This technique involves a conscious weighing up of the pros and cons of certain behaviours (e.g., AOD use). Considering the pros and cons can be used as a way of neutral counselling, where the worker is not trying to steer the client into making one choice over another, but instead allowing the client to make their own choice about personal change [758]. Clients are often aware of the negative aspects involved in certain behaviours but have never consciously assessed them. The decisional balance is a frequently used motivational strategy, particularly when clients are displaying ambivalence regarding their substance use, and as a useful way of determining their stage of change in regard to their substance use.
Begin by asking questions such as:
- ‘What do you like about your use of…?’
- ‘Tell me about your AOD use. What do you like about it? What’s positive about using for you?’
For clients who have difficulty articulating things they like about using, it may be useful to offer a menu of options for them to choose from, although this should be done sparingly. Remember the focus should be on finding out what the client enjoys about using, not making assumptions about why they like it! Encourage the client to write down good things they have identified (a useful template is included at the end of this MI summary).
Briefly summarise the good aspects of AOD use that the client has identified. Next, ask the client about the not-so-good things about their AOD use. Try to avoid using negative words such as the ‘bad things’ or ‘problems’. Questions that may be useful in obtaining this information include:
- ‘So, we have talked about some of the good things about AOD use. Now could you tell me some of the less good things?’
- ‘What are some of the things that you don’t like about your AOD/substance use?’
- ‘Tell me what some of the not-so-good things about using are’.
Again, it may be useful to provide some options or ask questions (based on collateral information), such as, ‘How does your family feel about your using?’ but avoid suggesting that an issue should be of concern, and do not put any value judgement on the beliefs of the client by saying something like ‘Don’t you think that getting arrested twice is a bit of a problem?’ The success of MI rests on the client’s personal exploration of their AOD use, and the good and not-so-good effects that it has on them. Explore each element in full with appropriate use of the core communication skills, such as the use of open questions and reflection.
Unlike the good things, the less good things need to be explored in detail. If the client claims AOD use reduces their mental health symptoms, explore this in particular detail: for instance, enquire about longer-term effects [1920]. It is important to maintain focus on the client’s perspective of the less good things. It can be useful to ask follow up questions such as:
- ‘How does this affect you?’
- ‘What don’t you like about it?’
Or ask for more detail:
- ‘Could you tell me a little more about that?’
- ‘Could you give me a recent example of when that happened?’
It can be particularly useful (especially when not-so-good aspects are not forthcoming) to explore the other side of the positive consequences of using listed. For example, if the high was listed as an advantage, explore the ‘come-down’ that inevitably followed and the length of this crash (which will usually have lasted longer than the euphoria).
It is then useful to assess, through the use of a scale from 1-10, the client’s perspective of how important an issue is. Beside each pro and con the client should rate the importance it holds for them. This exercise ascertains to what extent cons are a concern for the client. Many workers make the mistake of assuming that just because the client acknowledges a not-so-good thing about their AOD use, this automatically presents a direct concern for them.
Now give a double-sided, selective summary. For example:
- ‘You said some of the things you like about using were… and then you said that there was another side to it… you said some of the not so good things about using were…’
Skill is required here in order to emphasise the not-so-good things. It can be useful to give the client a chance to come to their own conclusions, for example:
- ‘Now that you’ve gone through both sides, where does this leave you?’
- ‘How do you feel about your AOD use now?’
If ambivalence is evident, attempt to explore the reasons that underlie this imbalance and re-establish the initial reasons for wishing to quit/cut down. Incorporate information on health and psychological effects of continued use. Guide the client through a rational discussion of issues involved, and carefully challenge faulty logic or irrational beliefs about the process of quitting. Positive reinforcement and encouragement are crucial, but if you encounter resistance from the client, do not push them.
NOTE: Use this strategy with caution for clients with high levels of anxiety or those who are not ready to deal with the pressure of increased ambivalence. In addition, do not leave a depressed client in psychological distress for too long after using the decisional balance strategy [1920]. Avoid using this strategy with a client who is currently tempted to use. Distraction is a better strategy to use with someone who is currently tempted rather than to discuss the things they like about using [448].