Case management principles and practice

¶ … Management

Stages of change: How to foster and support change in the life of a thirty-year-old HIV-positive man refusing to take his medications

Change rarely happens swiftly in an individual's life. However, in the case of a thirty-year-old man refusing to take his antiretroviral drugs, it is only natural for a caseworker to wish to hasten the man's progress in moving to a positive lifestyle change, given that a delay could result in a compromise of the patient's long-term health. According to James Prochaska and Carlo DiClementea's studies of drug abusers, the stages of change when an individual embarks upon a profound shift in behavior and lifestyle are: precontemplation (or denial), contemplation (awareness of a problem but uncertainty about the feasibility or desirability of change), preparation and determination to make a change, taking action and having the willpower to change, maintaining the new behavior, and relapsing into the old habits (Kern 2008).

This model suggests that it is critical to determine why the patient is not taking his medications, to move him out of a state of denial and precontemplation. Does the act of taking the medication uncomfortably affirm his illness, in this patient's mind? Or is he depressed and suicidal, and is refusing medical treatment as a passive form of suicide? Dealing with the reality of his illness as a chronic condition but not a death sentence, and affirming his right to live, when perhaps his partner or friends have died, is vitally important. Unlike a drug addiction, which often has a physical component, refusing to take medication is more likely to be rooted in psychological barriers, although financial or social pressures may also have their influence on the patient's noncompliance.

Once these initial psychological barriers are addressed, and the caseworker has a better idea of why the man is not taking his medication, the caseworker must help the man contemplate how to make a change and convince the man of the feasibility of overcoming logistical barriers to taking his medication. Helping the man find financial access and transportation to affordable healthcare clinics can demonstrate how change is easier than the man thought. During the contemplation stage, "people are on a teeter-totter, weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs" (Kern 2008). The man may justify not taking drugs by saying: "what if they don't work? I will have to put up with side effects, and may still die only I will be more miserable during my final days."

Researching is part of the critical preparation stage -- the man needs to learn how medications can be very effective for many people. He can talk other HIV patients who have established effective practices of self-care. In terms of fostering the client's preparation and determination to change, connecting him with community resources that support HIV-positive patients will provide him with social affirmation for taking his medications. This is a vital part of nudging him into the next stage of action. An active lifestyle change will be evidenced by the man's willingness to follow up with contacting appropriate social services, attending support meetings, going to doctor's appointments, and above all taking his prescribed medication. Maintaining a healthy life style and keeping connected to such social support systems are critical parts of the maintenance phase of change.