The EPICC Mentor Program Has Launched!  Access the Mentor Directory Now

Decisional Balance Sheets– Signposts for Charting Client Change

February 22, 2019

Life is full of difficult choices and hard decisions. Maybe, for you, becoming a clinical social worker wasn’t one of them, because you had an innate desire to help others and make the world a better place. For your clients, though, it can be very difficult to decide to try to change a behavior or a pattern.

Using motivational interviewing techniques and working through the stages of change, the therapist can work with a client to resolve ambivalence about changing – and sometimes a visual aid can help a lot. Consider a “decisional balance sheet” (or pro/con grid, or cost-benefit analysis): this tool works with clients struggling to stop drug-use, overeating, or floundering in a relationship.

Typically, this type of worksheet has a grid with four labels: columns titled “Benefits (pros)” and “Costs (cons)”, and rows titled “doing the behavior” and “not doing the behavior”. Although best done in individual session, it can also be used (as I have) with a group and a whiteboard. For example, if a client is continuing to use alcohol and has reasons for quitting and reasons for continuing (i.e. is ambivalent about changing) this balance-sheet activity may be well-suited.

Have the client fill in the sheet if possible, but have a discussion in advance as to sample “pros” of (e.g.) continuing to use alcohol and then some “cons.” After that, discuss pros of not using alcohol, and then the cons. The client will write down these pros and cons as they come up in discussion; and the consonance of some can serve as the basis for further discussion. This filled-out grid is a strong visual correlative of what the person needs, or what the person is missing, in their life. By creating a value-laden grid for consideration, the client can more clearly see the better, less-harmful behaviors to be pursued in order to get their needs met.

This is an activity that can be repeated – I’ve done these grids with ambivalent clients when they first enter treatment, then after 3 months, then after 6 months. A current grid can be compared to the past grid(s) to track any movement in one direction or another. Often you will find more entries in one box than in the 3 months earlier, and this counts as a success, to be noted on a treatment plan.

In the long process of bringing about change, a vivid graphic like a decisional balance sheet can be a very useful signpost, inspiring effective change-talk and creating a basis for continuing positive actions.

What is your experience with using worksheets with clients? Would you consider using this in your own life to make a tough decision?


Written By:

Ariana Tagliamonte, MSW

Leave a Reply