A Modified Balance-Sheet Procedure for Decision Making in Therapy: Cost-Cost ... her against his wishes or to send him to his father, as he clearly requested ...
Professional Psychology: Research and Practice 1995. Vol.26. No. 1.78-81
Copyright 1995 by the American Psychological Association Inc 0735-7028/95/53.00
A Modified Balance-Sheet Procedure for Decision Making in Therapy: Cost-Cost Comparisons Sheri Oz Kiryat Haim, Israel This article describes a simple intervention that can be used when clients find it difficult to make a decision: to weigh the costs and ignore the benefits of any alternative choices considered. A critique of the literature shows the advantages of this approach over I. L. Janis&L. Mann's (1977) full-scale balance-sheet procedure. Three case examples are presented to demonstrate the effectiveness of the cost-cost comparison.
Many clients enter therapy with either the specific goal of coming to terms with a particular dilemma that has them "stuck" and unable to decide, or with the more general goal of learning how to make decisions at all. Examples of the former may include decisions of whether to divorce or stay married, continue an extramarital affair, change career directions, adopt a child, or send an aging parent to a nursing home. Sometimes the decision-making element is masked by the client asking for help regarding the individual about whom a decision must be made. For example, a single mother entered therapy for the expressed purpose of learning to more effectively discipline her adolescent son who was increasingly acting out, when the underlying issue was whether to keep the boy with her against his wishes or to send him to his father, as he clearly requested that she do (Oz, 1994). When an individual finds that a decision situation is not resolved by applying previously acquired and perhaps habitually used coping skills, he or she may experience a crisis. During a crisis, cognitive functioning is reduced, and attempts at problem solving are likely to be a matter of trial and error (Caplan, 1964). It is at this point that many people seek therapy. For the wide variety of problem situations facing clients, the approach to decision making as a therapeutic process is identical: Step 1, alleviate the sense of crisis (Meichenbaum, 1985); Step 2, make the necessary decision or decisions; Step 3, prepare to implement the decision (Janis, 1983; Meichenbaum, 1985); Step 4, provide support during implementation (Janis, 1983; Salts, 1985; Wheeler & Janis, 1980); Step 5, assess the results and possibly repeat a number of steps if for some reason the selected choice is not workable or another decision becomes necessary (Janis, 1983) and the client wants further guidance. A modification of the balance-sheet procedure proposed by Janis and Mann (1977) for handling Step 2 of the process is
presented in this article. The reader is directed to the references in the above paragraph for clinical approaches appropriate for Step 1 and Steps 3 to 5. Following a brief critique of the balancesheet procedure is a description of the intervention and its application in three therapy situations. The Balance-Sheet Procedure Janis and Mann (1977) proposed a conflict-theory model of decision making in which they described five different patterns of decision-making strategies, distinguishable on the basis of specific configurations of five variables: information, risks, hope of finding a solution, time available, and stress level. According to Janis (1982), their model suggests the potential effectiveness of counseling to enhance decision making under stress by modifying the psychological and environmental factors that contribute to the inadequate handling of dilemmas. The main tool offered by them is the decisional balance sheet, which entails the detailed listing of pros and cons of each alternative. Interestingly, use of the balance-sheet technique is described as being appropriate to the second stage of decision making, the first stage being "deciding to decide" (Wheeler & Janis, 1980, p. 7). However, "deciding to decide" is no less a decision than choosing among alternative potential solutions to the "problem" concerning which the client seeks help, and it is not necessarily a decision the client has already made before embarking on therapy. In fact, choosing whether to actually change is a rather difficult challenge (Abelson & Levi, 1985; Janis, 1983) given certain apprehension about unknown consequences and anticipation of known costs that may be incurred as a result of choosing any of the apparent alternatives (Janis, 1982). Janis (1983) has suggested using an awareness-of-rationalizations procedure and role-playing to concretize for the client the costs of not changing in order to motivate them to change. By doing this, the therapist makes a very clear value statement to the client: It is not okay for you to decide not to decide. The balance-sheet procedure, which can also be applied to deciding to decide, sets up a formalized information search that is based on compensatory rules that have high cognitive processing demands (Johnson, 1990). If, as Janis (1982) has claimed, the human brain has a limited capacity regarding the units of information that can be processed simultaneously, then
SHERI Oz received her MSc in 1986 from the University of Guelph, Guelph, Ontario, Canada. She is currently in independent practice doing marital and family therapy. She also teaches sex education at the University of Haifa, Haifa. Israel. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Sheri Oz, Marital, Family, and Sex Therapy, Hakibbutzim 61 A, 26257 Kiryat Haim. Israel. 78
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the comprehensive balance sheets can become unwieldy. In fact, it has been shown that this activity does not reduce anxiety about the decision-making situation (Mau & Jepsen, 1992), and experienced decision makers have been shown to prefer a non-compensatory (low-demand) strategy (Johnson, 1990). Furthermore, considering of the benefits of a given alternative has been shown not to contribute in any way to effective decision making (Gollwitzer, Heckhausen, & Ratajczak, 1990). At times the decisional balance sheet has been misused by having individuals analyze only one side of the decision. For example, Marcus and Owen (1992) had subjects in a study list pros and cons of exercising without the corresponding list of pros and cons of not exercising. It is possible their results may have been different had respondents been encouraged to explore the costs of not changing as opposed to merely the (many) inconveniences of changing. Many clients in therapy know what is attractive about the alternatives they have already considered, and some are stuck precisely because they want to preserve all the benefits of all choices without paying any costs. Others engage in a "yes, but" activity, for example: I want to be open about my homosexuality but I don't want to hurt my religious parents; I want to take care of my elderly mother but I am afraid of the impact her living with us will have on my husband. These are values conflicts and not a problem of choosing among neutral alternatives. Furthermore, every benefit that can be listed under one alternative can be reworded as a cost under the opposite alternative. For example, able to be honest, a benefit of ending an extramarital affair, becomes forced to lie, a cost of continuing the affair. In fact, in their elaboration of the balance sheet, Wheeler and Janis (1980) describe the same phenomenon but do not attribute any importance to it. This is unfortunate because in most of their examples, it was the cost factor that determined the eventual choice made. And it is costs of favored choices that are most often ignored unless the decision maker is compelled to do otherwise (Abelson & Levi, 1985). Inadequate information about costs but not benefits may lead to postdecisional regret (Janis, 1982).
significant question is this: Is the client prepared to pay the cost if required to do so? Then the client is asked to think of ways in which the cost may be reduced in order to make a decision less expensive. This reduction will not be possible for all costs. Having made a decision, the client practices implementing it through role play, attempting to anticipate and prepare for the reactions of others.
Some Case Examples
Casel A, a 30-year-old housewife and mother of one, entered therapy with the goal of not feeling guilty about leaving her elderly parents so that she could, with clear conscience, accompany her husband on a year-long sabbatical to the United States. She believed that if she could stop feeling guilty she could decide to go with him. She was certain that the year away would be good for her marriage; they would be living near a much-loved older sister she had not seen in several years, and she would be able to study at the local university—all of which were good reasons for going. But A was frightened by the thought that something may happen to her parents while she was away and she would not be available to help them. Her list of costs can be found in Table 1. Reviewing the table, A remarked that she had not realized that regardless of her choice, someone would think her selfish. She elaborated on the fact that her younger sister, her parents' favorite, would be forced to take over all the tasks she had until then refused to do, because A had been so willing to do everything. "If she takes on all I used to do, they won't need me anymore." When she saw that the cost of losing her parents' love stood opposite the cost of endangering her marriage, and that her guilt actually masked her jealousy of her younger sister, she decided that staying in Israel was too expensive a choice. In following sessions, by examining the relative costs to her own fulfillment and to her marriage, A was able to define more explicitly what she was and was not prepared to do for others. Because she had a clear tool for assessing a variety of situations, she no longer needed guilt to cover her fear of being selfish.
Case 2 The Intervention Two or more alternatives to a particular dilemma are listed on the blackboard in the therapy room, and the therapist helps the client make a list of possible costs of implementing each alternative. Whether or not it seems probable that the client will have to incur a specific cost is irrelevant—all possible costs that come to mind are listed in a procedure similar to brainstorming. The therapist is free to add any costs he or she may think of. Many clients introject with comments about why one alternative is desirable; the therapist responds with, "That is a benefit, we are considering only the costs." When the client has no more to add, in order to ensure that the list is as exhaustive as possible, the therapist prompts the client with questions such as, "Who else might be affected or not approve?" "How else might this make life difficult for you?" Once the lists are complete, costs are considered for the values they represent. The client determines whether or not he or she is prepared to sustain particular costs "should the bill be delivered." It is clear that not all costs will have to be paid. The
A young accountant referred himself for therapy after having heard a lecture I gave at a community center on assertiveness in Table 1 Table of Costs for Client A Go to the United States
Stay in Israel
Not here if something happens to parents Younger sister will have to care for parents, and I'm not needed any more Parents will be angry at me Have to deal with my dissatisfaction in marriage Might end up egocentric and like mother and sister If I do this for myself, I will forget how to be helpful to others
Husband very angry at me Miss opportunity to be with older sister Miss opportunity for change of atmosphere and chance to study Husband will see me as selfish as I would be staying to satisfy my own needs and not considering his needs
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Table 2 Table of Costs for Client B Stand up to boss
Not stand up to boss
Get fired3 Get yelled at or ridiculed3 Boss won't ask me to do any special overtime for tasks that I still want to do" I'll start offfine. but boss gets the better of me
Feel like patsy: angry at self and angry at bossb Continue putting in overtime for no payb Colleagues look down on me Start being sloppy in work habits Come home with headache Avoid talking with boss on any subject May leave firm on own initiative because too angry to stay Feel like a failure
anyway8
I'll appear aggressive I will be offensive to myself If I succeed, I'll have to request the raise I think I deserve, and then I'll really get fired a b
From B's original list. Benefits from B's original list reworded as costs.
personal relationships. He described himself as having very little self-confidence but highly motivated to learn to assert himself. The current dilemma about which he came to see me involved an exploitative relationship with his boss. Whenever there was an inordinate amount of pressure in the office, his boss always requested that he stay overtime, without remuneration, to help reduce the load. As a new employee he had been flattered by the trust placed in him and considered the compliment payment enough for his time. But now, 2 years after joining the firm, he was alternately angry at himself for being such a patsy and angry at his boss for expecting him to continue being a patsy. He desperately wanted to be able to handle the situation but was afraid of the risk involved, and this paralyzed him. Before coming to see me, B had already made a list of the pros and cons of standing up to his boss. Table 2 shows the chart of costs of assertive versus nonassertive behaviors constructed in therapy building upon his original list. When he realized that the eventual outcome of not asserting himself may be quitting work of his own accord, he felt less threatened by the risk of being fired. B was most impressed by recognition of the fact that by not taking a chance and asserting himself, he was unknowingly resigning himself to costs far more damaging to his self-esteem and his health. This exercise increased his motivation to become assertive, but he did not feel ready to face his boss. Instead, he selected an easier task, one in which failure was less threatening: refusing to let his brother, a careless driver, drive his car. After a few role plays, he successfully denied his brother use of his car with no more than temporary damage to their relationship. As a result of this experience, B felt less fearful of the costs associated with unskilled attempts at assertiveness and decided to take on the challenge of standing up to his boss, relying on role play practice to adequately prepare him. By the time he faced his boss, he had already asserted himself in other areas and had thereby improved his self-image such that neither his boss nor his colleagues were surprised when he finally refused to do unpaid overtime.
With this accomplished, and as a result of some issues that arose during our work, B decided to embark on family-of-origin therapy, with the goal of being able to establish a healthy intimate relationship with a woman.
Case 3 The Cs were a young American couple living in Israel for 3 years, with a 6-month-old daughter. The identified problem was low sexual desire on the part of Mr. C. Ms. C was quite frustrated, wanting more frequent and more exciting sexual activity than her husband wanted. Their experiences with the initial sensate focus exercises indicated that, in fact, Ms. C was ambivalent toward her husband: She loved him and was very angry with him. Covert anger was an important unresolved issue from Mr. C's family of origin. When they decided to marry, Mr. C had already immigrated to Israel along with most of his extended family. He made it clear to his fiancee that marriage to him meant a commitment to live in Israel. She agreed; however, she had a difficult time integrating into Israeli society. After 3 years her Hebrew was minimal. Usually happily gregarious, she had made few friends, and she was unable to find work in her profession. At home, Mr. C became extremely agitated whenever she tried to express her dissatisfaction with her life, reminding her of her promise. She felt free to voice her distress only in a private session. Within a few joint sessions, she had found a way to impress on Mr. C the extent of her unhappiness, not with him but with living in Israel and with the fact that she did not want to lose him. He stated that given their marital agreement, his wife would have to make up her own mind: marriage in Israel or returning to the United States alone. Ms. C, however, wanted them to jointly decide what to do. At this impasse, I suggested we examine the costs of each alternative, letting Ms. C decide alone or deciding together (Table 3). It was clear to both spouses that deciding together really meant returning to the United States, at least temporarily. Living and raising his children in Israel were fundamental values to Mr. C, which Ms. C did not hold but did not oppose. However, this stood in conflict with other equally important values shared by both: that spouses work together as a team, showing mutual respect and consideration to each other, and that children grow up in an intact home with parents who have a healthy relationship.
Table 3 Table of Costs for Client Couple C Let wife decide alone
Decide together
Wife trapped in ambiguity Husband forces wife to take sole responsibility for marriage Fail to cooperate as team Nobody wins whatever her decision: if stays it is under duress; if leaves she "causes" divorce
Leaving Israel at least temporarily is inevitable Husband sacrifices dream Husband's family blames wife for taking him away Husband may feel trapped in U.S. the way wife does in Israel
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A MODIFIED BALANCE SHEET
Mr. C acknowledged that Ms. C had tried for 3 years to accommodate herself to life in Israel. Seeing that his insistence on strict adherence to their premarital agreement meant putting his wife in a no-win dilemma was untenable for him. Both were saddened by the sacrifice Mr. C would now be making, yet the atmosphere lightened appreciably once the decision had been made. Mr. C reassured his wife that he would claim equal responsibility for the decision when informing his family. The consequent confrontation with his family turned out to be an important part of his personal development, which had a significant impact on the couple's relationship. They intended to continue therapy in the United States. Both were cognizant of the possibility that Mr. C may not readjust to life in the States, necessitating a reevaluation of their decision. They felt secure in the fact that, as opposed to a decision to separate, this was a reversible one.
Conclusion This article describes a modification of Janis and Mann's (1977) balance-sheet procedure, a very simple instrument for helping clients make decisions: comparing the costs of one alternative with the costs of the other alternative or alternatives. It is unnecessary, in fact detrimental, to consider the benefits of the choices before one because (a) this makes comparisons too unmanageable; (b) we all want "to eat our cake and have it too" but wishful thinking does not make it happen; and (c) it is only by comparing what we may sacrifice in making a choice that gives us the opportunity to decide what we most value. In almost all instances, one alternative involves self-denial and the other involves costs to a relationship or to one's image in the eyes of others. My experience with this tool has been very positive. I use it not only in therapy but also in assertiveness training workshops and sex education. It can be applied to any kind of dilemma. The difference between its impact in group work and therapy is that in the former some participants choose not to decide. They are grateful for being shown respect for their current unpreparedness for change and express personal responsibility for their decision: "I decided to pay the consequences of maintaining the status quo because I don't want to pay the price of change." Thus a natural tendency to deny responsibility for difficult choices by attributing the inability to decide on external factors (Zakay, 1984) is averted. For this reason, even when the outcome is a decision not to decide or, indeed, a choice that the therapist views as wrong, it is important to see these as results of a successful decision-making process, the consequences of which the client is prepared to bear.
In therapy, clients usually decide to decide, perhaps because of the special relationship that develops between the therapist and the client and the ongoing one-on-one support that is available. Sometimes the client is satisfied with having solved the identified problem and with having acquired a tool that can be applied to future dilemmas (Case 1); at other times, this serves as a jump-off point into in-depth therapy (Case 2) or is used in conjunction with other techniques in ongoing therapy (Case 3).
References Abelson, R. P., & Levi, A. (1985). Decision making and decision theory. In G. Lindzey & E. Aronson (Eds.), Handbook of Social Psychology: Vol. 1. Theory and Method (pp. 231-309). New York: Random House. Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books. Gollwitzer, P. M., Heckhausen, H., & Ratajczak, H. (1990). From weighing to willing: Approaching a change decision through pre- or postdecisional mentation. Organisational Behavior and Human Decision Processes, 45, 41-65. Janis, I. L. (1982). Decisionmaking under stress. In L. Goldberger & S. Breznitz (Eds.), Handbook of stress: Theoretical and clinical aspects (pp. 69-87). New York: Free Press. Janis, I. L. (1983). Short-term counseling. Guidelines based on recent research. New Haven, CT: Yale University Press. Janis, I. L., & Mann, L. (1977). Decision Making: A Psychological Analysis of Conflict, Choice, and Commitment. New York: Free Press. Johnson, M. M. S. (1990). Age differences in decision making: A process methodology for examining strategic information processing. Journal of'Gerontology, 45, 75-78. Marcus, B. H., & Owen, N. (1992). Motivational readiness, self-efficacy and decision-making for exercise. Journal oj Applied Social Psychology, 22, 3-\(>. Mau. W., & Jepsen, D. A. (1992). Effects of computer-assisted instruction in using formal decision-making strategies to choose a college major. Journal of Counseling Psychology, 39, 185-192. Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press. Oz, S. (1994). Decisionmaking in divorce therapy: Cost-cost comparisons. Journal of Marital and Family Therapy. 20, 77-81. Salts, C. J. (1985). Divorce stage theory and therapy: Therapeutic implications throughout the divorcing process. In D. H. Sprenkle (Ed.), Divorce therapy (pp. 13-23). New York: Haworth. Wheeler, D. D., & Janis, I. L. (1980). A practical guide for making decisions. New York: Free Press. Zakay, D. (1984). The influence of perceived event's controllability on its subjective occurrence probability. The Psychological Record, 34, 233-240.
Received December 6, 1993 Revision received January 11, 1994 Accepted February 22, 1994 •
