Theory and Practice of Contemporary Psychotherapies

Motivational Interviewing Decisional Balance Video Transcript

Bill Matulich: Hello everybody. This is Dr. Bill Matulich. I'm a clinical psychologist and motivational interviewing trainer, and the author of the eBook, "How To Do Motivational Interviewing: A Guidebook For Beginners."

Today I'm speaking to you from my obviously plush and high-tech studios here in San Diego, California. Got my high-tech chart up here behind me. Today what I'd like to talk to you about is motivational interviewing.

You probably already know that motivational interviewing is an evidence based, best practices approach for helping people change their behavior in healthy directions. In a lot of situations in which we're sitting down with our clients and talking to them about changing their behavior, it's usually the health professional that's the spokesperson for change. It's usually the health professional that comes up with the arguments for change and tells the client what will happen if they change, what won't happen if they don't change, and lets them know what the consequences of their behavior are, and so forth.

The assumption is, is that if the client knows all of the information and understands the consequences of his or her behavior, then change should just be automatic. Unfortunately in the real world, it doesn't work exactly that way. There's a certain number of people who are convinced by information and by advice to change their behavior. Unfortunately, there's a lot of people that are somewhat ambivalent, at least, and sometimes downright resistant, to the notion of change altogether. These are the clients, these are the patients that we have that are somewhat frustrating for us, as healthcare providers. These are the kind of people that motivational interviewing works with to help move them towards change, without creating any kind of resistance.

How do we do that in motivational interviewing? One way is by using the decisional balance to elicit a client's own arguments for change. We call that change talk. We know that the more a client will talk about change themselves, the more that they will argue for change themselves, the more likely it is that change is going to occur. That's what we want to encourage with our clients, is their own arguments for change.

One way to do that is the decisional balance. The decisional balance is not much more than just a sophisticated pros and cons list. The decisional balance asks four questions, which are based on what are the good things and the not so good things about changing your behavior and not changing your behavior. In order to be effective, or most effective, the questions should be asked in a particular order, and I'll tell you what that particular order happens to be.

The first question is one that most people don't ask. It's based on what are the good things about not changing, and so the question is really, what are the advantages of the status quo? The particular content, of course, of the question will depend on the behavior under consideration.

If you are a dietician, for example, and you're working with a heart patient who's eating unhealthily, and your goal is to move that patient towards eating more healthy foods, in order to be healthier, in order to have some positive impact on his heart condition, the question you might ask if you're using the decisional balance, the first question you would ask would be, "What are the advantages of your current eating habits? What are some of the good things about your current diet?" You want to get the person to start talking about the behavior under consideration in a non-defensive kind of a way. This question is really going to do that.

If you're an addictions counselor, for example, and your client is using, say, crack cocaine, your first question might be something like, "What are the advantages to you of using crack cocaine? What are some of the good things about crack cocaine?" It's not a question that most people would ask. It sounds like kind of a silly question. Why would you ask a person, what are the good things about using crack cocaine? We all know what the bad things about that are.

Typically, the question isn't asked. Typically, what happens with healthcare professionals is that we tell them what the bad things are about their behavior, or we encourage them to change their behavior. We tell them how it would be good for them to change their behavior.

The decisional balance, we start with the advantages of the status quo, for a couple of reasons. One is that it gets a person talking in this non-defensive way, so it short-circuits resistance right off the bat. You're not going to get much change talk there, though. The change talk starts to come with the second question.

The second question is, "What are the not so good things about the status quo? What are the not so good things about not changing your behavior? What's the downside of the status quo?" Again, to use our examples of the heart patient and the person who's addicted to crack cocaine, the question might be, "What are some of the downsides of your current eating? What are some of the downsides of using crack cocaine?"

This is where your client's ambivalence is going to start to come up to the surface. Ambivalence is a key component, a key concept, in motivational interviewing. We need to pay close attention to ambivalence, but the important thing here for the purposes of this video, is that you're going to start getting some change talk. The person's going to start telling you. Now they've already told you what some of the good things about their behavior are. You've already made that connection with them. Now it's easier for them to start telling you what some of their concerns might be. That's what you're going to get here.

The third question then goes back to, "What are the not so good things about changing your behavior?" Staying in this column, the question is, "What are some of the downsides? What's the downside of changing your behavior?" This, again, is a question that's going to short-circuit any kind of resistance, because you're asking for your client to tell you, in their thinking, what are their thoughts about what's the downside to change their behavior.

You might start to get some of your client's fears at this point. They're starting to think about, "What if I were to really change my behavior? What would that be like? I don't know if I can tolerate that. I don't if that's going to be good for me. I don't know if I'm comfortable with that at all." You're starting to get a little bit of their fears and some of their reluctance to change their behavior here, very important information. Not much change talk there, but again, this is an area where you're short circuiting any resistance, because you're really asking to hear those difficulties.

Question four is where you're going to get most of the change talk. This question has to do with, "What are the good things about changing your behavior? What are the advantages of changing?" You would ask your heart patient, "What are the advantages of having a healthier diet? What are the advantages of changing your diet? What do you see as some of the good things about changing the way you're eating?" Or you might ask the person who's addicted to crack cocaine, "What are some of the advantages, what are some of the good things, about quitting using crack cocaine?"

The important thing here is that you're getting change talk, which is your client's own arguments for change, in their own words, their own way of thinking about it. It may not surprise you that some of the things that they're telling you are things that you already know, and you could've just given them advice in this regard, in the first place. But it's important to know that this is coming from the client and not coming from you. When it comes from the client, there's no resistance.

The other thing that might surprise you is that you're getting some advantages of changing their behavior that you might not even have thought about, something that's just particular to that person, rather than anything more general, or things that you might have thought about. That's the important information. That's really important and very key in helping your client move towards healthier change.

That's the decisional balance. What are the advantages of the status quo? What's the downside of the status quo? What's the downside of changing? And then what's the advantages or the upside of changing your behavior? If you ask that question, you start to generate some change talk, and you can just take off from there and continue with your conversation.

There's a few studies in the literature, which suggest that just using the decisional balance by itself can be very useful, can be very helpful in helping a person move towards healthy behavior change. But it's probably much more likely and much more powerful, certainly, to use the decisional balance as an integrated component with a full motivational interviewing session. In that session, you would be using other techniques, like asking non-judgmental, open-ended questions, for example, or following up some of the change talk that you're getting with strategic kinds of reflections. That would make this particular technique even more powerful.

I appreciate your attention. Thank you very much for listening. This is the decisional balance. Now you know how to use it to elicit change talk from your clients.

If you'd like some more information about motivational interviewing, I invite you to come to my web page, www.motivationalinterviewingonline.com, or you can also go to www.billmatulich.com.

Until next time we meet, I wish you joy and success in your work, and peace and happiness in your life. Thank you again.