If you’re familiar with the Decisional Balance Worksheet, you know how helpful it can be to weigh a decision’s benefits and drawbacks. For those unfamiliar with this conversational tool, the Decisional Balance sheet can help you hold space for clients during the beginning stage of change. The Decisional Balance Worksheet is a frequently used motivational strategy tool that weighs out the pros and cons, or the good and not-so-good things, about a decision.
At first glance, the Decisional Balance Worksheet seems deceptively simple, but when you dive into the concept and purpose of the approach, its value becomes quickly evident.
Focusing on Change Talk
Motivational Interviewing is all about listening for and responding to a served person’s Change Talk. When you use MI, you empower your clients to make positive changes and see the beneficial impacts of those changes on their lives. Change Talk is proactive.
Getting into the Change Talk is crucial, and the Decisional Balance scale helps clients explore the perceived pros and cons of behavior adoption. The tool can help them identify positive benefits and move through the stages of change toward an action plan. It’s important that, as practitioners, we hold space for this to occur without telling a client what they should do or how they should do it. We’re empowering them to make the change and providing positive reinforcement and support when they get there.
However, there are certain behavioral topics where a decisional balance can reinforce ambivalence. Those topics are where there is a clear, healthy choice. What you’re doing when you employ a decisional balance worksheet is to support the person in feeling and thinking through their ambivalence where there is not a clear health target behavior. A quick example:
- Leaving a relationship
- Leaving an unhealthy and/or abusive relationship
In the latter, there is a clear and healthy choice. In this instance, employing MI, we would lean on the change talk. In the former, we would not want to guide the person one way or the other. In MI, we call this equipoise—where we do not have a guiding style but more of a neutral style in our approach.
Both Change Talk and Sustain Talk express DARN: Desire, Ability, Reason, and Need. When employing a decisional balance worksheet, you are evoking (drawing out) both sustain talk and change talk. Sustain talk is any argument the client voices in favor of sustaining the behavior. Change Talk is any argument the client voices in favor of changing the behavior.
It’s important to know when to weigh in and when to hold space. For example, letting go of an unhealthy, toxic, or abusive relationship is a situation where you’d want to lean into and encourage Change Talk with a client. The breakup of an unfulfilling (but otherwise healthy) relationship isn’t necessarily something you’d weigh in on.
By focusing on and amplifying Change Talk, practitioners support clients in resolving their ambivalence and increasing their motivation to pursue positive changes in their behavior. A decisional balance conversation is entirely neutral.
More Examples of the Difference Between Change Talk and Sustain Talk
Change Talk is speech that focuses on positive change. Clients might express their desire or reasons for making a change. They may also express a commitment to the behavioral goal.
A few examples of Change Talk include:
- “I want to cut back on drinking.”
- “I think I could quit smoking with assistance.”
- “I need to do more physical activity to improve my health.”
- “I will start to take a pause before expressing my frustration with my kids.”
Sustain Talk is speech that resists change and favors the status quo. Clients might express doubts about the change, reasons that the change seems daunting, or a desire to maintain their behavior. Change can be tough, and Sustain Talk reflects a recognition and reluctance to take those difficult steps.
Some examples of Sustain Talk are:
- “I need to smoke to calm my nerves.”
- “But I really enjoy drinking with my friends.”
- “It’s too hard to change my eating habits—I don’t even know where to start.”
- “I can’t do the assignment. It’s too difficult.”
Since our goal as Motivational Interviewers is to reinforce Change Talk and minimize Sustain Talk, we can use skills like open-ended questions, affirmations, reflective listening, open-ended questions, and summarizing (a.k.a. OARS) to help clients explore their motivations and draw out the change talk. In a decisional balance conversation, we do the same but with both sides of the argument.
In a decisional balance conversation, it’s our role to reflect back the Change Talk and Sustain Talk so the person can think through the situation and talk it out. You aren’t guiding them toward change but helping them think through the process. The Decisional Balance Worksheet is an excellent tool for helping put those thoughts to paper.
The Importance of Equipoise
In the world of MI, you may hear the word “equipoise.” This refers to your (the practitioner’s) openness to the possibility of multiple outcomes. Meaning, it’s important to maintain neutrality and let go of your own expectations of a client deciding to change or stay the same. As practitioners, we must support our client’s autonomy and self-determination. It’s about empowering them, not pressuring them toward a decision.
When using OARS in a decisional balance conversation, we should work from a place of equipoise. For example:
- Open-Ended Questions: Open-ended questions allow your client to explore the different feelings and angles of their ambivalence without making them feel judged or pushed in a specific direction. For example, you may ask a client, “What are your thoughts on keeping things the same versus making this change?”
- Affirmations: Affirmations are given to support the client’s self-efficacy. You’re affirming and acknowledging their experiences and the validity of their feelings without trying to steer them toward a choice. An example of an affirmation would be, “It’s clear you’ve been putting a lot of thought into this situation, and that’s important.”
- Reflective Listening: Reflective listening is a neutral approach to reflecting back a client’s thoughts or feelings. Reflections are expressions of empathy (a deep understanding of this person’s experience, thoughts, feelings). For example, “You are seeing benefits of staying where you are, as well as benefits of making the change.”
- Summarizing: When we summarize during a conversation, we offer a balanced reply highlighting both sides of the Decisional Balance. This empowers the client to weigh their options. An example might be, “You mentioned that the change will improve your health, but you’re concerned about the time it will take.”
Throughout the process, it’s essential to maintain equipoise—this lets the client feel free to make their own informed decisions. It builds a sense of autonomy and mutual respect in your service relationship.
Reflective Supervision, Equipoise, and Decisional Balance
The Decisional Balance worksheet or matrix is a valuable tool for guiding you through almost any interaction with equipoise and objectivity. During a Reflective Supervision process, folks might address work concepts and personal concepts. Equipoise is important in both, but more often the latter.
The Decisional Balance worksheet is used in Motivational Interviewing, CBT, and Reflective Supervision to give clients a visual representation of weighing out the pros and cons. Sometimes, it can be helpful for clients to see their thoughts reflected on paper.
The worksheet is divided into four sections:
- Pros of Changing
- Cons of Changing
- Pros of Not Changing
- Cons of Not Changing
By spelling out these different factors, you can help your client evaluate the benefits of a change versus keeping the status quo. This can greatly aid in the decision-making process, helping individuals gain clarity on their current situation when they aren’t sure what to do.
Again, there are times when there’s a clear, healthy choice to make. At those times, exploring “both sides” of the issue might not be as helpful. It may reinforce the clients’ ambivalence, leaving them stuck.
When indicated, the Decisional Balance worksheet is a very useful tool for therapists, counselors, and others working in helping professions. It works well in the fields of education and even health care.
If you would like additional information or guidance on using this conversational tool in your work, please reach out! We’re happy to share our knowledge and facilitate a deeper discussion with you and your staff.