Schizophrenia Research 75 (2005) 405 – 416

www.elsevier.com/locate/schres

The token economy for schizophrenia: review of the literature

and recommendations for future research
Faith B. Dickersona,*, Wendy N. Tenhulab,c, Lisa D. Green-Padenb
a
Sheppard Pratt Health System, 6501 North Charles St., Baltimore, MD 21204, United States
b
Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
c
VA Capitol Health Care Network MIRECC, Baltimore, MD, United States
Received 29 April 2004; received in revised form 25 August 2004; accepted 31 August 2004
Available online 12 October 2004

Abstract

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 favor since that time. The current
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 treatments.
D 2004 Elsevier B.V. All rights reserved.

Keywords: Schizophrenia; Token economy; Behavior therapy; Social learning; Operant conditioning

1. Introduction however, have not been widely applied (Boudewyns

Token economy interventions have been developed
for the treatment of patients with schizophrenia and
other serious mental illnesses. These interventions,
* Corresponding author. Tel.: +1 410 938 4359; fax: +1 410 938
4364.
E-mail address: fdickerson@sheppardpratt.org
(F.B. Dickerson).
0920-9964/$ - see front matter D 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2004.08.026
et al., 1986; Dickerson, 1988; Corrigan, 1995; Liber-
man, 2000). The purpose of this article is to
summarize research studies about the token economy
for patients with schizophrenia.
The principles of operant conditioning comprise
the foundation for token economy interventions.
Building on the work of earlier psychologists,
Skinner postulated two blawsQ of operant behavior
(Skinner, 1953) which are broad generalizations that
apply to a wide range of human behaviors and have
406 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
been validated by a large body of research studies.
The laws help explain the natural development and
occurrence of behaviors. The principles can also be
used to deliberately change behaviors through the
application of operant conditioning strategies. It is
assumed that maladaptive behaviors are subject to
the same blawsQ of learning that govern bnormalQ
behavior.
The first principle, the blaw of effect,Q states that
the frequency of behavior is determined in part by the
consequences of the behavior or its effects. In other
words, behavior will be strengthened or weakened by
what follows. Consequences that increase the proba-
bility of behavior are known as reinforcers. Primary
reinforcers are ones that satisfy basic human needs,
such as hunger or thirst. Consequences that reduce the
probability of behavior include response cost and
punishment; they are less effective in changing
behavior than are reinforcers. Consequences are most
likely to influence subsequent behavior when they
immediately follow the behavior rather than when
there is a long interval between a behavior and its
consequences.
The second principle of operant conditioning, the
blaw of association by contiguity,Q posits that two
events will come to be associated with each other if
they occur together. A neutral stimulus that is paired
with a primary reinforcer will come to be a reinforcer
through its association with reinforcing consequences.
For example, in our society, money functions as a
reinforcer not because of its inherent characteristics
but because it is associated with the satisfying
commodities that are available through its use.
The paradigm of operant learning was applied to
clinical psychiatric settings in the 1950s with the aim
of modifying the behavior of severely regressed
psychotic inpatients (Lindsley and Skinner, 1954;
Lindsley, 1956). During the following decade, the
principles of operant conditioning were further refined
and applied to whole groups of patients in psychiatric
hospitals (Ayllon and Azrin, 1965; Atthowe and
Krasner, 1968). Such milieu-wide programs were
named btoken economiesQ, because they involve the
distribution of tokens as immediate reinforcers for
patients’ performance of specified target behaviors.
Target behaviors typically include adaptive behaviors,
such as self-care or work skills. Tokens may be
exchanged by patients at a later time for individually
selected reinforcers, called back-up or secondary
reinforcers, that include various desirable goods or
privileges.
Tokens or other similar media of exchange have
the advantage that they can be conveniently distrib-
uted to patients immediately after the performance of
target behaviors. The use of tokens serves to bridge
the delay between the performance of the behavior
and the opportunity to obtain back-up reinforcers. In
addition, unlike primary reinforcers, tokens are not
affected by the patients’ satiety; that is, patients are
motivated to earn tokens even if they are not
immediately in need of the back-up reinforcers that
can be purchased with the tokens (Ayllon and Azrin,
1968; Carlson et al., 1972). Target behaviors, rein-
forcers, and exchange rates are developed for each
token economy program; the specifics are determined
by local circumstances and the clinical needs of the
particular patient group. Although similar therapeutic
methods may be applied to different populations
(Kazdin and Bootzin, 1972; Stuve and Salinas,
2002; Seegert, 2003), this review concerns the use
of the token economy in programs designed primarily
for patients with schizophrenia.
The Schizophrenia Patient Outcomes Research
Team (PORT) recommendations, updated in 2003,
include a recommendation that systems of care that
deliver long-term inpatient or residential care should
provide a behavioral intervention based on social
learning principles (Lehman et al., 2004). This review
substantiates the PORT recommendation and includes
studies that have been published since previous
detailed summaries of research on the token economy
(Hagen, 1975; Glynn, 1990).
2. Method
Published articles describing empirical trials of
token economy interventions for patients with schiz-
ophrenia were identified by a National Library of
Medicine PubMed literature search using the follow-
ing key search words: token economy, behavior
therapy, social learning, operant conditioning, schiz-
ophrenia. The PubMed literature search covered the
years 1966–2002. Studies included in this review are
those that have a comparison condition with random
assignment by individual or group, or a comparison
 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
with matched controls. In addition, eligible for
inclusion are studies that utilize a quasi-experimental
A-B-A design, in which each study subject serves as
the subject’s own control; bAQ refers to the baseline
condition and bBQ the experimental condition. Studies
in this review were also limited to those written in
English and those that clearly describe and apply a
systematic token economy, social learning approach
focused on modifying patients’ behavior.
3. Results
A total of 13 studies met the criteria for inclusion
in the review. These studies are summarized in Table
1. The total number of patients involved in the trials is
approximately 1000, of whom about 600 are from one
study (Rimmerman et al., 1991). All five of the
studies that have random assignment by individual
show a significant benefit of the token economy
program. The design of the remainder of the studies
include random assignment by group (two studies),
comparison between groups without random assign-
ment (three studies), and a within-subject alternating
design (three studies). The focus of the studies
reviewed tends to be on behaviors that are adaptive,
observable, and operationally defined, so that they
may be objectively assessed. The target behaviors are
typically related to self-care and other activities of
daily living, basic social interaction, treatment partic-
ipation, and/or hospital work activity. Behavioral
outcomes may be measured as discrete events or as
continuous variables based on ward rating scales.
Although psychotic symptoms do not tend to be the
focus of token economy programs, at least two studies
targeted negative symptoms and found evidence for
their improvement.
All but two of the studies reviewed here found a
significant benefit for the token economy. Both of the
two negative studies (Marks et al., 1968; Baker et al.,
1977) compared and possibly confounded the token
economy with other active therapeutic approaches. To
our knowledge, there are no reviews combining the
results of more than one study that have utilized an
effect size analysis of the token economy in schizo-
phrenia. A recent review performed by the Cochrane
Library (McMonagle and Sultana, 2003) found only
three studies eligible for inclusion; the review
407
concluded that the token economy approach may
have benefit for negative symptoms and that more
research is warranted.
Examination of Table 1 indicates that the token
economy interventions differ among the studies. In
most of the studies, the token economy intervention
consisted of strict reinforcement procedures for
specified behaviors. In such cases, the token economy
was conceived of as an operant reinforcement
program and not as one element within a larger set
of rehabilitation strategies. By contrast, in a few
studies, reinforcement procedures were used as part of
a more comprehensive behavioral program, and it was
the broader token economy program that constituted
the experimental condition. Such an approach was
epitomized by the multifaceted social learning pro-
gram of Paul and Lentz (1977). This program
included skills training in a relatively enriched treat-
ment environment, along with the operant token
economy procedures. And, more recently, Li and
Wang (1994) studied an intervention that combined a
token economy with life skills training and active
interpersonal encouragement. Positive results for the
token economy were found in studies that focused on
discrete reinforcement procedures, as well as those
that used a broader-based token economy approach.
The studies under review can also be contrasted in
terms of the treatment condition(s) to which the token
economy was compared. In some of the studies,
especially the earlier ones, the comparison condition
was treatment as usual, a standard (for the era),
nonenriched treatment environment; invariably, the
token economy led to more improved outcomes. In
other studies, the token economy was compared with
a more social, interpersonal approach. For example,
Marks et al. (1968) directly compared reinforcement
procedures with individual supportive therapy; the
study found no significant differences in outcome
between the two conditions. And the seminal study by
Paul and Lentz (1977) included a comparison group
that involved supportive milieu therapy in addition to
a treatment-as-usual comparison group; the token
economy outperformed both. In some studies, various
elements of the token economy were also compared in
order to determine the active ingredients of the
intervention. For example, in a series of studies,
Baker et al. (1977) and Hall et al. (1977) studied the
relative benefit of token reinforcement both with and
408 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416

Table 1
Summary of controlled studies of token economy programs for patients with schizophrenia
Study Participants Intervention Comparison Other Results
and study design and duration condition(s) methodological
issues
Ayllon and Azrin, Eight to 44 female Operant Patients served as Study conditions The target
1965 inpatients, most reinforcement their own controls difficult to behaviors were
diagnosed as program; token in the A-B-A evaluate given the increased when
bschizophrenic reinforcers given design; in each context of study in reinforcement
reaction,Q at for adaptive experiment, the the state hospital in provided,
Illinois state behaviors, mostly intervention was early 1960s; many considerably
hospital; 6 A-B-A job performance, implemented, patients on no reduced when
design over the six discontinued, and medications reinforcement
experiments experiments which then implemented procedure
lasted 15–60 days; again discontinued, and
tokens exchangeable increased when
for privileges and reinforcement
items that reintroduced
were determined to
be of value to the
patients
Schaefer and Forty female Contingent token Standard ward Medications not Patients in active tx
Martin, 1966 inpatients with reinforcement for therapy on the specified; outcome group had reduced
schizophrenia at adaptive behaviors same ward measure derived behavioral ratings of
California state such as hygiene, from time sample apathy
hospital; social interaction, observations by
individual random work performance; independent raters
assignment tokens exchangeable
for range of
consumable items
and privileges; 6
months duration
Marks et al., 1968 Twenty-two male Contingent token Relationship Little data No significant
inpatients with reinforcement for therapy that provided about differences
chronic specified social involved daily 1-h medications; effort in overall
schizophrenia at behaviors; tokens supportive therapy to control for effectiveness
Washington state used to purchase sessions whether or not between two
hospital; all regular meals; 6 medication therapy
patients received months duration (3 changes made approaches
two therapy months in each tx during study;
conditions, order condition) difficulty in
balanced keeping two
therapy conditions
separate because
both were on the
same ward
Shean and Forty-two male Token economy Standard ward Medications not Adaptive behaviors,
Zeidberg, 1971 inpatients with with contingent rein- therapy on controlled and such as
chronic forcement for self- different ward but were used as self-care, work
psychiatric illness, care, with same staffing outcome; ratings performance,
most bpsychotic,Q interpersonal as experimental completed by ward communication,
at Virginia state interest, work ward attendants who and cooperation,
hospital, not performance, were not blind significantly more
randomly assigned reduction/ or independent improved in token
 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416 409

Table 1 (continued)
Study Participants Intervention Comparison Other Results
and study design and duration condition(s) methodological
issues
Shean and but groups elimination of economy patients;
Zeidberg, 1971 matched for age, bizarre behaviors; 1 mean dose of
diagnosis, year duration medications lower
chronicity in token economy
patients
Gripp and Forty-five female Token economy with Standard ward Most of patients Token economy
Magaro, 1971 inpatients with contingent token therapy on three had medications patients significantly
chronic mental reinforcement for separate wards discontinued after improved on 7/10
illness selected for adaptive behaviors token economy symptom and
being combative mostly related to started; diagnoses behavioral variables
or disruptive; work performance; not specified; and control patients
compared with tokens exchangeable ratings not blind or on 2/10 variables
patients on control for range of independent;
wards, not reinforcers including number of
randomly assigned food and activities; 6 comparison
months duration patients not
specified
Maley et al., 1973 Forty female Token economy with Standard ward, Study conditions Patients from
inpatients at West positive and negative custodial care, in difficult to token economy
Virginia state reinforcers; target same hospital evaluate given unit outperformed
hospital with behaviors were standard of care comparison patients
chronic grooming, when study was on cognitive tasks,
schizophrenia; appropriate performed; raters such as orientation
individual random behavior, and were blind to and also on
assignment cooperation with patients’ study behavioral adjustment
others. Individual condition; ratings made from
treatment, group, medications interview
and work unspecified
strategies also
provided; program
22–31 weeks
Paul and Lentz, Eighty-four Social learning Two comparison Ninety percent of Social learning
1977 patients, 18–55 program with conditions: patients received patients spent less
years old with highly specific (1) therapeutic bmaintenance time in hospital
chronic psychotic token economy community milieu levelQ drugs at and required less
disorder, from and many hours with well-specified start; extensive psychotropic
Illinois state structured procedures and battery of medications; 97% of
hospital; educational also structured assessments social learning pts
individual random activities; 6-year educational throughout study had successful d/c to
assignment study; patients activities; (2) with independent communication vs.
stratified by followed for 1.5–5 traditional hospital raters and direct 71% of patients from
overall level of years ward program. All observations of therapeutic milieu
functioning three conditions patient and staff and 45% of pts from
had same behavior traditional ward; once
resources discharged, no
differences b/t groups
in terms of successful
community tenure
(continued on next page)
410 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416

Table 1 (continued)
Study Participants Intervention Comparison Other Results
and study design and duration condition(s) methodological
issues
Baker et al., Eighteen Token economy Two comparison Patients received Both active treatment
1977; Hall inpatients with with contingent groups: standard groups improved on
et al., 1977 chronic token reinforcement (1) identical medications; behavioral measures
schizophrenia at for adaptive program on same ratings made by but no significant
UK hospital, b 48 behaviors; 12 ward as token ward nurses in two difference between
years old, not months duration economy; social active treatment groups; neither active
paranoid subtype, praise and feed- groups treatment group
allocated to three back provided for improved on
matched groups target behaviors; symptom measure
(2) No treatment
control group on
standard ward
Elliott et al., Eighteen male Token economy Three Study conditions During initial token
1979 inpatients with which included experimental difficult to economy phase,
chronic token conditions in evaluate given patients improved on
schizophrenia at reinforcement for bBQ phase of study: standard of care all measures of nurse
UK hospital, mean hygiene, work (1) contingent when study was and psychiatric rating
duration; habits, social social performed; scales and behavioral
individual random interaction with a reinforcement, but medications stable checklists except
assignment to one variety of back-up no tokens, given during study, but irritability and
of three variations reinforcers; study for target not specified; thought
of token economy duration 3 months behaviors; raters not blind to disorganization.
in A-B-A design (2) contingent study condition Behavior and
tokens given but symptoms worsened
not exchangeable some in all three con-
for back-up ditions during bBQ
reinforcers; (3) phase of study. When
noncontingent token economy
tokens given reintroduced, some
behaviors improved
and some declined
Nelson and Sixteen male Token economy pro- Usual treatment on Majority of Behavioral
Cone, 1979 inpatients at W. gram including ward for behaviors patients received observations and
Va. state hospital; prompting, tokens, that not focus of antipsychotic scores on nurse rating
13 psychotic and 3 and back-up token economy medication; raters scales showed
MR; sequential reinforcers were independent; substantial
multiple baseline introduced two of three raters improvement in
design sequentially for four were blind to performance of target
groups of nature of study; behaviors following
target behaviors fidelity check on implementation of
(personal hygiene, operation of token token economy
personal economy proce-
management, dures
ward work, and
social skills); study
duration 3 months
Rimmerman Outpatients (617) Token economy in Usual group home Patients not Patients in homes
et al., 1991 with chronic group homes; treatment individually with token economy
mental illness study took place randomly assigned had marginally better
residing in three over 18 months outcomes on all
adult homes in measures
New York,
assigned by home
 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416 411

Table 1 (continued)
Study Participants Intervention Comparison Other Results
and study design and duration condition(s) methodological
issues
Lippman and Thirty-six Two types of Program of Medications not Patients in both
Motta, 1993 outpatients at token economy noncontingent specified positive and negative
community over 6-week period: reinforcement reinforcement groups
residences in (1) contingent outperformed control
Queens, NY; most positive patients on ADL
schizophrenia, reinforcement for measure throughout
randomly assigned performance of study; no significant
by living unit target behaviors difference between
(mostly ADLs) groups in mood
with back-up scores
reinforcers;
(2) contingent
negative
reinforcement
Li and Wang, Fifty-two inpa- Behavioral Usual treatment on Patients all Negative symptoms
1994 tients, program of life skills ward received previous of pts in active tx
with schizophrenia training and token dosage of group significantly
and prominent economy program neuroleptic lower at end of
negative symp- over 3 months medications intervention and this
toms, throughout trial; group showed greater
ill N5 years, in raters independent overall improvement
Beijing, China and blind to study
hospital; individ- condition; dropout
ual random assign- rate of 23% over
ment course of trial

without social praise and feedback; there was also a
standard control group. In their studies, both active
treatment groups showed relative benefit. And in a
more recent investigation, Lippman and Motta (1993)
studied two different types of contingent reinforce-
ment, one positive and one negative, in comparison
with a noncontingent reinforcement control condition.
Both reinforcement groups outperformed the control
group, and there was not a significant difference
between the active treatment groups.
The studies under review can also be examined in
terms of the target outcomes that were used to
evaluate the effectiveness of the token economy. In
most studies, more than one type of assessment
measure was used to evaluate patients in the token
economy versus the comparison condition. The most
common type of outcome measure in the studies was
ward rating scales, such as the Nurse Observation
Scale for Inpatient Evaluation (NOISE-30; Honigfeld
and Klett, 1965) or the Wing Ward Behavior Scale
(Wing, 1961). These measures were used in 7 of the
13 studies reviewed here and provide the most
consistent data favoring the token economy. Another
type of outcome measure that was used consisted of
behavior time sampling and behavior checklists; data
from these measures also tended to show a relative
advantage for patients in the token economy con-
dition. Less consistently associated with improvement
in the token economy versus the comparison con-
dition were ratings made on symptom rating scales
and patients’ performance on cognitive tests of
orientation or intelligence.
In the following section, we describe three of the
studies currently reviewed and summarized in Table 1.
These three studies were published in different
decades and illustrate the range of studies that have
been done of the token economy approach.
Studies with an A-B-A design that were performed
in the 1960s and 1970s found a marked and some-
times dramatic effect of contingent reinforcement. For
example, in a ground-breaking study by Ayllon and
Azrin (1965), female patients on a long-stay state
412 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
hospital unit increased their performance of ward jobs
from nearly none to a high level depending on
whether or not contingent token reinforcement was
provided. The contingent reinforcement entitled the
patients to personal selections of goods and privileges.
Important in this seminal study was the use of
individually calibrated reinforcement contingencies
based on patients’ preexisting levels of preferred
behaviors. Despite the marked effect of the social
learning approach in the study, the authors note the
approximately one quarter of patients for whom the
reinforcement procedure had only limited effect on
work performance; this finding underscores the
individual variability in response to the intervention.
Studies with random assignment by individual
provide the clearest evidence of the benefits of the
token economy. The 6-year investigation by Paul and
Lentz (1977) was highly rigorous in its design and
implementation and represents the most comprehen-
sive study of the token economy to date. In this study,
the effectiveness of three inpatient programs for
severely debilitated hospital patients was compared:
social learning token economy, milieu supportive, and
standard hospital control. A total of 84 patients were
randomized to one of the three conditions from
stratified blocks based on patients’ initial functioning
level. The three programs were implemented at the
same state hospital and had equivalent staffing levels.
Patients were followed through the duration of their
hospital stay and after discharge into the community
when discharge was possible. Results of the study
indicate that the social learning program yielded
significant improvement in 100% of the participating
patients compared with 55% in the milieu condition
and 33% in the control group. Furthermore, in the
social learning program, 97% of patients were
successfully discharged to the community for at least
18 months compared with 71% in the milieu condition
and 45% in the control condition. Strengths of the
study include the detailed and objective measures that
were collected, the thoroughness with which each of
the interventions was specified and implemented, and
the length of the study that allowed for follow-up after
hospital discharge.
The most recent controlled study of the token
economy to appear in the medical literature is from
China and represents a more contemporary treatment
program. In this study (Li and Wang, 1994), 52
inpatients with schizophrenia and prominent negative
symptoms were randomized to a rehabilitation pro-
gram or a control condition. The rehabilitation
program included life skills training and positive
reinforcement delivered in a token economy; the other
activities and expectations for patients were similar
between the two conditions. After 3 months, the
patients in the experimental group showed signifi-
cantly more improvement in negative symptoms than
did those in the comparison group.
4. Discussion
The efficacy of token economy social learning
programs for patients with schizophrenia is supported
by substantial research evidence. The evaluation of
token economy programs in the literature, however, is
complicated by the fact that most of the studies were
performed more than 20 years ago with long-stay
inpatients. It is uncertain how these patients compare
with patients on contemporary inpatient units or
residential programs. In the earlier studies, a persistent
illness course was typically required for study
participation. This inclusion criterion was operation-
alized by the fact of a patient’s placement on a long-
stay hospital unit or by a minimum length of the
hospital stay preceding the study. For example, in the
Paul and Lentz (1977) study, all participants had to
have been hospitalized for a minimum of 2 years, and
the average duration of participants’ previous hospi-
talization was 17 years. One can assume that the vast
majority of inpatients in early token economy studies
would not currently be receiving hospital-level care.
It is also difficult to evaluate the clinical character-
istics of the patients who participated in many of the
token economy studies in light of current standards
and current treatments. Many of the studies were
performed before the introduction of more objective
diagnostic criteria for schizophrenia in the Diagnostic
and Statistical Manual of Mental Disorders III of 1980
(DSM-III; American Psychiatric Association, 1980).
And, although token economy programs in psychiatric
settings were developed primarily for individuals with
schizophrenia, few of the programs reported in the
literature were diagnostic-specific; the study by Li and
Wang (1994) is an exception. Most of the token
economy programs summarized here had broad
 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
inclusion criteria. In the earlier studies particularly,
participants were often all patients who were physi-
cally able to participate on a long-stay inpatient unit
where the token economy was implemented. Patients
with mental retardation or borganicQ disorders were
typically not excluded.
The settings in which most of the token economy
studies were performed were also relatively deprived
and restrictive by today’s standards. The settings were
typically long-stay units at state hospitals with few
available psychosocial or medication treatments. Most
of the studies were performed before the era of
atypical antipsychotic medications, leaving medica-
tion options relatively limited. And, weakening the
research design of almost all of the studies is that the
medication treatment was unspecified and it is
uncertain if it was optimized.
Apart from issues related to the different era in
which many of the studies were performed, a major
issue in the literature concerns the extent to which
patient gains in a token economy may not transfer or
generalize to other clinical settings (Kazdin and
Bootzin, 1972; Glynn, 1990; Corrigan, 1995). Critics
of the token economy also note that improvements
that take place when behavioral contingencies are in
effect may not be maintained once the contingencies
are removed (Kazdin and Bootzin, 1972). On the
other hand, in studies with an A-B-A design, this
phenomenon has been used as positive evidence of the
effectiveness of reinforcement programs (e.g., Ayllon
and Azrin, 1965). And, it may be argued that many
treatments, both psychosocial and psychopharmaco-
logical, do not maintain their full beneficial effects
after they have been withdrawn (Corrigan, 1995). The
token economy promotes an increase in adaptive
behaviors and a reduction of inappropriate behaviors,
and it should be primarily evaluated on this basis.
Procedures have been identified to maximize the
likelihood that benefits accrued from a token economy
intervention may be enduring and may persist after
discharge from the hospital or residential setting. For
example, target behaviors may be selected on the
basis of those behaviors that will be reinforced after
hospital discharge (Ayllon and Azrin, 1968; Corrigan,
1991). Services may be provided that help patients to
apply skills in the community that have been learned
in the inpatient setting (Glynn et al., 2002). External
reinforcers may be faded prior to discharge as the
413
patient’s behavior improves (Silverstein et al., 2002).
There are not any studies since the seminal work of
Paul and Lentz (1977) that have formally investigated
the transfer of token economy benefits from the
hospital setting where the intervention took place to
the community.
There has been controversy over the degree of
control that staff members exert in token economy
programs. Critics of the token economy have put
forth the view that reinforcement contingency pro-
grams may be coercive, degrading, and inhumane
(Hagen, 1975; Bilken, 1976; Corrigan, 1995). The
argument is that patients need to be empowered to
make their own treatment choices, and that any
restriction in autonomy may constitute an infringe-
ment of bpatients’ rights.Q A counterargument is that
a high degree of control is often exerted by staff in
hospital and residential settings even if such author-
ity is not explicitly stated or systematically applied;
unfortunately, some treatment programs, whether
labeled behavioral or not, have misused their control
over patients through the imposition of punishment
and aversive consequences. It has also been noted
that reinforcement contingencies are ubiquitous; all
persons, psychotic and bnormalQ alike, are affected
by such contingencies (Skinner, 1953). The issue
then is how to best structure contingencies and focus
them on positive reinforcers in order to facilitate
patients’ improvement.
The application of social learning principles to
current treatment settings is limited by several
considerations. In order for a token economy program
to be effective, there must be control over external
environmental contingencies. Such conditions are
difficult to create in community treatment settings
where the vast majority of schizophrenia patients
currently receive their care and where patients have
access to a wide variety of reinforcers from numerous
sources (Glynn, 1990; Corrigan, 1991; Dickerson,
1996). It is of note that only 2 of the 13 studies
reviewed here (Rimmerman et al., 1991; Lippman and
Motta, 1993) were performed in outpatient settings,
and both are limited by aspects of their study design.
Suggestions have been made about how token
economy social learning programs may be applied
in nonhospital settings for patients with serious mental
illness (Corrigan, 1991; Dickerson, 1996); however,
there has been little research published on this topic.
414 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
Current ethical and legal standards differ from
those in place when the original token economy
studies were performed. At that time, basic amenities
such as food and sleeping space were sometimes
included as reinforcers. Some of these reinforcers
could not be included as reinforcers in the present era
because they are basic necessities to which patients
are entitled and that cannot legally be withheld.
Current policies are backed by court decisions that
have been made since the initial development of the
token economy; these decisions have held that
patients are entitled to access to their personal
property that cannot be denied in the name of
treatment (Glynn, 1990). In addition, some reinforcers
that were central to early token economy programs are
no longer ethical to use because they are now
recognized to be unhealthy, such as cigarettes and
other tobacco products.
Consent to participate was not included in the
process of enrolling patients in the early token
economy research studies, and, not surprisingly, these
programs report few dropouts. Once protected by the
right to refuse the intervention or to discontinue,
patients may be less willing to participate. More rapid
turnover in hospital settings also adds to patient
attrition from studies, making it difficult to assess the
long-term benefit of token economy interventions. A
relatively recent study of the token economy had a
23% dropout rate among participants due mostly to
hospital discharges during the 3-month study period
(Li and Wang, 1994).
Token economy interventions are complex and
difficult to deliver, which also has limited their
application in treatment settings. It is important to
ensure consistency among staff in carrying out a token
economy program and in administering reinforce-
ments to patients that are positive, immediate, and
specific. These standards are difficult to meet. Design-
ing a token economy is also challenging in terms of
selecting the particular target behaviors and contin-
gencies, as well as determining how the program
should be individualized for patients.
A treatment setting may need to be reorganized to
carry out a token economy, which may serve as an
impediment to the use of the token economy approach
(e.g., Franco and Kelley, 1994). Because it is an
organized system, a token economy program must be
coordinated among all of the clinical staff who work
with participating patients. As part of the development
of any token economy program, staff training is
necessary. In the days of early token economy
programs, the challenge of training staff was consid-
ered daunting, and there is no reason to think that the
challenge is any less difficult in the current era. In
addition, standardized training materials are not
widely available. And, to our knowledge, fidelity
tools for the token economy have not been developed.
The costs of the token economy also need to be
taken into account. A token economy program usually
requires additional costs for training, for the staffing
of units to implement the program, for the admin-
istration and record keeping associated with the
program, and also for the cost of reinforcers (Glynn,
1990). In the current era of care, it is uncertain that
public sector systems would be willing to make these
expenditures, particularly as state agencies face
budget cutbacks. A favorable cost-benefit analysis
would be helpful in order to justify use of the
approach. Paul and Lentz (1977) concluded that the
social learning program was cost-efficient because the
cost of the program was more than offset by savings
from reduced hospital stays. However, studies have
not been performed of the cost-effectiveness of the
token economy in current treatment environments.
5. Future research directions
Research studies, including the rigorous study
performed by Paul and Lentz (1977), indicate that
interventions based on social learning principles are
effective in increasing the adaptive behaviors of
patients with schizophrenia in institutional or resi-
dential treatment environments. While the token
economy has been provided in some current settings
(Silverstein et al., 2002; W Tenhula, personal com-
munication), more research is needed about social
learning token economy programs in the contempo-
rary treatment of schizophrenia. Studies should be
undertaken to assess the efficacy of the token
economy in the context of inpatient and residential
programs that provide evidence-based psychosocial
treatments. These treatments have been developed and
established as effective since the time period when
many of the earlier token economy studies were
performed and include skills training and cognitive
 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
behavioral psychotherapies (Lehman et al., 2004). In
order to determine the specific benefit of the token
economy approach, it is also important that medica-
tion treatments are optimized and in conformance
with treatment standards. Because atypical antipsy-
chotic medications may also reduce negative symp-
toms and social withdrawal, the interaction between
the token economy approach and atypical antipsy-
chotic medications needs to be investigated. One
relatively recent study evaluated the combined effec-
tiveness of clozapine and a comprehensive social
learning program for schizophrenia (Menditto et al.,
1996), but such an integrated approach is rare in the
treatment literature.
Methodological improvements over many previous
token economy studies are necessary. Explicit inclu-
sion and exclusion criteria should be used, as well as
masked ratings of patient behavior and psychopathol-
ogy. Random assignment by individual to treatment
condition, present in less than half of the studies
reviewed here, is desirable in future investigations. In
addition, dependent measures are needed beyond
those that assess adaptation to the hospital unit;
measures should evaluate patients’ transition to less
restrictive residential and community settings. The
ultimate test of the token economy is its cost
effectiveness in leading to shorter hospital or resi-
dential stays and a reduced need for other high cost
services.
The seminal studies of the token economy were
undertaken in an era with different ethical and legal
standards guiding the selection of reinforcers. Studies
in contemporary settings that are performed with
appropriate reinforcers by today’s standards would be
helpful in establishing the types of reinforcement
systems that are the most effective. Standardized
token economy materials would also be useful.
Results of research studies may help in establishing
the benefits of the token economy in the context of
modern psychiatric settings and may enable it to
regain a greater role in the contemporary treatment of
schizophrenia.
Acknowledgements
Preparation of this manuscript was supported by
NIMH grant P50 MH43703.
415
References
Studies with an * are summarized in the accompanying evidence
table.
American Psychiatric Association, 1980. Diagnostic and
Statistical Manual of Mental Disorders, Third edition.
DSM-III. Washington, DC.
Atthowe, J.M., Krasner, L., 1968. Preliminary report on the
application of contingent reinforcement procedures (token
economy) on a bchronicQ psychiatric ward. J. Abnorm.
Psychology 73, 37 – 43.
*Ayllon, T., Azrin, N.H., 1965. The measurement and reinforcement
of behavior of psychotics. J. Exp. Anal. Behav. 8, 357 – 383.
Ayllon, T., Azrin, N.H., 1968. The Token Economy: A Motivational
System for Therapy and Rehabilitation. Prentice Hall, Engle-
wood Cliffs, NJ.
*Baker, R., Hall, J.N., Hutchinson, K., Bridge, G., 1977. Symptom
changes in chronic schizophrenic patients on a token economy:
a controlled experiment. Br. J. Psychiatry 131, 381 – 393.
Bilken, D.P., 1976. Behavior modification in a state mental
hospital: a participant observer’s critique. Am. J. Orthopsy-
chiatr. 46, 53 – 61.
Boudewyns, P.A., Fry, T.J., Nightengale, E., 1986. Token economy
program in VA medical centers: where are they today? Behav.
Ther. 6, 126 – 127.
Carlson, C.G., Hersen, M., Eisler, R.M., 1972. Token economy
programs in the treatment of hospitalized adult psychiatric
inpatients. J. Nerv. Ment. Dis. 155, 192 – 204.
Corrigan, P.W., 1991. Strategies that overcome barriers to token
economies in community programs for severe mentally ill
adults. Community Ment. Health J. 27, 17 – 30.
Corrigan, P.W., 1995. Use of a token economy with seriously
mentally ill patients: criticisms and misconceptions. Psychiatr.
Serv. 46, 1258 – 1263.
Dickerson, F.B., 1988. Behavior therapy in private psychiatric
hospitals: a national survey. Behav. Ther. 12, 157.
Dickerson, F.B., 1996. Lessons from the token economy for today’s
rehabilitation programs. Psychiatr. Rehabil. Skills 1, 3 – 6.
*Elliott, P.A., Barlow, F., Hooper, A., Kingerlee, P.E., 1979.
Maintaining patients’ improvements in a token economy. Behav.
Res. Ther. 17, 355 – 367.
Franco, H., Kelley, T.H., 1994. Obstacles in the implementation of a
behavior therapy ward in a state psychiatric hospital. In:
Corrigan, P.W., Liberman, R.W. (Eds.), Behavior Therapy in
Psychiatric Hospitals. Springer, New York, pp. 167 – 178.
Glynn, S., 1990. Token economy approaches for psychiatric
patients: progress and pitfalls over 25 years. Behav. Modif.
17, 383 – 407.
Glynn, S.M., Marder, S.R., Liberman, R.P., Blair, K., Wirshing,
W.C., Wirshing, D.A., Ross, D., Mintz, J., 2002. Supplementing
clinic-based skills training with manual-based community
support sessions: effects on social adjustment of patients with
schizophrenia. Am. J. Psychiatry 159, 829 – 837.
*Gripp, R.F., Magaro, P.A., 1971. A token economy program
evaluation with untreated control ward comparisons. Behav.
Res. Ther. 9, 137 – 149.
416 F.B. Dickerson et al. / Schizophrenia Research 75 (2005) 405–416
Hagen, R.L., 1975. Behavioral therapies and the treatment of
schizophrenia. Schizophr. Bull. 13, 70 – 96.
Honigfeld, G., Klett, C.J., 1965. The nurse observation scale for
inpatient evaluation: a new scale for measuring improvement in
chronic schizophrenia. J. Clin. Psychol. 21, 65 – 71.
*Hall, J.N., Baker, R.D., Hutchinson, K., 1977. A controlled
evaluation of token economy procedures with chronic schizo-
phrenic patients. Behav. Res. Ther. 15, 261 – 283.
Kazdin, A.E., Bootzin, R.R., 1972. The token economy: an
evaluative review. J. Appl. Behav. Anal. 5, 343 – 372.
Lehman, A.F., Kreyenbuhl, J., Buchanan, R.W., Dickerson, F.B.,
Dixon, L.B., Goldberg, R., Green-Paden, L.D., Tenhula, W.N.,
Boerescu, D., Tek, C., Sandson, N., Steinwachs, D.M., 2004.
The Schizophrenia Patient Outcomes Research Team (PORT):
updated treatment recommendations 2003. Schizophr. Bull. 30,
193 – 217.
*Li, F., Wang, M., 1994. A behavioural training programme for
chronic schizophrenic patients: a three-month randomized
controlled trial in Beijing. Br. J. Psychiatr., Suppl. 24, 32 – 37.
Liberman, R.P., 2000. The token economy. Am. J. Psychiatry 157,
1398.
Lindsley, O.R., 1956. Operant conditioning methods applied to
research in chronic schizophrenia. Psychiatry Res. Rep. 5,
118 – 153.
Lindsley, O.R., Skinner, B.F., 1954. A method for the experimental
analysis of psychotic patients. Am. Psychol. 9, 419 – 420.
*Lippman, M.R., Motta, R.W., 1993. Effects of positive and
negative reinforcement on daily living skills in chronic
psychiatric patients in community residences. J. Clin. Psychol.
49, 654 – 662.
*Maley, R.F., Feldman, G.L., Ruskin, R.S., 1973. Evaluation of
patient improvement in a token economy treatment program. J.
Abnorm. Psychology 82, 141 – 144.
*Marks, J., Sonoda, B., Schalock, R., 1968. Reinforcement versus
relationship therapy for schizophrenics. J. Abnorm. Psychology
73, 397 – 402.
McMonagle, T., Sultana, A., 2003. Token economy for schizo-
phrenia. Cochrane Library, Issue 1, Update Software.
Menditto, A.A., Beck, N.C., Stuve, P., Fisher, J.A., Stacy, M.,
Logue, M.B., Baldwin, L.J., 1996. Effectiveness of clozapine
and a social learning program for severely disabled psychiatric
inpatients. Psychiatr. Serv. 47, 46 – 51.
*Nelson, G.L., Cone, J.D., 1979. Multiple baseline analysis of a
token economy for psychiatric patients. J. Appl. Behav. Anal.
12, 255 – 271.
*Paul, G.L., Lentz, R.J., 1977. Psychosocial Treatment of Chronic
Mental Patients: Milieu versus Social-Learning Programs.
Harvard University Press, Cambridge, MA.
*Rimmerman, A., Finn, H., Schnee, J., Klein, I., 1991. Token
reinforcement in the psychosocial rehabilitation of individuals
with chronic mental illness: is it effective over time? Int. J.
Rehabil. Res. 14, 123 – 130.
*Schaefer, H.H., Martin, P.L., 1966. Behavioral therapy for
"apathy" of hospitalized schizophrenics. Psychol. Rep. 19,
1147 – 1158.
Seegert, C.R., 2003. Token economies and incentive programs:
behavioral improvement in mental health inmates housed in
state prisons. Behav. Ther. 26, 208 – 211.
*Shean, G.D., Zeidberg, Z., 1971. Token reinforcement therapy.
Behav. Ther. Exp. Psychiatry 2, 95 – 105.
Silverstein, S.M., Hatashita-Wong, M., Bloch, A., 2002. A second
chance for people with btreatment-refractoryQ psychosis. Psy-
chiatr. Serv. 53, 480.
Skinner, B.F., 1953. Science and Human Behavior. McMillan, New
York.
Stuve, P., Salinas, J.A., 2002. Token economy. Encyclopedia of
Psychotherapy, vol. 2. Elsevier, New York, pp. 821 – 825.
Wing, J.K., 1961. A simple and reliable subclassification of chronic
schizophrenia. J. Ment. Sci. 107, 862 – 875.