Using the Decisional Balance Technique for Ambivalence

Decisional balance is one of my favorite techniques to use for any client who is feeling ambivalent about change. I joke with clients that I’ve used it from major decisions like job changes to smaller ones like whether to get Chipotle. (They mostly tell me that Chipotle is never a bad decision.) Decisional balance is typically used within the context of substance use treatment; however, I’ve seen it’s benefits when targeting any type of unsafe or self-sabotaging behavior, such as:

• Self-harming behaviors (like cutting)

• Overeating or binge eating

• Staying in or leaving an abusive relationship

• Leaving a toxic work environment

• Forgoing or pursuing a form of health treatment

Basic instructions for use of decisional balance:

1. Take a pen and piece of paper. (Or do this on an electronic document.)

2. Draw a line down the middle of the page and one line across to create four quadrants.

3. Label the first column “Pros” and the second column “Cons”.

4. Label the first row “No Change” and the second row “Change”.

   1. Alternatively, you can label these rows with specific decisions or choices, such as “Not going to rehab” and “Going to rehab”.

5. Ask the following four questions:

   1. “What are the pros of no change?”

   2. “What are the cons of no change?”

   3. “What are the cons of change?”

   4. “What are the pros of change?”

Example of decisional balance re: substance use behavior:

TIP 1: Ask about how important or meaningful the pros/cons are.

This is important both for helping the client to develop insight and for the therapist to understand the client’s concerns. For example, look at the above example regarding substance use behavior. At a glance, the list of cons for substance use is longer than the list of pros for substance use. If we were just basing this on the quantity of items, we might jump ahead too quickly. If the client voices that the pros of substance use are more meaningful, lean into that and ask exploratory questions. Maybe even reflect back to them, “It sounds like staying connected with your friends is very important to you,” or “I hear that your stress is unmanageable, and this seems to be the only thing that helps.”

TIP 2: Acknowledge that there’s not necessarily a right versus wrong answer, but rather a best answer given one’s circumstances.

It can be tough to try to remove judgment from the pros, cons, and potential decision(s). It can be even more challenging when the decisions themselves are related to substance use, self-harm, or a related risky behavior. I’ve met with clients who, after completing the decisional balance activity, have said that continuing with the identified self-harming behavior is a valid decision for the reasons listed. These folks may merely be in the precontemplation/contemplation stages of change. Even if they are not yet ready for change, the mere fact that some insight into their behavior has been built should be celebrated. This brings me to the final tip…

TIP 3: Accept that these pros, cons, and decisions can change at any time.

This is especially critical to keep in mind for clients who are in the precontemplation/contemplation stages. Change is inherently uncomfortable, but not impossible. Keeping this in mind also helps therapists to respect client autonomy. A client probably has everyone else telling them that they need to change, and a therapist saying that too isn’t necessarily going to help them get there. However, if a client knows that a therapist will respect that they have choices and that it’s up to the client to make those choices, the change is likely to “stick” because it comes from the client and not from someone else.