Reflecting on "The token economy: A motivational system for therapy and rehabilitation"

How have things changed in treatment and research in the field of serious mental illness (SMI) in the 50 years since the publication of the landmark text by Allon and Azrin ”The token economy: A motivational system for therapy and rehabilitation”?   This was the primary question in a recent spirited discussion including several eminent serious mental illness clinical researchers at the November 2018 meeting of the Association of Behavioral and Cognitive Therapy (ABCT).   The panel was chaired by Drs. Shirley Glynn and Charlie Davison, and was organized and supported by the Serious Mental Illness ABCT Special Interest Group, overseen by Dr. Jerome Yoman.  Drs.  Kim Mueser, David Penn, Steve Silverstein, and Will Spaulding highlighted the good, the bad, and the ugly in the development of the field of treatment for serious mental illness during the span of their careers.

When queried about both theoretical or applied frameworks informing their work, Mueser and Penn noted the significance of more established models such as “stress-vulnerability” and social skills training,  and Silverstein and Spaulding highlighted the necessity of also incorporating older perspectives from self-psychology (e.g., involving defensive maneuvers to protect self-esteem, and efforts to create meaning) and newer insights from neuroscience (including social and affective neuroscience), into the work if  more effective interventions are to be developed.    A reverberating theme in the discussion was the fact that science goes through cycles of rediscovering (and then re-envisioning) older truths.   

The speakers noted that, while there is a continual press to develop the “new”, this is often at the expense of disseminating, or even remembering, the proven “old”.   For example, both Penn and Mueser pointed out that social skills training is still a powerful intervention for people with psychosis, and yet it is not widely available.   Silverstein also reminded the audience that many of the core tenets of, and new developments in, cognitive-behavioral practice were anticipated and first used and described by writers such as Jung, Adler, Frankl, Perls, and others.  Silverstein suggested that students in training today would benefit from a careful reading of these seminal thinkers.  

When asked about the biggest changes they have seen in the field, Spaulding highlighted the deinstitutionalization movement and its later mixed consequences, both Penn and Silverstein noted the growing prominence of interventions in first episode psychosis, and Mueser and Penn highlighted the increasing emphasis on social and functional outcomes as treatment targets.  

The speakers were asked about the most salient research questions today, and there was consensus among panel members that dissemination is an ongoing concern—how do we make interventions scalable?   How do we move from the lab to the real world?  How do we create supportive environments for change?  There was spirited exchange, though, about whether lack of dissemination is a research question or a policy failure.  Mueser pointed out that mental health continues to be stigmatized, both in society and as reflected in poor funding for research and services, and that these impediments limit dissemination of proven interventions, even when they have empirical support.   

Participants expressed mixed feelings about the increasing interest in using technology in the treatment of SMI.  While several saw the promise of these interventions, that appreciation was tempered by concerns that enthusiasm often “gets ahead of” the evidence, that the uptake of scientifically established digital interventions was often limited among typical providers and consumers, and the creators needed to think through carefully the optimal use of these interventions.  That is, at least in SMI, apps could be very helpful in supporting generalization of clinical work and in collecting “real-world real-time” data, but are unlikely to ever be the sole strategy for delivering treatments.   There is also the issue that new treatments are almost always described along with positive findings in initial publications that are not replicated in later studies, and so it may be too soon to have a good sense of how helpful these technologies are, and when, and for whom.     

Towards the end of the discussion, speakers had the opportunity to reflect on some of the challenges in their own careers, as well as give a piece of advice to students and early career psychologists interested in the field of SMI.  With regard to the first point, both Silverstein and Spaulding noted the disappointments of having strong clinical/research SMI programs closed by officials or administrators even when the programs had had positive outcomes and offered unique training opportunities.  Both noted that the closing of these programs had been unanticipated and that even vigorous lobbying had not been effective in reversing the closures.  Part of the issue here seems to be these programs are cost-effective in the long run, but can be expensive to stand-up and maintain (compared to typical care), and the longer-term cost benefits do not necessarily accrue to the agency providing the more intensive initial treatment.   Silverstein and Spaulding reminded the audience that we live in a political world, and that we must work to be strong advocates for our work as well as rigorous clinical researchers.    

With regard to advice to students, several points were made.  Silverstein noted the importance of reading broadly, and attending to literature outside of the standard CBT curriculum (as noted above).   Penn highlighted the importance of good mentors and “thinking outside the box”.  Reflecting some of the comments made earlier, Spaulding noted the importance of questioning authority and having an open mind.   He also emphasized the importance of social justice and advocacy work.   Mueser encouraged those interested in entering the field to develop expertise in the existing empirically-supported interventions and work in areas that are personally compelling. 

So, how far have we come in the treatment of serious mental illness in 50 years?  In some ways, considering the deinstitutionalization movement and the current prominence of the recovery orientation, very far indeed.  In other ways, when we think about how far there is still to go, our speakers reminded us there is a LOT of work to do, and it is both in the scientific world and the policy arena.   


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