896
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
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
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
3
Satisfactory completion of morning activities of daily
living
3
Satisfactory participation in a social skills training
group or recreational therapy activity
10
Satisfactory participation in individual behavioral
therapy session
10
Satisfactory participation in leisure time activities
(per activity)
5
Meets criteria for dress and grooming checks during
day (per check)
3
Showers satisfactorily
3
Completes assigned jobs or tasks on unit (per job or task)
4
Participates in off-unit vocational rehabilitation or
adult education activity (per half-day)
10
Token fines
Smoking rule violation
5
Lying on floor
5
Stealing
10
Forgery of token credit card
10
Assault or property destruction
20
Late return from grounds privileges
20
Reinforcers available for tokens
Cigarettes
4
Drinks (coffee, tea, sodas, hot chocolate)
10
Snacks (potato chips, pretzels, ice cream, candy)
10
Grounds privileges (per half-hour)
4
Music time (per half-hour)
4
Private room time (per half-hour)
4
Nintendo, Walkman stereo, private TV (per half-hour)
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.)
