This technique involves a conscious weighing up of the pros and cons of certain behaviours (e.g., drug use). This 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 [389]. 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 for when you want to determine their stage of change in regard to their substance use.
Begin by asking questions like:
- ‘What do you like about your use of…?’
- ‘Tell me about your drug use. What do you like about it? What’s positive about using for you?’
For clients who have difficulty in articulating things they like about using, you may need to offer a menu of options for them to choose from, although you should do this sparingly. Remember you are trying to find out what this client likes about using, not what you think he/she might like about it! Encourage the client to write down these good things (a useful template is included at the end of this MI summary).
Briefly summarise the good aspects of AOD use. Next, ask the client about the not-so-good things about his/her AOD use. Try to avoid using negative words such as the ‘bad things’ or ‘problems’. The AOD worker could ask questions such as:
- ‘So we have talked about some of the good things about using drugs, now could you tell me some of the less good things?’
- ‘What are some of the things that you don’t like about your drug use?’
- ‘What are some of the not-so-good things about using?’
Again you may have to offer a menu of options or ask questions (based on collateral information) like ‘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 his/her AOD use, and the good and not-so-good effects that it has on him/her. 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 his/her mental health symptoms, explore this in particular detail: for instance, enquire about longer-term effects [1168]. It is important to remember you are after 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 it on the importance it holds for him/her. This 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 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 his/her own conclusions, for example:
- ‘Now that you’ve gone through both sides, where does this leave you? ‘
- ‘How do you feel about your drug 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 [1168]. 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 [296].