Mental Health Nursing

Cognitive behaviour therapy in in-patient care 187
difficulty, Wolpe successfully treated many patients with phobias. During
the late 1960s and early 1970s, systematic desensitisation was replaced by
a more practical form of treatment known as graduated exposure, something
to which we will refer below, as it has become very important to
specialist mental health nursing. Other forms of behaviour therapy, based
on classical conditioning, were developed primarily for the treatment of
people with conditions known as neuroses, or today more commonly called
‘common mental disorders’. Thus behaviour therapy was widened to
include treatments for obsessive compulsive disorder, social phobias and
sexual problems. For a more detailed account of these developments in
nursing, see Newell and Gournay (2000).
With regard to treatments for serious and enduring mental illnesses
such as schizophrenia, the learning theories of Skinner provided the basis
for other developments. The first clinical applications of this approach
were made in the 1950s and 1960s,when American psychologists used
Skinner’s theories as a basis for treating patients with chronic schizophrenia.
These developments, largely based in the USA, led to the now
legendary token economy units (Ayllon and Azrin, 1968). Token economies
were essentially in-patient units where staff/patient ratios were very high,
often one to one. Following very detailed assessment, patients were subjected
to treatment, which focused on a number of ‘socially desirable behaviours’.
Thus, the common problems which one sees in chronic schizophrenia,
such as lack of motivation, poor daily living skills and social withdrawal,
were targeted. The programme worked 24 hours a day and all socially
desirable behaviours were reinforced by giving the patient tokens. These
tokens normally took the form of discs, which were carried in pouches by
the nursing staff. Each time the patient performed a behaviour, which was
on the target list, the patient was immediately reinforced by the nurse who
gave the token. At the end of the day, the patient could exchange the
tokens for a wide range of rewards, including tobacco, sweets and additional
food, or the patient could save the tokens to buy extra privileges
such as leave outside the wards. In the UK, token economy systems were
developed in specialist units during the 1970s, the most well known of
which were in Wakefield, Yorkshire, and Hellingly, Sussex. In these hospitals,
the staffing ratios were very high and while the patient was on the
unit, progress was often very dramatic. However, when they were discharged
to the community or to other more ordinary wards in the hospital,
the treatment gains were often quickly lost. Nevertheless, it became
clear that the approach could be used as an intensive ‘quick start’ for a
rehabilitation process. Unfortunately, because of the expense of running
such highly staffed units, and the additional expenses for staff training
and rehabilitation resources, the use of the token economy drifted into
oblivion. Nevertheless, this development (although this is not widely