Journal of Women & Aging

ISSN: 0895-2841 (Print) 1540-7322 (Online) Journal homepage: https://www.tandfonline.com/loi/wjwa20

Rehabilitation Programs for Elderly Women

Inpatients with Schizophrenia

Carlos M. Coelho , António P. Palha , Daniela C. Gonçalves & Nancy Pachana

To cite this article: Carlos M. Coelho , António P. Palha , Daniela C. Gonçalves & Nancy Pachana
(2008) Rehabilitation Programs for Elderly Women Inpatients with Schizophrenia, Journal of
Women & Aging, 20:3-4, 283-295, DOI: 10.1080/08952840801984816

To link to this article: https://doi.org/10.1080/08952840801984816

Published online: 11 Oct 2008.

Submit your article to this journal

Article views: 1533

View related articles

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=wjwa20
 Rehabilitation Programs for Elderly
1540-7322
0895-2841
WJWA
Journal of Women & Aging
Aging, Vol. 20, No. 3-4, June 2008: pp. 1–20

Women Inpatients with Schizophrenia

Carlos M. Coelho
Coelho et al.
JOURNAL OF WOMEN & AGING

António P. Palha
Daniela C. Gonçalves
Nancy Pachana

ABSTRACT. This study aims to describe rehabilitation and resocializa-

tion methods we believe to be appropriate for application to female patients
with schizophrenia, in a psychiatric unit with a predominantly older
population. We briefly describe the unit and the interventions used as an
example of the proposed rehabilitation and resocialization methods
applied. The article provides an overview to guide accurate intervention,
particularly in inpatient women, in different types of cognitive impairment
under the broad category of schizophrenia. Our clinical approach includes
a token economy approach, cognitive remediation therapy, and social skills
training. The token economy intervention is particularly directed to patients
that present with a high mental deterioration and/or debility. Cognitive
remediation training is applicable to subjects with both cognitive and social
dysfunction, but that do not possess signs of an organic cerebral illness or

Carlos M. Coelho (E-mail: ccoelho@hms.uq.edu.au) is Senior Research

Fellow at the School of Human Movement Studies, University of Queensland,
Level 5, Building 26, St Lucia QLD 4072, Australia.
António P. Palha, MD, PhD Psychiatry is affiliated with the Hospital de
S. João, Serviço de Psiquiatria Avenida, Porto, Portugal.
Daniela C. Gonçalves, PhD Candidate, attends Universidade do Minho,
Instituto de Educação e Psicologia, Braga Portugal.
Nancy Pachana, PhD, works with the University of Queensland, School of
Psychology, Queensland, Australia.
This work was supported by a grant from the Portuguese Foundation for Sci-
ence and Technology (ref. SFRH/BPD/26922/2006) awarded to the first author.
Journal of Women & Aging, Vol. 20(3/4) 2008
Available online at http://www.haworthpress.com
© 2008 by The Haworth Press. All rights reserved.
doi:10.1080/08952840801984816 283
284 JOURNAL OF WOMEN & AGING

of substance abuse. Social skills training can be the third step to resocial-
ization, training verbal and nonverbal communication competencies.

KEYWORDS. Schizophrenia, inpatients, token economy, cognitive

remediation therapy, social skills training

INTRODUCTION

A gradual aging of the population is already the prevailing reality in

most developed countries (Kincannon, He, & West, 2005; Lutz, Kritzinger,
& Skirbekk, 2006). This fact continually exerts an increasing need for an
appropriate response from the health and social sectors (Baldwin & Wild,
2004; Costa, 2004; Lee, Volans, & Gregory, 2003). A decrease in infant
mortality, a decline in birth rates, and an increase in life expectancy have
led to an inversion of the population pyramid, whereby, for the first time
in Portuguese demographic history, the percentage of older adults is
higher than that of youths (INE, 2002).
With an average life expectancy of 78 years (75 years for men and 82 for
women; INE, 2002), the current Portuguese landscape is characterized by
considerably high indices of illiteracy and poor socioeconomic conditions
(Botelho, 2005). These factors, along with the functional decline that comes
with ageing (Katona & Shankar, 1999, 2004), constitute risk factors for the
occurrence and maintenance of psychiatric conditions (Bowling & Farqu-
har, 1996; Ebmeier, Donaghey, & Steele, 2006; Tafaro, Cicconetti, Zan-
nino, Tdeschi, Tombolilla, Ettore, & Marigliano, 2002; Woods, 1999).
Although cognitive deterioration resulting in significant functional
impairment occurs only in pathological aging conditions, and therefore
should not be considered a normative stage of aging (Baltes & Baltes,
1990), epidemiologic data point toward an increasing prevalence of
symptoms related to dementia. Even though there may be fluctuations in
these rates, based on the methodology selected for the assessment (Form,
2000; Paúl, Ayis, & Ebrahim, 2006) or on the samples considered—for
example older adults either living in a community or institutionalized—
the figures regarding symptoms of cognitive deterioration in older adults
are too significant to be ignored. Blazer’s studies indicate that between
15% and 69% of elderly patients committed to psychiatric hospitals and
between 35% and 70% of those in long-term institutions show signs of
organic mental disorders (Blazer, 1980, 2002a, 2002b).
 Coelho et al. 285

Population aging inevitably spurs the need for a response by profes-

sionals who deal directly with this population group. However, the inability
of both older adults and their general practitioners to recognize declining
medical and psychiatric states (Löpönen, Räiha, Isoaho, Vahlberg, & Kivelä,
2003; Mills, 2001; Voyer & Martin, 2003), the absence of specific
training for professionals (APA, 2004; Murphy, 2000), and the specifici-
ties associated with old age psychopathology, which make it significantly
different from earlier age pathological conditions (Frazer, Christensen, &
Griffiths, 2005; Katona & Shankar, 2004), often obstruct the implementa-
tion of effective strategies to work with the elderly.
With the purpose of overcoming some of the difficulties inherent to the
use of generalized strategies with older populations, and considering the
difficulties that might lead older adults and their caregivers to frustration,
we have prepared an article that provides professionals working with this
population with a successful framework for treatment in these particular
settings and considering the specificities of older female inpatients.

UNIT AND INPATIENT CHARACTERISTICS

At Bom Jesus Health Centre in Braga, Portugal, there are approxi-

mately 280 women as long-term inpatients. These patients are distributed
into four units, one of which has numerous older patients and, as such,
presents different and challenging characteristics. At the time this article
was written, there were 77 patients in this building, which has capacity
for 80.
We used the Mini Mental State Exam (MMSE; Folstein, Folstein, &
McHugh, 1975), administered by the healthcare unit psychologist, to
evaluate mental status. In addition, a questionnaire administered by the
social worker, the ward nurse, and the assistant nurse, wherein the num-
ber and duration of the patients’ contact with family members or friends is
recorded, was used to evaluate the patients’ existing social support.
The age of the patients in this building varies between 26 and 94, with
an average of 67.08; (SD = 14.39). The elderly patients (over 65 years)
constitute the majority of the population (n = 46), corresponding to 59%.
The patients’ entry diagnoses were made by the psychiatrists in the
unit, according to the ICD 10 (1992). The clinical evaluations show a
considerable percentage of schizophrenic patients (n = 34, 42%). Consid-
ering other psychosis diagnoses (n = 6), we reach a number of patients
with psychotic disorders of almost 50%. The patients’ other psychiatric
286 JOURNAL OF WOMEN & AGING

diagnoses included schizophrenia, Alzheimer’s disease (n = 12), mental

retardation (n = 10), mood disorders (n = 10), and antisocial personality
disorder (n = 5).
Folstein’s Mini Mental State Exam (MMSE) reveals fairly heteroge-
neous results. From the 77 assessed patients, 38 present results between
0 and 15; 27 patients score between 16 and 25; and 5 had between 26 and
30 points on the test.
The questionnaire regarding existing social support reveals that
58 patients have some contact with their family (76%), representing
around three-quarters of the total population.1

SUGGESTIONS FOR PROGRAMS SUITED

FOR THE PATIENTS

Taking into account the characteristics of the environment in which

these patients live and their own characteristics, we summarize a few
intervention proposals that we believe are compatible with this type of
population. The program selection was based on the diagnosis of the patients,
their chronological and functional age, the level of mental deterioration, and
the existing social support network.
Token Economy Program
These programs, based on social learning principles, offer incentives for
patients to engage in functional behaviors that increase daily living skills
and independence (Tenhula, Bellack, Suarez, Lambert, & Ford, 2003). The
operant learning paradigm has been applied in psychiatric environments
since the 1950s, with the purpose of changing the behavior of psychotic
inpatients (Lindsley & Skinner, 1954) and was progressively generalized to
all institutionalized patients in the 1960s. Relevant studies from this period
include Ayllon and Azrin’s work (1965, 1968). This procedure is based on
a close control of the environment, in order to structure rehabilitating
behavior of a person or group of people (Encinas & Cruzado, 1993). In the
case of its actual application in institutionalized mental health contexts, the
final objective is psychiatric rehabilitation (Lutzker & Withaker, 2005).
The Token Economy was introduced in psychiatric hospitals with the
underlying theoretical rationale of operant behavior principles (Skinner,
1953; McMonagle & Sultana, 2000). The first premise, the law of effect,
states that behavioral frequency is in part determined by the consequences
 Coelho et al. 287

of that behavior or its effects. Additionally, reinforcers are more effective

in changing behaviors than punishment.
The second operant conditioning law or principle is the law of contiguity
association, which states that two events become associated with one
another if they happen together. In this case, a neutral stimulus paired
with a primary reinforcer will become a reinforcer by its association with
satisfying consequences. Money is a good example of contiguity, given
that it is not a reinforcer by its inherent characteristics, but by its capabil-
ity to satisfy us through commodities we can acquire through its use
(Dickerson, Tenhula, & Green-Paden, 2005).
It is also important, in order to guarantee the success of this type of
intervention, to train and evaluate the staff, who have a decisive role in
this kind of work (e.g., Coleman & Paul, 2001; Corrigan, Williams,
McCracken, Kommana, Edwards, & Brunner, 1998; LePage, DelBen,
Pollard, McGhee, VanHorn, Murphy, Lewis, Aboraya, & Mogge, 2003).

Methodology
Executing the token economy system, according to Rimm and Masters
(1974), involves an objective definition of the premises involved, in order
to maximize their efficiency. These authors consider it essential to establish
from the first moment: i) toward which patients will the intervention be
directed; ii) which behaviors are therapeutically desired, are observable,
and can be registered; iii) the delivery of tokens with desirable behavior,
and non-delivery of tokens without behaviors that are desirable, observable,
and that can be registered, and withdrawal of tokens with behaviors con-
trary to the desirable ones; iii) which reinforcements are effective; and v)
how the benefits in tokens and the costs of reinforcements will be balanced.
In order to obtain a good characterization of the behaviors we want to
decrease, maintain, or increase in frequency and intensity, we recommend
the use of the Time-Sample Behavioral Checklist [TSBC] (Paul, Licht,
Mariotto, Power, & Engel, 1987) and REHAB (Baker & Hall, 1983)
instruments. Through staff meetings, additional behaviors can also be
listed. After listing and understanding the desirable and the inadequate
behaviors of the selected patients, the therapists assign points to each of
the listed behaviors (Coelho & Palha, 2006). Some of the desired behav-
iors listed might include “Greeting and starting a conversation with a
member of staff or another patient” (1 token) and “Getting dressed”
(2 tokens). Behaviors to be extinguished might include “Verbal aggres-
sion” (1 token) and “Leaving the table during meals” (2 tokens).
288 JOURNAL OF WOMEN & AGING

There should be recognition of the patient’s commitment in following

his or her program with a contingent reinforcement (token), even if the
attempt is not successful, in order to motivate and shape the patient
toward increasingly more appropriate behaviors. For example, a patient can
receive from 1 to 3 tokens for a given behavior, according to the proximity
to the actual desirable behavior and the effort put into it. In the case of
absence at a task for justified reasons, the patient can receive the
maximum number of tokens the task has to offer.
This intervention is particularly directed toward patients that present
with a high mental deterioration and/or debility. Considering that this is a
behavioristic rationale intervention, relatively simple in its conceptualiza-
tion, it presents a significant potential for rehabilitating action, especially
when working with patients with challenging or disruptive behaviors
(LePage, 1999).

Cognitive Remediation Training

Cognitive remediation training (CRT) is a therapeutic technique
directed toward patients with schizophrenia. Its main objective is to pro-
mote cognitive functioning, which in psychotic states frequently presents
prevailing deficits, interfering with the subject’s day-to-day functioning
(Coleman & Gillberg, 1996). Some of the most documented cognitive
deficits presented with schizophrenia diagnosis are in executive functioning,
memory, and attention (Michel, Danion, Grangé, & Sandner, 1998;
Warner, 1994). Each one of these deficits impacts the subject’s functioning,
resulting in a general state of vulnerability toward recurrences.
Recently, Reeder, Smedely, Butt, Bogner, and Wykes (2006) presented a
revised program for cognitive remediation training that has its effectiveness
maximized by i) working on specific cognitive functions; ii) using
tangible techniques, developed in a laboratorial context; and iii) personal-
izing the intervention according to a subject’s unique characteristics. The
cognitive remediation training is applicable to subjects who have been
diagnosed with schizophrenia, with both cognitive and social dysfunction,
but that do not possess signs of an organic cerebral illness or of substance
abuse (Michel et al., 1998).
Methodology
CRT implementation proceeds in two stages: i) early evaluation of
the subject based on memory, attention, and executive functioning;
and ii) individualized intervention based on the results of the previous
 Coelho et al. 289

evaluation (Wykes, Reeder, Williams, Corner, Rice, & Everitt, 2003).

Therefore, although it is an intervention based on a manual, there are
guarantees that the intervention plan is individualized and adapted, con-
sidering not only the subject’s specific needs, but also maximizing his
or her strengths.
The implementation of the intervention program involves 3 modules
(Cognitive Change, Memory, and Planning), administered in the course
of 40 individual sessions, 60 minutes long, which happen with a mini-
mum frequency of 3 times a week. The sessions are composed of tasks of
increasing difficulty, which the subject should execute, addressing cogni-
tive change, memory, and planning (Wykes et al., 2003). The fact that the
therapy starts with tasks of reduced difficulty motivates the subject
toward participation; however, the therapist must be alert to the subject’s
reaction to the proposed exercise, given that selecting tasks that are too
easy might lead to a feeling of infantalization. As long as the tasks are
mainly of low difficulty, they can be adapted to each participant’s abili-
ties, with the goal of promoting the acquisition of new competencies in
the 3 designated areas.
The CRT’s underlying strategies, which make it particularly useful to
work with patients with schizophrenic symptomatology, are learning with
minimum error, tasks difficulty adjustment, practice, positive reinforce-
ment, and promoting information processing strategies (Reeder et al.,
2006).

Social Skills Training Program

With schizophrenic patients—along with cognitive disorders, failure in
goal-directed behavior, and affective dulling—there is a serious compro-
mise of social relations. The implications of behavior are evident in social
interactions, as they involve responses at the right moment, with the appro-
priate latency periods (e.g., Bourgeois, Schulz, Burgio, & Beach, 2004).
According to Liberman (1991), the abilities needed for social compe-
tency include i) being conscious of the feelings and objectives of the person
with whom one is dealing, as well as their rights and responsibilities in
that particular situation; ii) translating perceptions into various possible
actions and being capable of choosing the best solution; and iii) conveying
the chosen response to the other person, using suitable verbal and nonverbal
behaviors.
These prerequisites for an effective social contact demonstrate the need
for training in verbal and nonverbal communication competencies and
290 JOURNAL OF WOMEN & AGING

training in problem solving (Bourgeois et al., 2004), as well as in compre-

hension and in following the social rules and norms regarding limits
between the individual and others (Chen, Ryden, Feldt, & Savik, 2000;
Moore & Davis, 2002).
The paranoid symptomatology in an older individual might indicate
schizophrenia, dementia, or paranoid psychosis, with different prevalence
and prognosis for each, making the evaluation and consequent diagnosis a
complex process, albeit a necessary one (Hopkins, Kilik, Day, Bradford,
& Rows, 2006). Therefore, this program for training social competencies
focuses on patients with that same symptomatology, not provoked or
affected by dementia, in other words, for those patients with diagnosed
schizophrenia and with MMSE results that reveal an absence or low index
of mental deterioration.
Schizophrenia promotes social losses, which limits support
(e.g., Pentland, Miscio, Eastabrook, & Krupa, 2003); support which is
important in reducing stress, depressive symptoms, and recovering from
illnesses (Siegler & Poon, 1989). It follows that this support implies a
reciprocal relationship, and that the vehicle of social support (caregiver)
might experience extreme stress and depression (Bruce, Paley, Nichols,
Roberts, Underwood, & Schaper, 2005). It is therefore helpful to endow
the receptor with social abilities so that he or she benefits more from the
caregiver.

Methodology
Given that a person with psychosis experiences a loss of his sense of
boundaries and, consequently, his sense of identity, the group might, at
any moment, lose objectivity of speech. However, group intervention is
possible as long as some crucial aspects are considered, for example,
maintaining a structured and friendly environment. In this type of inter-
vention, the therapist should also stop criticisms between patients, offer
positive feedback, and avoid telling the patient that his or her answers are
wrong (Coelho & Palha, 2006).
The choice of positive behaviors that can be promoted should be
favored over unwanted behaviors that one intends to extinguished (Liberman,
1991). The chosen behaviors should also be those that bring the most ben-
efits to the patient and those the patient applies more frequently, for
example, knowing how to ask for help.
Social skills training (SST) teaches the patient to think in terms
of communication competencies, problem solving, and assessment of
 Coelho et al. 291

environmental resources. The nonverbal communication competencies

include eye contact, body posture, body movement, facial expression,
voice volume, and speech fluency (Carballo, 1993). These competencies
serve simultaneously two purposes for the patient: expressing his or her
needs as a patient and understanding the interest of the interlocutor in
continuing the interaction. Finally, the evaluation of environmental
resources includes negotiation with the patient about the resources avail-
able and the most effective way to use them. Examples of resources are
time, space, people, objects, the telephone, money, and transportation.
Basic training with these subjects includes operationalization of appar-
ently obvious abilities, for example, starting a conversation. Even basic
activities such as this can be divided into small steps: choosing an appro-
priate place and time, greeting, saying some words about the present situ-
ation or of general interest, assessing if the other person is listening and
wants to continue the conversation, and taking the conversation with the
subject in the actual desired direction (Goldstein, 1976). Each of these
steps could be subdivided and trained separately according to social learn-
ing principles.
The great diversity of cognitive problems and social deficits that exist
in psychiatric illnesses requires an adaptation of social skills training to
each subject. A generalization of the benefits, however, depends on the
chances patients have to apply their learning to different contexts and dif-
ferent people (Martin-Cook, Davis, Hynan, & Weiner, 2005), which is
ideal if there is a therapeutic involvement between all the individuals
dealing closely with the patient.

CONCLUSION

The description of this unit intends to show and relate the patients and
their context in order to select appropriate methods of treatment. Older
women with schizophrenia that began in early adult life continue to need
psychiatric treatment (Dickerson, 2007), although treatment consider-
ations may require modification with age (Lehmann, 2003). The interven-
tion programs presented aim to prevent the deterioration caused by
biological, psychological, and social factors related to age, institutional-
ization, and lack of social support, among others. The Token Economy,
Social Skills Training, and Cognitive Training described are some of the
intervention possibilities that can be used with the population of interest,
namely older inpatients. It is important to consider that the selection of a
292 JOURNAL OF WOMEN & AGING

strategy for working with older institutionalized patients should contem-

plate all idiosyncrasies associated with the context, the patients, and the
competencies of the therapists administering interventions (Baldwin &
Wild, 2004). The existing stereotypes underlying a negative image of
mental illness are frequently associated with prejudiced behavior toward
older adults, attributing to them characteristics of fragility and incompe-
tence (APA, 2004). Additionally, therapists’ attitudes often associate
work with older adults to a lesser need for training (Kimuna, Knox, &
Zusman, 2005) to close existing gaps in the offering of specific training
for work with this group (Murphy, 2000). In order to help professional
caregivers working in these types of impatient facilities, we have
proposed different rehabilitation methods that we believe to be most
appropriate considering each clinical situation.

NOTE

1. Family contact is considered nonexistent when the patient has had no visitors for
more than six months, and this is the case for over one-fifth of the sample.

REFERENCES
American Psychiatric Association. (2004). Guidelines for psychological practice with
older adults. American Psychologist, 59, 236–260.
Ayllon, T., & Azrin, N. H. (1965). The measurement and reinforcement of behavior of
psychotics. Journal of the Experimental Analysis of Behavior, 8, 357–383.
Ayllon, T., & Azrin, N. H. (1968). TheToken Economy: A motivational system for therapy
and rehabilitation. Englewood Cliffs, NJ: Prentice Hall.
Baker, R., & Hall, J. N. (1983). Rehabilitation evaluation of Hall and Baker. Aberdeen,:
Vine Publishing.
Baldwin, R., & Wild, R. (2004). Management of depression in later life. Advances in
Psychiatric Treatment, 10, 131–139.
Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging:
The model of selective optimization with compensation. In: P. Baltes & M. Baltes,
Successful aging: perspectives from the behavioural sciences (pp. 1–34). Canada:
Cambridge University Press.
Blazer, D. G. (1980). The epidemiology of mental illness in late life. In: E. N. Busse & D.
G. Blaser (Eds.), Handbook of Geriatric Psychiatry. New York: Nostrand Reinhold.
Blazer, D. G. (2002a). Depression in late life. New York: Springer Publishing Company, Inc.
Blazer, D. G. (2002b). Self-efficacy and depression in late life: A primary intervention
proposal. Aging and Mental Health, 6, 315–324.
 Coelho et al. 293

Botelho, A. (2005). A funcionalidade dos idosos. In C. Paúl & A. M. Fonseca. Envelhecer

em Portugal: Psicologia, saúde e prestação de cuidados. (pp. 115–138). Lisboa:
Climepsi Editores.
Bourgeois, M., Schulz, R., Burgio, L., & Beach, S. (2004). Skills training for spouses of
patients with Alzheimer’s disease: Outcomes of an intervention study. Journal of
Clinic Geropsychology, 8, 53–73.
Bowling, A., & Farquhar, M. (1996). Outcome of anxiety and depression at two and a half
years after baseline interview: Associations with changes in psychiatric morbidity
among three samples of elderly people living at home. International Journal of
Geriatric Psychiatry, 11, 119–129.
Bruce, D. G., Paley, G. A., Nichols, P., Roberts, D., Underwood, P. J., & Schaper F.
(2005). Physical disability contributes to caregiver stress in dementia caregivers. The Journals
of Gerontology Series A: Biological Sciences and Medical Sciences, 60, 345–349.
Carballo, V. E. (1993). Manual de evaluación y entrenamiento de las habilidades
sociales. Madrid: Siglo Veintiuno de España Editores.
Chen, Y., Ryden, M., Feldt, K., & Savik, K. (2000). The relationship between social
interaction and characteristics of aggressive, cognitively impaired nursing
home residents. American Journal of Alzheimer’s Disease and Other Dementias,
15, 10–17.
Coelho, C. M., & Palha, A. P. (2006). Treino de habilidades sociais aplicado a doentes
com esquizofrenia. Lisboa: Climepsi Editores.
Coleman, M., & Gillberg, C. (1996). The schizophrenias: A biological approach to the
schizophrenia spectrum disorders. New York: Springer Publishing Company, Inc.
Coleman, J. C., & Paul, G. L. (2001). Relationship between staffing ratios and effective-
ness of inpatient psychiatric units. Psychiatric Services, 52, 1374–1379.
Corrigan, P. W., Williams, O. B., McCracken, S. G., Kommana, S., Edwards, M., &
Brunner, J. (1998). Staff attitudes that impede the implementation of behavioral treat-
ment programs. Behavior Modification, 22, 548–562.
Costa, A. (2005). A depressão nos idosos portugueses. In C. Paúl & A. M. Fonseca
(Coods.). Envelhecer em Portugal: Psicologia, saúde e prestação de cuidados. Cap. 6,
pp. 157–176. Lisboa: Climepsi Editores.
Dickerson, F. B. (2007) Women, aging, and schizophrenia. Journal of Women & Aging,
19, 49–61.
Dickerson, F. B., Tenhula, W. N. & Green-Paden, L. D. (2005). The token economy for
schizophrenia: Review of the literature and recommendations for future research.
Schizophrenia Research, 74, 405–416.
Ebmeier, K. P., Donaghey, C., & Steele, J. D. (2006). Recent developments and current
controversies in depression. Lancet, 367, 137–167.
Encinas, F. L., & Cruzado, J. A. (1993). Técnicas de control de contingencias. In:
M. A.Vallejo, P. M. Angeles, & R. Fernandez (Eds.) Manual Prático de modificación
de conduta. Madrid: Fundacion Universidad Empresa.
Folstein, M., Folstein, S., & McHugh, P. (1975). Mini Mental State. Journal of Psychiat-
ric Research, 12, 189–198.
Form, A. F. (2000). Does old age reduce the risk of anxiety and depression? A review of
epidemiological studies across the life span. Psychological Medicine, 30, 11–22.
294 JOURNAL OF WOMEN & AGING

Frazer, C. J., Christensen, H., & Griffiths, K. M. E. (2005). Effectiveness of treatments for
depression in older people. Medical Journal of Australia, 182, 627–632.
Goldstein, A. P., Sprafkin, R. P., & Gershaw, M. J. (1976). Skill training for community
living: Applying structural learning theory. New York, Pergamon Press.
Hopkins, R., Kilik, L., Day, D., Bradford, L., & Rows, C. (2006). The Kingston Standard-
ized Behavioural Assessment. American Journal of Alzheimer’s Disease and Other
Dementias, 21, 339–346.
INE (2002). O envelhecimento em Portugal. Portugal: Serviço de Estudos para a
População do Departamento de Estatísticas Censitárias e de População.
Katona, C., & Shankar, K. (1999). Depression in old age. Reviews in Clinical Gerontology,
9, 343–361.
Katona, C., & Shankar, K. (2004). Depression in old age. Reviews in Clinical Gerontology,
14, 283–306.
Kimuna, S. R., Knox, D., & Zusman, M. (2005). College students’ perceptions about older
people and aging. Educational Gerontology, 31, 563–572.
Kincannon, C. L., He, W., & West, L. A. (2005). Demography of aging in China and the
United States and the economic well-being of their older populations. Journal of
Cross-Cultural Gerontology, 20, 243–255.
Lee, K. M., Volans, P. J., & Gregory, N. (2003). Attitudes toward psychotherapy with older
persons among trainee clinical psychologists. Aging & Mental Health, 7, 133–141.
Lehmann, S. W. (2003). Psychiatric disorders in older women. International Review of
Psychiatry, 15, 269–279.
LePage, J. P. (1999). The impact of a token economy on injuries and negative events on an
acute psychiatric unit. Psychiatric Service, 50, 941–944.
LePage, J. P., DelBen, K., Pollard, S., McGhee, M., VanHorn, L., Murphy, J., Lewis, P.,
Aboraya, A., & Mogge, N. (2003). Reducing assaults on an acute psychiatric unit using
a token economy: A 2 year follow-up. Behavioral Interventions, 18, 179–190.
Liberman, R. P. (1991). Réhabilitation psychiatrique des malades mentaux chroniques.
Paris: Masson.
Lindsley, O. R., & Skinner, B. F. (1954). A method for the experimental analysis of the
behavior of psychotic patients. American Psychologist, 9, 419–420.
Löpönen, M., Räiha, I., Isoaho, R., Vahlberg, T., & Kivelä, S. (2003). Diagnosing cognitive
impairment and dementia in primary health care—a more active approach is needed.
Age and Aging, 32, 606–612.
Lutz, W., Kritzinger, S., & Skirbekk, V. (2006). Population: The demography of growing
European identity. Science, 314(5798), 425.
Lutzker, J. R., & Withaker, D. J. (2005). The expanding role of behavior analysis and
support: Current status and future directions. Behavior Modification, 29, 575–594.
Martin-Cook, K., Davis, B. A., Hynan, L. S., & Weiner, M. F. (2005). A randomized,
controlled study of an Alzheimer’s caregiver skills training program. American Journal
of Alzheimer’s Disease and Other Dementias, 20, 204–210.
McMonagle, T., & Sultana, A. (2000). Token economy for schizophrenia (Cochrane
Review). The Cochrane Database of Systematic Reviews, 3, CD001473.
Michel, L., Danion, J. M., Grangé, D., & Sandner, G. (1998). Cognitive skill learning and
schizophrenia: Implications for cognitive remediation. Neuropsychology, 12, 590–599.
 Coelho et al. 295

Mills, T. L. (2001). Comorbid depressive symptomatology: Isolating the effects of chronic

medical conditions on self-reported depressive symptoms among community-dwelling
older adults. Social Science & Medicine, 53, 569–578.
Moore, L., & Davis, B. (2002). Quilting narrative: Using repetition techniques to help
elderly communicators. Geriatric Nursing, 23, 2–5.
Murphy, S. (2000). Provision of psychotherapy services for older people. Psychiatric
Bulletin, 24, 181–184.
Paúl, C., Ayis, S., & Ebrahim, S. (2006). Psychological distress, loneliness, and disability
in old age. Psychology, Health & Medicine, 11, 221–232.
Paul, G. L., Licht, M. H., Mariotto, M. J., Power, C. T., & Engel, K. L. (1987). Observational
assessment instrumentation for service and research. The Time-Sample Behavioral
Checklist: Assessment in residential treatment settings (Part 2). Champaign, IL:
Research Press.
Pentland, W., Miscio, G., Eastabrook, S. & Krupa, T. (2003). Aging women with schizo-
phrenia. Psychiatric Rehabilitation Journal, 26, 290–303.
Reeder, C., Smedely, N., Butt, K., Bogner, D., & Wykes, T. (2006). Cognitive predictors
of social functioning improvements following cognitive remediation for schizophrenia.
Schizophrenia Bulletin, 32, 123–131.
Rimm, D. C., & Masters, J. C. (1974). Terapia de la conducta: técnicas y hallazgos
empíricos. México: Trillos.
Siegler, C. I., & Poon, W. L. (1989). A Psicologia do envelhecimento. In: Busse e Blazer,
Psiquiatria Geriátrica. Porto : Artes Médicas. .
Skinner, B. F. (1953). Science and human behavior. New York: McMillan.
Tafaro, L., Cicconetti, P., Zannino, G., Tedeschi, G., Tombolilla, M., Ettore, E., &
Marigliano, V. (2002). Depression and aging: A survival study on centenarians.
Archives of Gerontology and Geriatrics, Supplement, 8, 371–376.
Tenhula, W. N., Bellack, A. S., Suarez, E., Lambert, M., & Ford, R. (2003). Integration of
a token economy program with psychosocial and psychopharmacological research on a
treatment refractory schizophrenia unit. Schizophrenia Research, 60, 329–330.
Voyer, P., & Martin, L. S. (2003). Improving geriatric mental health nursing care: Making
a case for going beyond psychotropic medications. International Journal of Mental
Health Nursing, 12, 11–21.
Warner, R. (1994). Recovery from schizophrenia: Psychiatry and political economy.
2nd ed. New York: Routledge.
Whanger, A. D. (1992). Tratamento Hospitalar do paciente psiquiátrico idoso. In E. W. Busse
& D. G. Blazer (Orgs). Psiquiatria Geriátrica. Porto Alegre: Artes Médicas.
Woods, R. T. (1999). Mental health problems in later life. In R. T. Woods (Ed.). Psychological
Problems of ageing: Assessment, Treatment and Care (Chap. 4, pp. 73—110). England:
John Wiley & Sons Ltd.
World Health Organization. (1992) The ICD-10 Classification of Mental and Behavioral
Disorders. Geneva: WHO.
Wykes, T., Reeder, C., Williams, C., Corner, J., Rice, C., & Everitt, B. (2003). Are the
effects of cognitive remediation therapy (CRT) durable? Results from an exploratory
trial in schizophrenia. Schizophrenia Research, 61, 163–174.