Harm Reduction, Part Six: To Change or Not to Change? The Decisional Balance

​Want to make a change, but feeling stuck?
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Here's how to to turn awareness of both your motivations and roadblocks into a solid action plan.
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The DECISIONAL BALANCE is one of my favorite therapeutic tools to help folks initially explore their ambivalence about making chang​es.

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We tend to criticize ourselves for failing to take action in our lives. However, this “stuck” feeling may be a signal that we harbor some fears and doubts about the process: if you felt 100% certain that change was necessary and completely beneficial, you would have already taken action!

Often our uncertainty serves as a reminder that there are important and unacknowledged factors involved; in my experience, it is usually these factors that secretly stand in our way. (This is particularly helpful in addressing substance issues, as the helpful and positive aspects of our use are often shamefully ejected from consciousness, or publicly denied.) The decisional balance is a way to honor and explore ALL your potential feelings and doubts about making change.

This format goes beyond a simple pros/cons list, with power to pull out some additional information. We'll also see how there is a balance that must be tipped before any movement will occur.

​Here's how to begin: think about something in your life that you've been contemplating changing. You might even feel a little guilty or bad that you haven't worked on this part of your life yet.

​Grab a piece of paper (or create a 2x2 table in your program of choice), and divide it up like this:

	Benefits/Pros	Costs/Cons
Making a Change	​
Not Changing	​	​

​In the first cell, please list all the benefits, pros, and positive outcomes you can think of that might result from making a change. (You can note both short-term and long-term outcomes.)

In the cell below that, try to think of all the benefits, pros, and positive outcomes from NOT making a change--having things stay exactly as they are.

In the top right cell, you can now list all the costs, cons, and negative outcomes that you think might occur if you made a change.

​Finally, in the bottom right cell, contemplate all the costs, cons, and negative outcomes you predict might happen if you do NOT change.


I'll show you how this might go with someone who is considering a change in drinking behaviors:

	Benefits/Pros	Costs/Cons
Making a Change	-I'd be proud of myself! -I'd spend less money -​Have more energy at work -Sleep will improve (in the longer term) -My health might improve, stop getting stomachaches	-I might feel awkward when I go to parties--what do I do with my hands? -I might have to stop going to the bar, which is where I meet people, so I might feel really lonely -Sleeping will be harder (in the short term)
Not Changing	-Inertia is easier, wouldn't have to do anything hard or be uncomfortable ​-Maybe that stomach irritation is unrelated and will go away on its own ​-Get to still have fun	-I'd feel like a failure -Health might deteriorate (probably not actually good for my stomach lining) -Continue to be tired at work​ -Might have an impact on my relationship at some point -This behavior might get old pretty soon

Next, take a look back over the results. It’s important to consider not just the number of items listed in each cell, but each item’s weight, or how personally significant you rate that item. Circle or highlight the item that stands out as the most significant factor to you at this moment.

(The real key here is to focus on YOUR motivations, fears, and concerns. Your doctor would immediately target the health issues, and your partner might be concerned about the quality of your relationship, but our goal here is to get to the very heart of YOUR dilemma, and where you feel most stuck.)


In the example above, if the person selected the items related to work as the most significant points (because they recently were written up for poor performance and are concerned about losing their job), our focus will be very different than if they were terrified of feeling loneliness (because they have a history of depression and self-injury, and know isolation can easily trigger an episode).

Let’s now look at the item you find most compelling. Does it show us what motivates you, displaying the core value that will drive your change process? Does it point towards the barrier that we most need to address, and can we use this information as a jumping-off point to explore potential solutions or other ways to get your needs met?

Brainstorm about your most significant items, and use this set of ideas to begin building your plan of action:

• Do you need to address other life problems first before any change can happen?
• Do you need to reach out to professional helpers or a support network?
• Would it be helpful to embed reminders of your core values and motivations into your daily life? (e.g. the smoker who tapes a photo of their family to their pack)
• Can you be patient with this process, or is there anything that needs urgent action?

Before committing to change, the balance must shift towards the reasons for changing having greater weight than the reasons for maintaining the status quo. Addressing the roadblocks and narrowing in on our motivations helps us begin to tip that balance. 


I hope that this exercise helped you discover some new and helpful information, and I thank you for your participation! If you are just now joining me, and are curious about the Harm Reduction model, I invite you to check out the other posts in this series.

Next time, I intend on laying out a potential menu of change options, which allows us to see the infinite variety of positive steps we can take towards our goals. Have a wonderful week!