoxification unit was similar to a somatic hospital with no recreational activities, except for table-tennis. The patients had to wear hospital clothes and were not allowed leaves of absence or to receive visitors. All patients participated in the treatment programme voluntarily and could leave the ward whenever they wished. Most of the patients came to the detoxification unit voluntarily, but a small portion (7 per cent) was admitted involuntarily. The patients stayed on this unit between 1 and 14 days (the median was 5 days). The opiate addicts were detoxified via methadone during a 5-10 day period and the amphetamine addicts got mostly neuroleptics if needed. When the urine analysis was negative and the patient had been informed about the treatment programme, he could choose between entering the treatment programme, going to a ward with traditional psychiatric care or leaving the hospital altogether. During the 34 weeks the token economy was running, 33 per cent of the 160 detoxified patients entered the treatment unit. The treatment unit had a nicer physical milieu with more recreational activities. The patients could wear their own clothes and have much more freedom. The unit consisted of three two-bed rooms. five single rooms. a dayroom. a music-room, a dining room and a kitchen. During their stay inside the ward, intake of unprescribed drugs or alcohol was strictly forbidden. If the patients were noticeably intoxicated they had to return to the detoxification unit and stay there until they were detoxified.

J. H. ERIKSSO~. I(. G. GBTESTAM. L. MELIK and L.-G. &T

116

When the patient entered the treatment program he had to collect 70 points before he was allowed to leave the ward without being accompanied by a staff member. This ordinarily took 3-5 days. When he had reached 70 points he had to collect 15 points each day (on weekdays) and 5 points on Saturdays to keep the privilege of leaving the ward alone. If a patient did not reach the criterion one day he could not have his leave the next day and had to reach the criterion 1 day before he could regain this privilege. During the stay on the treatment unit each patient had to give a urine sample every day before 12 o’clock. If he refused to do this. or if the sample was positive he lost the privilege of leaving the ward until he had collected 40 points, which ordinarily took 2 days. The staff on the ward consisted of one head nurse. three nurses and seven aides. with six persons on duty at the same time. There were also two psychiatrists. one psychologist and one social worker serving the ward.

AcriMes.

were divided

The activities that the patients could perform in the treatment programme into two categories: common activities (which all patients could perform) and Table

I. Common

and bookable

A. Common activities I. Up and dressed in the morning 2. Morning conference 3 Bed making Cleaning own room 5 Exercise walks (with personnel) i: Physical education 7. Giving a urine sample 8. Planned excursion 9. Garden work IO. Work in the woods I I. Courses 12. Treatment conference 13. Cooking course 14. Social errands

activities Points 7 ;

4:

B. Bookable activities I. Purchase 3. Coffee making 3 Kitchen works i: ScrvintT meals 5 Cleanl:g the davroom Cleaning the dining room 7. Cleaning the music room x. Clcamng the bathroom 9. Cleaning the toilets IO. Cleaning the washroom therap) I I. Occupational 12. Invltins usltors 13. Host,hostcss for \iqitors II. Prcparatlon for ward meeting 15. Work outside the hospital I 6. School attendance Il. Bakmg IS. Collcctlnp mane! for baking I’). Purchasing ingrrdlents for baking ‘0. Collcctlng fowxrs in the garden 21. Tahing cart of the Rowers on the ward

6:

3 5 4 II 612 20 5 3 5 IO 2 2

3 7 3 4

2 3 5 3 5lhr

; 3 6- I 6 &I6 I0 5 5

i 2

A token economy

treatment

117

of drug addiction

bookable activities (which only one at a time could perform). These activities are shown in Table 1, together with the number of points the patients received for performing each activity according to its criterion. Except for getting up in the morning. the most important of these activities was the morning conference. During this the patients planned what they were going to do during the day and they could book two or more (depending on the number of patients present) of the bookable activities. In order to teach the behaviour of planning, patients could receive points for bookable activities only if they had signed up for them beforehand. Recording. In order to make the recording of patient behaviour easier and more reliable the ‘Time and Place Rule’ of Ayllon and Azrin (1968) was adhered to. This meant that every activity had a specific time and a certain place when and where it could be performed. The recording was made on individual recording sheets as soon as possible after the observation of a certain activity. The observation and recording was done by one of the aides. This assignment alternated between six of the aides on the ward so that one aide did not have this job more than one day at a time. From the 28th week one special staff member had this job continuously. Reliability. During the first week of the programme two aides observed and recorded the patients’ activities independently of each other. During the 29th week the same procedure was applied by the special staff member and the other aides. The mean percentage of observer agreement (calculated as the number of agreements divided by the number of disagreements plus the number of agreements) was. for weeks 1 and 29 respectively: up and dressed 97-100 per cent. morning conference 83-100 per cent. bed making 100-100 per cent, and occupational therapy 83-100 per cent. The overall mean was 93 per cent for the first week and 100 per cent for the 29th week. Before the programme started. the observers participated in a 2-hr session in which the definitions of target behaviour were discussed. When the programme had started there were discussions concerning problems with the programme during the daily staff conference. and once a week the staff was provided with feedback about the preceeding week’s results. Back-up r~Gr~fo~~~r*s. The reinforcers that the patients could obtain through their surplus points are shown in Table 2. Leaving the ward after 4 p.m.. when the activities were finished for the day, was free providing the patient had collected his 15 points the preceeding day. However, if he wanted to leave before 4 p.m. it cost him 5 points. If they had enough surplus points, the patients could twice a day get access to the reinforcers numbered 510. Table 2. Back-up

reinforcers Cost in points

I. 2. 3. 4. 5. 6. 7. X. 9. IO.

Leaving the ward tr/trr 4 pm. Leaving the ward hq/o~ 4 pm. Leave of absence. rc~c~hr/tr~~.\ Leave of absence. ~IY&W/S Cigarettes: small packet large packet Ale. lemonades Sweets Fruit Newspapers. wcokly papers. comics Ticket to the cinema or football

0 5 I S/day S/day 3 5 Z/bottle l-5 I l-4 8

118

J. H. ERIKSSON. K. G. GGTESTAM. L. MELIN and L.-G. 6s~

Design. An ABABC-design was applied. The first phase. A 1 was a 3-week baseline period during which a ‘therapeutic community system’ was running. Then the token economy program started. Bl. and ran for 8 weeks. After that a 3-week reversal period followed. A2. when all the activities were performable, but there were no back-up reinforcers or points delivered. Leaving the ward was then decided individually through clinical judgement. The token system was started again as before and ran for I8 weeks. B2. During the last 2 weeks of the study a non-contingent reinforcement system. C. was applied. This meant that the patients started each morning with 23 points (the mean for B2-phase) and they could not collect more points through performing the activities. For a new patient. it took 4 days before he could have this privilege. All the activities and the reinforcers were the same as in the B2-phase. The day before a change in the program the personnel was informed at the regular staff meeting and the patients at a ward meeting usually later the same day. The introduction of the token economy (Bl) was explained as a method for activating the patients and making the rule system on the ward more consistent. The reversal (A2) and reintroduction (B3) of the token economy was explained as due to lack of funds and the receipt of new funds. The non-contingent reinforcement phase was introduced with the explanation that the high activity in B2 made a contingent reinforcement unnecessary. The patients were told that they were expected to continue booking and performing the activities. The same privileges and back-up reinforcers as in B2 were accessible but the patients received 23 points each morning regardless of their activity. RESULTS

The mean number of patients staying on the ward in the different phases were 5.6. 6.1. 6.2, 6.2 and 4.0 respectively. The differences between the phases were not significant. Furthermore there was no significant correlation between the mean number of patients staying on the ward and the different behavioural measures. The average time of treatment was 17 days (range 2-204 days). No patient participated in all the phases of the study. Of the 52 treated patients 31 (60 per cent) were in only one phase and the influence of changed contingencies on their activity level could not be evaluated. Of the remaining 2 1 (40 per cent) patients 7 were in the A 1-B 1 phases. 2 in A2-B2. 4 in BI-A2 and 5 in the B2-C phases. Furthermore, 2 patients participated in Bl-AZ-B2 and one in B 1-A2-B2-C.

If one considers BI and B3. i.e when the token economy was in effect on the ward. to be treatment phases, and A 1, A2 and C. i.e. baseline. reversal and non-contingent reinforcement, as non-treatment phases the following groups emerged. Group I, 12 patients who participated first in Al or A2 and then in Bl and B2 respectively, and Group 2. 13 who were first in B I or B2 and then in A2 and C. For these patients the mean number of points collected per day were calculated for the last 5 days of their first phase and the first 5 days in their second phase. For the first group of patients the mean number of points per day was 8.7 and 16.3 respectively. This difference. tested with r-test for correlated samples (Ferguson. 1959) was significant (t = 3.81 : p < 0.01). The second group had means of 19.5 and 9.6 respectively. This difference was also significant (t = 5.95; p < 0.001). This way of analyzing the data shows a significantly higher activity level when the token economy was in effect compared

A token economy

treatment

I

I

5

119

of drug addiction

20

I

I

25

30

I

Weeks

Fig.

I. Up and dressed in the morning.

to when it was not. To test if time on the ward per sr affected the mean number of points the following analysis was made. For the 31 patients who had been on the ward during one phase only the mean number of points for the first and the last 5 days of their treatment period was calculated. The 6 patients who participated in non-treatment phases only had a mean of 7.6 points/day for the first, and 5.5 for the last 5-day period (r = 1.04). For the 25 patients who stayed on the ward during treatment phases only, the corresponding means were 21.7 and 20.0points/day respectively (t = 1.52). Neither difference was statistically significant. Reinforced

actitlities

Up and dressed ar 8.00 (Fig. 1). This activity was defined as “The patient shall be out

of his bed and wearing day-clothes”. During baseline 63 per cent* of the patients performed this activity. This increased to 82 during the first treatment phase, increased further to 85 during reversal and to 92 during the second treatment phase. Finally it decreased sharply to 46 during non-contingent reinforcement phase. For this particular activity there was thus no decrease in A2. Momhg co@~e~~e (Fig. 2). This activity was defined as “The patient must be in the dayroom during the whole conference and he must wear day-clothes”. Forty-three per cent of the patients performed this activity according to its definition during baseline. During * The

percentages

given are means for the respective

I

5

IO

phases.

I5

20

25

Weeks Fig. 2. Morning

conference.

30

120

J. H. ERIKSON, K. G. CiiirrsTAht. L. MELIN and L.-G. 6,~

z

c

Al

lOOr

sE b t $

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I

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Weeks

Fig. 3. Bed-makmg.

Bl there was an increase to 84 per cent. During reversal there was a decrease to 74 per cent and during the second treatment period 96 per cent performed this activity. During C the activity decreased to baseline level (43 per cent). Be&nuking (Fig. 3). This is a very interesting activity because most psychiatric patients (including drug-addicts) generaXy get their beds made for them by the ‘service-minded staff. This is also reflected in the baseline data, only 6 per cent made their own bed. When the token economy was introduced 3 pqints were given for bed making because of the low initial level. However, after 6 weeks both patients and staff agreed upon this being too much and it was lowered to one point. As can be seen in Fig. 3 (weeks 8 and 9) the performance continued to increase despite this reduction. The mean for the BI-phase was 89 per cent and during reversal it decreased to 47 per cent. The reintroduction of the token economy (B2) brought about an increase to 90 per cent and the C-phase a decrease to 23 per cent. Physicul exercise (Fig. 4). This activity either meant going for a 30-min walk (with a staff member) or participating in some form of physical education (with a teacher) for half an hour. The activity showed the same change between phases as morning conference and bed-making and the mean percentages were 32, 78, 38, 84 and 24 respectively. Bookable acricities (Fig. 5). Several measures concerning the bookable activities were calculated: the proportion of patients that booked at least one activity, the proportion of booked activities that was performed accurately. and the mean number of booked activities per patient/day. All these measures were significantly (p < 0.01) correlated with the total activity on the ward (0.90. 0.66. and 0.69 respectively). The measure of booked activi-

Weeks

FIB. 4. Physical

exercise

A token economy treatment of drug addiction

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50-

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25

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Fig. 5. Proportion

of patients that booked at least one of the bookable activities.

ties shown in Fig. 5 was the proportion of patients that booked at least one of the bookable activities. During baseline this figure was very low (14 per cent) but it increased to 87 per cent when the token economy was introduced. decreased slightly (to 81 per cent) during reversal, and again increased to 96 per cent in the B2-phase. During the non-contingent reinforcement phase 44 per cent of the patients booked at least one of the bookable activities. This measure correlated significantly (1.= 0.50; 17< 0.01) with the proportion of booked activities that were actually performed. Total actiz*it_r(Fig. 6). This measure showed the most striking changes and consisted of the proportion of all possible activities (both genera1 and bookable) that were performed accurately. The changes in total activity followed the genera1 pattern of the other measures and the mean percentages for the different phases were 27, 79, 53, 86 and 33 respectively. P~po~ior~ qfpati~rts rrachir~y tlrc c’riterim (Fig. 7). This measure represented the proportion of patients who received at least I5 points. which gave them the privilege of leaving the ward without personnel. During baseline only 12 per cent of the patients would have gotten this privilege if the rule had been in effect. This proportion sharply increased to 79 per cent in BI, decreased to 38 per cent during reversal and increased to 94 per cent in B2. During the non-contingent reinforcement phase the proportion returned to about baseline level (18 per cent). Mearr n~thrr~ qf‘l1oinf.sper. patierrrjda_t~(Fig. 8). The last overall measure was the mean number of points the patients collected per day. It was on the average 5.94 during baseline (Al) and surpassed the I5-point criterion already during the first week of the token

50/

oI

\

, 5

I IO

I I5

I 20

Weeks Fig. 6. Total

activity

I 25

I 30

J. H. ERIKSSON. K. G. G~TESTAM. L. MELIN and L.-G. 6s~

122

I

5

IO

15

20

25

30

Weeks

Fig. 7. Proportion

of patients

reaching

the 15 points per day criterion.

economy. Then it continued to stay above this criterion every week in both treatment phases. During the non-treatment phases. however. it never reached the 1Spoint criterion. The means were 17.6, I 1.3. 22.4 and 8.1 in the B 1, A2. B2 and C phases respectively. Non-winforced

actiuitirs

Two activities that were characteristic of the former therapeutic community system on the ward, group therapy and ward meetings, were not included in the token economy program. The purpose was to find out whether these activities would change as a function of the reinforcement contingencies applied to the other behaviors. The non-reinforced activities are represented in Fig. 9, and as can be seen during the first token phase the proportion of patients attending ward meetings decreased from 95 to 67 per cent and group therapy from 47 to 19 per cent. During the reversal phase (A2) for the other activities these non-reinforced activities continued to decrease further to 55 and 13 per cent respectively. and during the second treatment phase (B2) there was an increase to 70 and 20 per cent. (The group therapy was discontinued after the 17th week when the group therapist left for vacation.)

The usual negative consequence for intoxication (spotted through urine analysis) on the treatment unit was that the patient got minus 40 points, i.e. he had to collect 40 points

0

I

5

IO

15

20

25

30

Weeks Fig. 8. Mean number

of points per day.

A token economy

oa I

d, 5

treatment

b IO

86 15

1’3

of drug addiction

I 25

I 20

I 30

Weeks

Fig. 9. Proportion

of patients

attending

ward meetings

(0) and group

therapy

(01

before he could have the privilege of leaving the ward again. If a patient refused to give a urine sample or gave it after 12.00 the same consequence was applied. i.e. he was considered intoxicated. However. if a patient gave his urine sample on time he earned 1 point. which made this the only activity connected with both positive reinforcement and response cost. Figure 10 presents the proportion of patient giving their urine sample on time and the percentage of intoxications (i.e. the proportion of positive urine samples plus refusals to give samples). These measures covary and change between the phases as could be expected. The mean percentages of intoxication during the different phases were 45, 9, 22, 10 and 8 respectively. The only difference between the phases was that positive reinforcement was applied in the treatment but not in the non-treatment phases. whereas the response cost contingencies for refusals or for positive urine samples remained intact over all phases. E’cts of into.uication OII acticin+rel. Daily urine samples were collected. Since the drug addicts, when taking drugs injected large amounts, these were easily traceable even 2-4 days later in their urine (by thin layer and gas-liquid chromatography). Therefore analyseswere only made ofall samples delivered 2 or 3 days a week. The 52 patients in the present study have given a total of 1062 urine samples and 447 (42 per cent) of these have been randomly selected for testing. This proportion was approximately the same for all phases of the study. The urine analyses resulted in 50 samples (11.2 per cent) which had traces of illegal drugs. An interesting question was whether an intoxication affected the activity-level of the patients in any way. In order to elucidate this question the following analysis was made.

Weeks Fig. IO. Proportion

of patients giving their urine samples urine samples (0).

on time (0) and proportion

of positive

124

J. H. ERIKSSON. K. G. GBTESTAM.

L. MELIN and L.-G. &r

For the group of 19 patients with positive samples the mean number of points received on the day of the urine sample. the day before and the day after were calculated for both positive and negative urine samples. The mean on the positive day was 22.1 points and on the negative day 19.0 points. This difference was not significant (r = 1.43). The same figures for the day before the tested urine sample were 20.9 and 20.2 respectively and the day after the urine sample 18.8 and 17.4 points. Neither difference was significant.

DISCUSSION

The main purpose of the present study was to design and evaluate a treatment programme that did not have the disadvantages of the former programmes at the clinic (Melin and Gotestam. 1973: Melin er ul.. 1974). This purpose was achieved as the present token economy had flexibility. concerning both the number of activities that the patient could choose to perform and in access to the reinforcers. Furthermore, the patients could use surplus points and the delay of negative consequences was I day only (with very few exceptions). All these factors. we believe. contributed to maintain a high activity-level throughout the treatment phases. The hypothesis underlying the token economy program is that it is the applied contingent reinforcement during the treatment phases rather than some extraneous variables that influence the activity-level of the patients. This hypothesis was verified in this study. Except for “up and dressed in the morning”, all the activities studied increased from baseline to treatment phase. decreased during reversal. increased again during the second treatment phase and finally decreased during the non-contingent reinforcement phase. Two activities that are considered very important in therapeutic community programmes, ward meetings and group therapy. were kept during the token economy but not reinforced. The result for these activities does not support the claim that the reinforced activities “take away the patients’ interest from these important activities”. The tentative conclusion that could be drawn was that the reinforcement contingencies applied to other activities did not influence these non-reinforced activities in any systematic way. As the patients could leave the ward unaccompanied by staff members. it was impossible to control their illegal drug taking. The urine analyses showed during non-treatment phases that either the patients refused to deliver urine samples or the samples were positive on 27 per cent of the occasions which is about the same as for the former therapeutic community treatment on the ward (Gunne and Sandberg. 1969). During treatment phases, however. the corresponding figure was IO per cent. These intoxications did not influence the patients’ activity-level to any significant degree. We consider it difhcult to improve the token economy as such, further in the application to drug addicts. To develop the treatment programme it is necessary to apply individual treatment techniques. According to Atthowe (1973) a token economy seems to work most efficiently if target behaviour is individualized according to the particular needs of the patient. Such an improved token economy should include reinforcement of steps towards social rehabilitation such as visits to social agencies, applying for jobs, or future planning activities. Furthermore, treatments geared at the drug-seeking behaviour itself could be implemented, such as covert extinction (Gotestam and Melin, 1974) or irr P&J exposure to environments previously associated with drug-taking. Of course the final evaluation of the place for token economies in the treatment of drug addiction will be possible only when follow-up figures for treatment groups and control groups are available.

A token economy

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REFERENCES ATHOWE JR. J. M. ( 1973) Token economies come of age. Bchor. Thrrapp 4,646-654. ATTHOWE JR. J. M. and KRASNER L. (1968) Preliminary report on the application of contingent reinforcement procedures (token economy) on a ‘chronic’ psychiatric ward. J. ahmrm. Psycho/. 73. 37-43. AYLLON T. and AZRI~ N. (1968) T/u, Tookrr~ Econo,nj,. A Morirarional Systrnt for Thrrapy and Rehahilitatror~.

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A token economy treatment of drug addiction.

Bchav Res. & Therapy. 1975. Vol 13. pp I I! A TOKEN 125. Pergamon Press Prmtrd m Great Bntam ECONOMY TREATMENT DRUG ADDICTION* OF JAN H. ER...
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