Free Therapist Training›Motivational Interviewing Toolkit›Decisional Balance Worksheet
Last updated: November 11, 2026
A decisional balance worksheet helps a person weigh a decision by listing the benefits and costs of making a change and of keeping things as they are. This free decisional balance worksheet, available as a PDF and a Google Doc, adds prompts about what matters most and where the person stands now, and it ends with a short clinician guide to when a decisional balance fits. The worksheet comes with a completed example for Harold, a 78-year-old weighing a move to assisted living, steps for running it without steering and a summary of what motivational interviewing (MI) research has found about it.
The template comes from Sentio's free motivational interviewing toolkit, and MI is one of the core therapy models taught in the Sentio MFT program. When you hope to strengthen a particular change, the importance and confidence rulers fit better, because their follow-up questions evoke the client's own reasons for change.
This is an optional aid from Sentio's motivational interviewing toolkit, free to adapt to your setting.
Make a copy (Google Doc)Download the PDF
The change I am considering
| Describe the change in a sentence or two |
Benefits and costs
| Option | Benefits | Costs |
|---|---|---|
| Making the change | What could be better if I make the change? | What would be hard, or what would I give up? |
| Not making the change (keeping things as they are) | What is good about keeping things as they are? | What concerns me about keeping things as they are? |
What matters most to me in this decision
| The people, values or hopes that weigh most for me |
Where this leaves me now
| Where I am leaning, or what I want to find out before I decide |
Clinician guide: when a decisional balance fits
- When it fits. Use the full worksheet when you are counseling with neutrality: you are helping the client make a decision and have chosen not to steer it, as with a choice between medical treatments (Miller & Rose, 2015) or about where to live.
- When it does not fit. Skip it when the client is ambivalent about a change you hope to strengthen, such as drinking less. The cell for the benefits of keeping things as they are draws out sustain talk, and with ambivalent clients a decisional balance tends to decrease commitment to change (Miller & Rose, 2015).
- What to do instead. Evoke change talk by asking about the client's own reasons for change, and answer sustain talk with a double-sided reflection that joins the two sides with “and” and puts the change talk second (SAMHSA, 2019).
What Does a Completed Decisional Balance Worksheet Look Like?
Harold, 78, filled in this worksheet on November 12, 2026, with R.M., a hospital social worker who has no stake in whether he moves to an assisted living community or stays in his home with more help.
The change I am considering
| “Moving to an assisted living community instead of staying in my house.” |
Benefits and costs
| Option | Benefits | Costs |
|---|---|---|
| Making the change (moving to assisted living) | “Someone would be there day and night if I fell again. Meals are made, and I'd have people to eat with. My daughter would worry less.” | “Leaving the house Ruth and I shared for 40 years. Giving up my garden and my workshop. A smaller place, with less privacy. It would cost more each month than I spend now.” |
| Not making the change (staying home with more help) | “My own home, my garden and my routines. The neighbors know me and look in on me. Help a few mornings a week might cost less than moving.” | “The stairs up to the bedroom are getting harder. I'd be alone at night if I fell. I'd have to find aides and keep track of their schedules. My daughter would keep worrying.” |
What matters most to me in this decision
| “Staying independent as long as I can, and not becoming a burden to my daughter. Feeling safe at night matters more to me since the fall.” |
Where this leaves me now
| “I haven't decided. I want to tour the assisted living place with my daughter and get a price for help at home before I choose.” |
R.M. gave each cell the same time and the same depth of reflection, then summarized both options in Harold's words. Harold chose the next step himself, and R.M. treated “not decided yet” as a reasonable place to end the meeting.
When Does a Decisional Balance Worksheet Fit?
A decisional balance worksheet fits when you are counseling with neutrality: the client faces a choice, and you have deliberately decided not to favor either option. Miller and Rose (2015) call this stance equipoise and conclude that the decisional balance is the appropriate procedure when a clinician wants to stay neutral about the outcome; their example is a patient weighing treatment options. Harold's choice is the same kind of decision, and so are a parent's choice about a change of school and a couple's decision about moving closer to family. The four cells give each option the same attention, which matches the purpose Janis and Mann gave the method: careful, unbiased weighing that leaves less room for regret afterward (Miller & Rose, 2015).
The worksheet does not fit when a client is ambivalent about a change you hope to strengthen, such as drinking less, quitting smoking or taking a medication every day. Its cell for the benefits of keeping things as they are asks the client to argue for not changing, which is sustain talk, and Miller and Rose (2015) concluded from the outcome research that with ambivalent people a decisional balance tends to decrease commitment to change, while evoking change talk promotes it. The difference matters because, in a meta-analysis of 36 studies, sustain talk in sessions went with worse outcomes (Magill et al., 2018). TIP 35 likewise advises clinicians to weigh their own intention before using a structured decisional balance and to avoid reinforcing sustain talk during one (SAMHSA, 2019). For a person who has already decided to change, a decisional balance may strengthen commitment further, although Miller and Rose note that it is not needed for that purpose and carries some risk when the decision is still tentative.
When you hope to strengthen a change, evoke change talk instead. Ask open questions about the client's desire, ability, reasons and need for change and about what concerns the client in the way things are now, reflect the change talk you hear, and answer sustain talk with reflections that do not ask the client to defend it. A double-sided reflection acknowledges the sustain talk and then pairs it with change talk, joined with “and” so that the change talk comes second (SAMHSA, 2019). A man who smokes might tell his primary care nurse, “I know cigarettes are wrecking my lungs, but they're the only break I get at work,” and the nurse might answer, “Those smoke breaks are the one pause in your workday, and you're worried about what they're doing to your lungs.” The importance and confidence rulers offer another route, because asking why the client chose a number and not a lower one draws out reasons for change.
How Do You Run a Decisional Balance Without Steering?
Give each of the four cells the same time, curiosity and depth of reflection, and let the client's words fill every cell. Watch for small habits that tilt the exercise, such as reflecting one option more warmly than the other or offering information about only one of them. These steps keep it even:
- Check your own leaning first. If you favor one option, or your role requires you to, as when a safety concern makes one option risky, say so openly and reconsider whether a neutral decisional balance is the right tool.
- Ask the client to name the decision in their own words.
- Work through all four cells with open questions, giving each about the same time.
- Reflect each side with the same depth, and affirm the client's careful thinking itself.
- Offer information only with permission, using Ask-Offer-Ask: ask permission, offer the information briefly, then ask what the client makes of it (Miller & Rollnick, 2023). Offer it for both options, such as the monthly cost of assisted living and of help at home.
- Summarize both sides evenly, then ask what matters most to the client in the decision.
- Accept the client's conclusion, including “not decided yet,” and let the client choose the next step.
R.M.'s closing summary for Harold gave both options the same weight: “Moving would mean someone there at night, company at meals and less worry for your daughter, and it would also mean leaving the house you and Ruth shared, along with your garden and workshop, at a higher monthly cost. Staying would keep your home, your neighbors and your routines, with help a few mornings a week, and the stairs and the nights alone would still be there. What matters most to you is staying independent and feeling safe at night, and you want to see the place and get prices before you decide.”
Where Did the Decisional Balance Come From, and What Have Trials Found?
The decisional balance began as a decision-making aid long before MI. Miller and Rose (2015) trace the first published version to a 1772 letter in which Benjamin Franklin described listing the reasons for and against a choice in two columns over several days and then weighing them. Irving Janis proposed a decisional matrix in 1959, and Janis and Leon Mann (1977) expanded it into a method for vigilant, unbiased decision making meant to reduce regret afterward; their 16-cell grid was later condensed into the familiar two-by-two table of the pros and cons of change and of the status quo, and early descriptions of MI used the decisional balance as both a measure and a clinical procedure (Miller & Rose, 2015).
The research findings are mixed, and most of the studies involved college students.
| Study | Sample | What it found |
|---|---|---|
| Apodaca and Longabaugh (2009), a review | 19 studies of MI delivered individually for substance use disorders | Effect sizes were generally mixed; among specific techniques, a decisional balance exercise showed the strongest association with better outcomes. |
| Collins and Carey (2005) | 131 college students whose drinking put them at risk | A decisional balance alone, in person or in writing, did not change drinking compared with assessment only. |
| LaBrie et al. (2006) | 47 college men, with no comparison group | Motivation to change rose and drinking fell one month after a decisional balance on drinking. |
| Carey et al. (2006) | 509 college students who drank heavily | A brief motivational intervention improved drinking outcomes at one month; the same intervention with an added decisional balance module did not. |
| Collins et al. (2014) | 724 undergraduates who drank | Web-based decisional balance feedback reduced drinking quantity and alcohol problems at six months, with no effects remaining at 12 months. |
| Krigel et al. (2017) | 82 college students who smoked and did not intend to quit | Perceived benefits of smoking rose after one session of MI limited to the decisional balance and fell after health education; both groups smoked less, with no significant differences between them. |
Three of these studies were controlled trials of decisional balance counseling (Carey et al., 2006; Collins & Carey, 2005; Krigel et al., 2017), and in each the decisional balance did no better than the comparison condition. In Carey et al. (2006), the brief motivational intervention improved drinking at one month and the same intervention with an added decisional balance module did not, although the two versions did not differ significantly from each other. Krigel et al. (2017) concluded that the decisional balance as used in early MI may be counterproductive and should be used with caution.
Practice the Skill Behind This Template
Practice double-sided reflections next, because they acknowledge both sides of a client's ambivalence while keeping the client's change talk in view, which is the skill you need whenever a decisional balance does not fit. Rehearse them with the motivational interviewing practice scenarios, watch Episode 9 on Practice Time, and use the exercises in Deliberate Practice in Motivational Interviewing (Manuel et al., 2022).
Keep reading
Readiness Ruler Worksheet, importance and confidence rulers with follow-up questions that evoke change talk.
Change Plan Worksheet, for the client who has decided and is ready to plan.
Motivational Interviewing Cheat Sheet, OARS, change talk and responses to sustain talk on one page.
Free Motivational Interviewing Toolkit, every template with a completed example.
Deliberate Practice in Motivational Interviewing, a free webinar with Robert Scholz, Tony Rousmaniere and Alexandre Vaz.
Frequently Asked Questions
What is a decisional balance worksheet?
A decisional balance worksheet is a sheet for weighing a decision, usually a four-cell grid of the benefits and costs of making a change and of keeping things as they are. It helps a person look at every side of a choice before deciding. This free version adds prompts about what matters most and where the person stands, along with a short clinician guide.
Is the decisional balance part of motivational interviewing?
Early descriptions of MI used the decisional balance as both a measure and a procedure, but MI's authors have since distinguished the two methods. Miller and Rose (2015) describe the decisional balance as a tool for counseling with neutrality and recommend leaving it out when MI is used to help a client resolve ambivalence in the direction of change. In that situation, MI evokes and strengthens the client's own change talk instead.
Who created the decisional balance?
Irving Janis proposed a decisional matrix in 1959, and he and Leon Mann expanded it in their 1977 book, Decision Making, into a procedure for weighing choices carefully and without bias. The idea is older still: Miller and Rose (2015), who trace this history, treat Benjamin Franklin's 1772 letter to Joseph Priestley, which described weighing reasons for and against a choice in two columns, as the first published decisional balance.
Can a decisional balance backfire?
It can, when the client is ambivalent and the goal is a particular change. Exploring the benefits of the status quo draws out sustain talk. In trials, a decisional balance raised college students' perceived benefits of smoking (Krigel et al., 2017), and adding one to a brief motivational intervention for college students who drank heavily did not improve its results; only the version without it outperformed the control condition at one month (Carey et al., 2006). When the clinician is neutral about the outcome, Miller and Rose (2015) consider it the appropriate tool.
What can you use instead of a decisional balance?
When you hope to strengthen a change, evoke change talk: ask about the client's own reasons for change and concerns about the status quo, reflect what you hear, and use a double-sided reflection when the client voices both sides. The importance and confidence rulers also help, because asking why the client chose a number and not a lower one draws out reasons for change.
References
Apodaca, T. R., & Longabaugh, R. (2009). Mechanisms of change in motivational interviewing: A review and preliminary evaluation of the evidence. Addiction, 104(5), 705-715. https://doi.org/10.1111/j.1360-0443.2009.02527.x
Carey, K. B., Carey, M. P., Maisto, S. A., & Henson, J. M. (2006). Brief motivational interventions for heavy college drinkers: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(5), 943-954. https://doi.org/10.1037/0022-006X.74.5.943
Collins, S. E., & Carey, K. B. (2005). Lack of effect for decisional balance as a brief motivational intervention for at-risk college drinkers. Addictive Behaviors, 30(7), 1425-1430. https://doi.org/10.1016/j.addbeh.2005.01.004
Collins, S. E., Kirouac, M., Lewis, M. A., Witkiewitz, K., & Carey, K. B. (2014). Randomized controlled trial of web-based decisional balance feedback and personalized normative feedback for college drinkers. Journal of Studies on Alcohol and Drugs, 75(6), 982-992. https://doi.org/10.15288/jsad.2014.75.982
Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. Free Press. ISBN 0-02-916160-6. https://openlibrary.org/isbn/9780029161609
Krigel, S. W., Grobe, J. E., Goggin, K., Harris, K. J., Moreno, J. L., & Catley, D. (2017). Motivational interviewing and the decisional balance procedure for cessation induction in smokers not intending to quit. Addictive Behaviors, 64, 171-178. https://doi.org/10.1016/j.addbeh.2016.08.036
LaBrie, J. W., Pedersen, E. R., Earleywine, M., & Olsen, H. (2006). Reducing heavy drinking in college males with the decisional balance: Analyzing an element of motivational interviewing. Addictive Behaviors, 31(2), 254-263. https://doi.org/10.1016/j.addbeh.2005.05.001
Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting and Clinical Psychology, 86(2), 140-157. https://doi.org/10.1037/ccp0000250
Manuel, J. K., Ernst, D., Vaz, A., & Rousmaniere, T. (2022). Deliberate practice in motivational interviewing. American Psychological Association. ISBN 978-1-4338-3618-3. https://www.apa.org/pubs/books/deliberate-practice-motivational-interviewing
Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press. ISBN 978-1-4625-5279-5. https://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781462552795
Miller, W. R., & Rose, G. S. (2015). Motivational interviewing and decisional balance: Contrasting responses to client ambivalence. Behavioural and Cognitive Psychotherapy, 43(2), 129-141. https://doi.org/10.1017/S1352465813000878
Substance Abuse and Mental Health Services Administration. (2019). Enhancing motivation for change in substance use disorder treatment (Treatment Improvement Protocol (TIP) Series No. 35, SAMHSA Publication No. PEP19-02-01-003). https://library.samhsa.gov/product/tip-35-enhancing-motivation-change-substance-use-disorder-treatment/pep19-02-01-003
