Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

Milieu Therapy The locus of milieu is a living, learning, or working environ- ment. The defining characteristics of treatment are the use of a team to provide treatment and the time the patient spends in the environment. Recent adaptations of milieu therapy include 24-hour-a-day programs situated in community locales fre- quented by patients, which provide in vivo support, case man- agement, and training in living skills. Most milieu therapy programs emphasize group and social interaction; rules and expectations are mediated by peer pres- sure for normalization of adaptation. When patients are viewed as responsible human beings, the patient role becomes blurred. Milieu therapy stresses a patient’s rights to goals and to have freedom of movement and informal relationship with staff; it also emphasizes interdisciplinary participation and goal-oriented, clear communication. Token Economy The use of tokens, points, or credits as secondary or generalized reinforcers can be seen as normalizing a mental hospital or day hospital environment with a program mimicking society’s use of money to meet instrumental needs. Token economies estab- lish the rules and culture of a hospital inpatient unit or partial hospitalization program, offering coherence and consistency to the interdisciplinary team as it struggles to promote therapeutic progress in difficult patients. These programs are challenging to establish, however, and their widespread dissemination has suf- fered because of the organizational prerequisites and the addi- tional resources and rewards needed to create a truly positively reinforcing environment. Table 28.12-2 lists behaviors that can be reinforced by tokens. Cognitive Rehabilitation Increased recognition of the prevalence and importance of neuro- cognitive deficits over the past decade has stimulated increasing interest in remediation strategies. Much of the work in this area has focused on psychopharmacological approaches, especially on the new-generation antipsychotics. New-generation medica- tions appear to have a positive effect on neurocognitive test per- formance, but the effect size for any of the medications is small to medium, and little evidence indicates that these medications have a clinically meaningful impact on neurocognitive functioning in the community. As a result, a parallel interest has arisen in the potential for rehabilitation or cognitive remediation. This body of work is distinguished from cognitive-behavioral therapy and cognitive therapy, which focus on reducing psychotic symptoms. A study at the National Institutes of Health (NIH) found that patients with schizophrenia were unable to benefit from explicit instructions and practice on the Wisconsin Card Sort- ing Test (WCST), a widely used test of executive functioning. The study was linked to data demonstrating that patients had diminished prefrontal blood flow in dorsolateral prefrontal cor- tex while responding to the WCST, implying that schizophrenia was marked by an unmodifiable abnormality of the dorsolateral prefrontal cortex. The NIH work stimulated a series of mostly successful laboratory demonstrations that WCST performance deficits, albeit widespread, are neither endemic to the illness nor

Table 28.12-2 Contingencies of Reinforcement in the Token Economy Used at the Camarillo–UCLA Clinical Research Unit a

Token earnings Morning rising from bed and getting dressed on time Satisfactory completion of morning activities of daily living Satisfactory participation in a social skills training group or recreational therapy activity Satisfactory participation in individual behavioral therapy session Satisfactory participation in leisure time activities (per activity) Meets criteria for dress and grooming checks during day (per check) Completes assigned jobs or tasks on unit (per job or task) Participates in off-unit vocational rehabilitation or adult education activity (per half-day) Showers satisfactorily

3 3

10

10

5

3

3 4

10

Token fines

Smoking rule violation

5 5

Lying on floor

Stealing

10 10 20 20

Forgery of token credit card Assault or property destruction Late return from grounds privileges

Reinforcers available for tokens Cigarettes

4

Drinks (coffee, tea, sodas, hot chocolate) Snacks (potato chips, pretzels, ice cream, candy)

10 10

Grounds privileges (per half-hour)

4 4 4

Music time (per half-hour)

Private room time (per half-hour)

immutable. For example, one study demonstrated that WCST performance could be enhanced by financial reinforcement and specific instructions. Other laboratories have since produced comparable and enduring effects using similar training strate- gies and extended practice alone. Ethical Issues The ethics of conducting rehabilitation strategies are generally the same as for conducting other psychotherapies. Two issues come up regularly, however: avoiding infantilization and main- taining confidentiality. The first concerns the risk of viewing the patient as unable to make adult choices, such as whether to participate in rehabilitation, where to live, whether or not to work, and whether or not to use drugs and alcohol. Although it may be more of a value than an ethical standard, psychiatric rehabilitation is based on the assumption that the practitioner and the patient are in a partnership to facilitate recovery and improve quality of life. The basic model involves collaboration 4 a This token economy uses a card that can be punched with holes to docu- ment token earnings and purchases. The token economy has three levels, which differ in the immediacy and type of reinforcement and privileges. At the highest level of performance, the patient carries a “credit card” and has full access to all unit privileges and rewards without having to pay with tokens. (Courtesy of Robert Paul Liberman, M.D.) Nintendo, Walkman stereo, private TV (per half-hour)