The first group project I was involved in which could legitimately be called a token economy started in a long-term psychiatric ward some 4½ yrs. ago and ran for 2½ yrs. I do not intend to go into all the details of the project, as they have been published elsewhere (Presly et al., 1976) and the project was similar to others (e.g. Mumford et al., 1975). I want instead to describe some of the things I learned from running a token economy and also to raise a number of issues which seem to be all too seldom discussed in relation to token economies in particular and to psychologists' involvement with long-term patients in general.

Examination of the results of previous treatment trials suggests that although behavioural treatment is effective in reducing agoraphobic symptoms, a large amount of treatment time is required, and patients tend to make no further gains when regular therapy sessions stop. A treatment programme was developed which was designed to provide an on-going alternative within the patient's own environment for the instructions and support normally given by the therapist, with the intention of reducing therapist time requirements and maintaining progress in the absence of contact during follow-up. This was done by incorporating the following features: detailed but easily understood instructions were given in written form as well as in discussion, all practice was carried out from the patients' own home, the patients spouse was actively involved in planning and encouraging practice attempts, and both patient and spouse were asked to take overall responsibility for running the programme themselves. Instructions were given in the form of manuals which contained material covering the nature of agoraphobic symptoms, the selection of targets, graded practice and suggestions for panic management.

Previous research suggests that the main causes of dental fear are a traumatic dental experience and negative expectations from others (Lautch, 1971), (Kleinknacht, 1973).

The paper reports a Token Economy project involving 18 long stay male patients (diagnosis chronic schozophrenia), average length of hospitalisation twenty-five years. The project comprised a one month baseline period, a six month Token Economy phase, a two month experimental phase and a second three months Token Economy. Conditions were the same for all patients except during the experimental phase where they were randomly assigned to one of three experimental groups to investigate the relative importance of social reinforcement and other variables involved in token systems. The groups were (1) a social reinforcement only group; (2) a social reinforcement and non-contingent tokens; (3) a social reinforcement and contingent, non-spendable tokens. Each groups' performance was compared both with the other groups and with their own performance over all phases of the study. Assessment measures comprised standardised psychiatric rating scales - the Nurses Observation Scale for In-patient Evaluation (Honigfeld and Klett, 1965; Honigfeld et al 1966), and the Psychotic Reaction Profile (Lorr et al, 1960); other rating checklists, and time-sampling data. Analysis of Variance was carried out on all data over the four phases of the programme. The total token economy package as represented by the first token economy period was shown to be effective in promoting improvements in most areas of patients' functioning as compared to baseline. Results during the experimental phase suggest that contrary to our initial hypothesis social factors involved in exchanging tokens are not demonstrably important sources of reinforcement in Token Economies. There were no inter-group differences during the experimental phase, suggesting that none of the variables studied were critical factors. After the experimental phase the return to the complete token package produced an unclear picture where there were significant improvements on some scales, but significant declines on others.

No previous trial has been reported in which only patients with social phobia were treated. There were nine such patients in a previous trial involving 18 agoraphobics and 18 other phobics (Gelder et al, 1973), in which they responded poorly to desensitization but no conclusion could be drawn from such a small sample. Gordon Paul (1966) found that volunteers with public speaking anxiety, a limited manifestation of social phobia, responded better to desensitization than to psychotherapy. Donald Meichenbaum (1971) also showed that similar volunteers responded well to desensitization but when social anxiety was more general subjects did better with a psychotherapy involving modification of self-instructions. It seemed clear that desensitization in the treatment of patients with social anxiety required further investigation and in the present trial it was compared with imaginal implosion and also with social skills training, an in-vivo treatment.

The study by Shaw, P.H. et al (This Bulletin) has described the effect of 3 kinds of treatment on one kind of social problem - social phobia. The present study compared the effect of 2 treatments on another kind of social problem - social inadequacy (the two studies were carried out in parallel so that comparisons could be made between them).