Drugs Decisional Balance Scales

1. Abstract

The Drugs Decisional Balance Scales (DDBS) represent a pivotal multidimensional psychometric instrument developed within the overarching framework of the Transtheoretical Model (TTM) of behavior change pioneered by James O. Prochaska and Carlo C. DiClemente. Derived originally from Irving Janis and Leon Mann’s seminal conflict-theoretic model of decision-making, the decisional balance construct operationalizes an individual’s cognitive appraisal of the perceived benefits (“Pros”) and perceived costs (“Cons”) associated with continuing or modifying illicit drug use. The standard DDBS comprises 20 self-report items evenly divided into two orthogonal or moderately inversely correlated primary subscales: the Pros of Using Drugs (10 items) and the Cons of Using Drugs (10 items). Each item is evaluated on a 5-point Likert-type importance scale ranging from 1 (Not important at all) to 5 (Extremely important).

Extensive psychometric investigations across diverse clinical, community, and co-occurring severe mental illness populations have substantiated the instrument’s structural integrity, factorial invariance, and cross-sectional as well as longitudinal validity. Confirmatory factor analytic investigations routinely validate the two-factor orthogonal or oblique model over unidimensional configurations. Reliability estimates across empirical cohorts are robust, with internal consistency coefficients (Cronbach’s alpha) typically exceeding .85 for both the Pros and Cons dimensions. In clinical and research contexts, decisional balance assessment serves as a critical biomarker of an individual’s stage of change—progressing systematically from Precontemplation (where Pros significantly outweigh Cons) to Contemplation (where Pros and Cons reach ambivalence or parity) and onward to Preparation, Action, and Maintenance (where Cons clearly exceed Pros). Consequently, the DDBS serves as an indispensable diagnostic and therapeutic tracking tool for addiction medicine, motivational interviewing, tailored psychosocial interventions, and clinical trials.

2. Keywords

Drugs Decisional Balance Scales, Transtheoretical Model, Stages of Change, Substance Use Disorders, Psychometrics, Pros and Cons, Motivational Assessment, Addiction Treatment, Behavioral Economics, Cognitive Appraisal

3. Authors

The theoretical conceptualization, psychometric adaptation, and empirical validation of the decisional balance construct within substance abuse interventions emerged through collaborative programs of research led by prominent figures in behavioral health:

• Carlo C. DiClemente, Ph.D. – Professor Emeritus of Psychology, University of Maryland, Baltimore County (UMBC); Co-developer of the Transtheoretical Model of Health Behavior Change; Director of the Habits Lab at UMBC.
• Wayne F. Velicer, Ph.D. (1944–2017) – Former Professor of Psychology and Co-Director of the Cancer Prevention Research Center (CPRC) at the University of Rhode Island; leading quantitative psychologist who formalized the mathematical operationalization of the decisional balance inventory and structural equation modeling within the TTM.
• James O. Prochaska, Ph.D. (1942–2023) – Former Professor of Clinical Psychology and Founder of the Cancer Prevention Research Center at the University of Rhode Island; principal architect of the Transtheoretical Model.

Significant clinical adaptations and population-specific psychometric validations have also been advanced by Kate B. Carey, Ph.D. (Brown University School of Public Health), Stephen A. Maisto, Ph.D. (Syracuse University), Alan S. Bellack, Ph.D. (University of Maryland School of Medicine), Melanie E. Bennett, Ph.D., and Mary M. Velasquez, Ph.D. (The University of Texas at Austin).

4. Purpose

The primary purpose of the Drugs Decisional Balance Scales is to provide a standardized, psychometrically sound quantification of the cognitive and motivational factors that govern an individual’s illicit or non-prescribed drug use. Substance use disorders represent complex behavioral phenotypes characterized by profound ambivalence: individuals frequently recognize the adverse physical, social, legal, and occupational sequelae of their substance consumption while simultaneously depending upon the psychoactive, hedonic, coping, and social-facilitation properties of those same substances. The DDBS formally captures this internal conflict by measuring the cognitive weight an individual assigns to the positive aspects of drug consumption relative to the negative consequences.

In clinical practice, the DDBS serves multiple pivotal functions. First, it enables clinicians to perform diagnostic and readiness-to-change staging without relying exclusively on overt behavioral markers. Because cognitive shifts predictably precede behavioral cessation, an increase in the perceived importance of the “Cons” serves as an early indicator that a client is transitioning from the Precontemplation stage to the Contemplation or Preparation stage. Second, the scale provides actionable targets for motivational interviewing and cognitive-behavioral therapy (CBT). By examining specific item endorsements, therapists can identify unique functional reinforcers (e.g., “Using drugs helps me deal with problems” or “Not using drugs at a social gathering would make me feel too different”) and help clients develop tailored behavioral substitution and emotional regulation strategies.

In clinical trials and epidemiological research, the DDBS acts as an essential mediator variable and outcome predictor. Researchers utilize the instrument to track whether psychosocial or pharmacological interventions successfully alter the client’s internal balance sheet regarding drug use. Longitudinal research demonstrates that interventions failing to increase the perceived Cons of drug use or decrease the perceived Pros rarely achieve sustained post-treatment abstinence. Furthermore, the DDBS has been adapted for use across diverse clinical groups, including individuals with co-occurring severe mental illnesses (e.g., schizophrenia, bipolar disorder), justice-involved populations, and adolescent or emerging-adult substance users, making it a universal assessment benchmark in addiction science.

5. Psychological Construct

The psychological construct assessed by the DDBS is the cognitive appraisal of decision-making conflict within the context of psychoactive drug consumption. Rooted in psychological decision theory, the decisional balance framework conceptualizes human intentionality as the product of comparative cognitive calculus. Rather than viewing substance dependence purely as an involuntary neurobiological compulsion or an automatic behavioral reflex, this construct emphasizes the conscious and semi-conscious evaluative weights an individual assigns to competing behavioral outcomes.

The Pros of Using Drugs Subscale

The Pros of Using Drugs dimension evaluates the reinforcing, functional, and subjectively beneficial dimensions of substance use as perceived by the individual. In the DDBS, this construct is not merely a measure of physical pleasure or euphoria; rather, it reflects a broad, multidimensional array of functional utilities across three core domains:

• Affect Regulation and Coping: Items such as “Using drugs helps me deal with problems” (Item 4) and “My drug use helps give me energy and keeps me going” (Item 16) measure the extent to which drugs serve as an external compensatory coping mechanism for psychological distress, fatigue, or dysphoria.
• Self-Perception and Confidence: Items like “I like myself better when I use drugs” (Item 2) and “I am more sure of myself when I am using drugs” (Item 17) tap into the chemical enhancement of self-efficacy, self-worth, and identity stabilization.
• Social Facilitation and Affiliation: Items including “Using drugs helps me to have fun and socialize” (Item 7), “Using drugs makes me more of a fun person” (Item 9), “Using drugs helps me to loosen up and express myself” (Item 11), “Not using drugs at a social gathering would make me feel too different” (Item 14), “Without drugs, my life would be dull and boring” (Item 19), and “People seem to like me better when I use drugs” (Item 20) evaluate the perceived social rewards, peer integration, and relief from social anxiety derived from drug consumption.

The Cons of Using Drugs Subscale

The Cons of Using Drugs dimension captures the perceived severity, salience, and personal relevance of the negative consequences and internal conflicts generated by continued substance misuse. This dimension assesses several distinct categories of psychosocial, ethical, and functional impairment:

• Interpersonal Conflict and Stigmatization: Items such as “My drug use causes problems with others” (Item 1), “Because I continue to use drugs some people think I lack the character to quit” (Item 3), “Some people try to avoid me when I use drugs” (Item 6), and “Some people close to me are disappointed in me because of my drug use” (Item 10) assess the relational friction, social rejection, and moral disapprobation experienced by the user.
• Internalized Guilt and Self-Concept Violations: Items such as “Having to lie to others about my drug use bothers me” (Item 5) and “I am setting a bad example for others with my drug use” (Item 18) quantify the internal dissonance experienced when drug-seeking behavior violates an individual’s personal moral code, core values, or parental/mentorship roles.
• Functional and Occupational Disruption: Items including “Using drugs interferes with my functioning at home or/and at work” (Item 8) and “I am losing the trust and respect of my coworkers and/or spouse because of my drug use” (Item 15) measure tangible impairments in primary adult social and economic role obligations.
• Behavioral Dyscontrol and Risk of Harm: Items like “I seem to get myself into trouble when I use drugs” (Item 12) and “I could accidentally hurt someone because of my drug use” (Item 13) reflect awareness of impulsivity, legal jeopardy, physical vulnerability, and externalized danger resulting from drug-induced intoxication.

6. Theoretical Framework

The DDBS is grounded theoretically in the convergence of two major psychological models: the Conflict Model of Decision-Making formulated by Irving Janis and Leon Mann (1977) and the Transtheoretical Model of Behavior Change (TTM) formulated by James O. Prochaska and Carlo C. DiClemente (1983, 1992).

Janis and Mann proposed that every critical life choice induces psychological stress and cognitive conflict. Their model organized decisional considerations into an exhaustive eight-cell balance sheet: utilitarian gains and losses for self, utilitarian gains and losses for significant others, approval and disapproval from self, and approval and disapproval from others. When Wayne Velicer and colleagues (1985) empirically evaluated these eight theoretical categories in the context of smoking cessation, mathematical factor analyses revealed that the eight cells did not emerge as eight separate empirical dimensions; instead, they consistently collapsed into two orthogonal or primary second-order factors: the Pros (combining all categories of positive gains and approvals) and the Cons (combining all categories of losses, costs, and disapprovals).

Within Prochaska and DiClemente’s Transtheoretical Model, decisional balance functions as one of the central cognitive-evaluative constructs that interface dynamically with the Stages of Change. The TTM posits that intentional behavior change unfolds over five discrete, non-linear chronological stages:

1. Precontemplation: Individuals have no intention of altering their drug use in the foreseeable future (typically defined as within the next 6 months). In this stage, the Pros of drug use strongly outweigh the Cons. The individual remains largely unmotivated, defensive, or uninformed regarding the objective hazards of their drug use.
2. Contemplation: Individuals acknowledge that a problem exists and are seriously considering reducing or stopping drug use within the next 6 months, but have made no firm commitment to take immediate action. Here, the Cons of drug use increase substantially, approaching parity with the Pros. This stage is characterized by profound ambivalence, as the cognitive weights of Pros and Cons hang in delicate equilibrium.
3. Preparation: Individuals intend to take explicit behavioral action within the next 30 days and have often initiated preliminary small steps. Psychometrically, the crossover point occurs: the Cons of drug use clearly surpass the Pros in subjective importance.
4. Action: Individuals have successfully modified their overt behavior, abstaining completely from illicit drug use for a period ranging from one day to 6 months. In this stage, Cons remain high while the perceived Pros continue to decline significantly.
5. Maintenance: Individuals have sustained behavioral change for greater than 6 months and actively engage in relapse prevention processes. The perceived Pros of drug use reach their nadir, while Cons remain moderately elevated or stabilize as an internalized cognitive protection against relapse.

A profound cross-behavioral finding published by Prochaska et al. (1994) across 12 distinct health-risk behaviors established two universal mathematical principles governing decisional balance:

• The Strong Principle of Change: Progression from Precontemplation to Action is accompanied by approximately a 1 standard deviation (1.0 SD) increase in the perceived Cons of the problem behavior.
• The Weak Principle of Change: Progression from Precontemplation to Action is accompanied by approximately a 0.5 standard deviation (0.5 SD) decrease in the perceived Pros of the problem behavior.

These theoretical axioms underline why the DDBS is not merely a descriptive questionnaire, but an indispensable navigational instrument for tracking structural cognitive transformation during psychological and medical addiction treatment.

7. Validity

The Drugs Decisional Balance Scales have undergone rigorous psychometric validation across multiple clinical settings, establishing exemplary construct, criterion, convergent, and discriminant validity.

Construct and Structural Validity

Construct validity for the DDBS has been confirmed through repeated factor analytic demonstrations that the 20 items reliably load onto two distinct, theoretically coherent latent dimensions (Pros and Cons). Studies examining the structural validity of the decisional balance construct across different substances of abuse—including cocaine, heroin, cannabis, methamphetamine, and polydrug use—demonstrate that the two-factor architecture remains invariant across substance classes (Carey et al., 2001; DiClemente et al., 2008). The independence or moderate negative correlation between the Pros and Cons factors confirms that individuals do not view benefits and costs as mutually exclusive poles of a single bipolar continuum, but rather as distinct, simultaneous cognitive evaluations.

Convergent and Concurrent Validity

Convergent validity is robustly demonstrated through significant correlations with standardized measures of readiness to change, motivation, and substance consumption patterns. Empirical investigations by Carey, Maisto, Carey, and Purnine (2001) evaluating psychiatric outpatients with co-occurring substance misuse demonstrated that the DDBS Cons scale was positively and significantly correlated with the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Recognition subscale (r = .55 to .68, p < .001) and the University of Rhode Island Change Assessment (URICA) Contemplation subscale. Conversely, the Pros scale correlated positively with URICA Precontemplation scores and measures of substance craving and dependence severity.

Predictive and Criterion Validity

Predictive validity has been substantiated in both outpatient and inpatient clinical trials. Nidecker, DiClemente, Bennett, and Bellack (2008) examined the psychometric properties of TTM measures among patients with severe mental illness (schizophrenia, schizoaffective disorder, major affective disorders) and co-occurring drug dependence. Baseline DDBS scores reliably predicted prospective treatment engagement, retention in substance abuse group therapy, and biological urinalysis outcomes at 3- and 6-month follow-up evaluations. Specifically, individuals exhibiting a higher baseline Cons-to-Pros ratio, or who demonstrated a rapid early elevation in Cons during the initial weeks of treatment, achieved significantly higher rates of verified continuous abstinence.

Discriminant Validity

Discriminant validity has been confirmed through the scale’s ability to differentiate clearly between distinct stages of change. Individuals classified clinically into the Precontemplation stage display statistically significant differences in Pros scores (consistently higher) and Cons scores (consistently lower) compared to individuals in the Preparation and Action stages (Prochaska et al., 1994; Ward, Velicer, & Rossi, 2004). Furthermore, the DDBS shows negligible correlations with unrelated personality dimensions such as extraversion or generalized trait anxiety when controlling for general distress, establishing that the measure captures substance-specific cognitive appraisals rather than generalized negative affectivity or response styles.

8. Reliability

The Drugs Decisional Balance Scales demonstrate high internal consistency and temporal stability across a diverse spectrum of demographic and clinical populations.

Internal Consistency Reliability

Across validation studies, both the 10-item Pros and 10-item Cons subscales routinely achieve Cronbach’s alpha coefficients well above the accepted threshold of .70 for research instruments and exceeding the .80 benchmark recommended for individual clinical decision-making:

• In general adult substance-abusing samples evaluated during the development of group treatment protocols (Velasquez, Maurer, Crouch, & DiClemente, 2001), Cronbach’s alpha for the Pros subscale ranged from .86 to .91, while the Cons subscale yielded alpha values between .84 and .89.
• In psychiatric outpatient cohorts with co-occurring substance use disorders, Carey et al. (2001) reported Cronbach’s alphas of .87 for the Pros scale and .85 for the Cons scale.
• In dual-diagnosis samples with severe and persistent mental illness, Nidecker et al. (2008) reported coefficient alphas of .86 for the Pros of drug use and .84 for the Cons of drug use, demonstrating that cognitive impairment or active psychiatric symptomatology does not compromise the internal reliability of the instrument.
• Mean inter-item correlations across the subscales consistently fall within the ideal psychometric window of .30 to .50, confirming conceptual cohesion without excessive item redundancy.

Test-Retest Stability

Test-retest reliability has been evaluated over intervals ranging from 48 hours to 2 weeks among non-treatment-seeking or stable baseline cohorts. Intraclass correlation coefficients (ICC) and Pearson correlation coefficients consistently range from .81 to .88 for both subscales, indicating robust temporal stability in the absence of therapeutic intervention. In contrast, among individuals actively receiving motivational or cognitive-behavioral interventions, test-retest scores appropriately demonstrate dynamic shifts reflecting psychological movement through the stages of change, confirming that the scale is sensitive to true therapeutic change while remaining stable against random measurement error.

9. Factor Analysis

The factorial validity of the Decisional Balance inventory has been extensively investigated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

Exploratory Factor Analyses

In the original structural derivations modeled after the smoking and alcohol decisional balance inventories (Velicer et al., 1985; Prochaska et al., 1994), principal component analyses with Varimax and Promax rotations uniformly identified a clear two-component solution. The two eigenvalues clearly separated from the scree plot drop-off, accounting for between 48% and 58% of the total scale variance. Items 2, 4, 7, 9, 11, 14, 16, 17, 19, and 20 consistently loaded strongly on the first component (Pros), with primary factor loadings typically ranging between .52 and .81, and cross-loadings onto the Cons component remaining negligible (< .25). Conversely, Items 1, 3, 5, 6, 8, 10, 12, 13, 15, and 18 loaded cleanly onto the second component (Cons), with primary loadings between .49 and .78.

Confirmatory Factor Analyses and Model Fit

Subsequent confirmatory factor analyses using structural equation modeling (SEM) rigorously compared competing structural representations:

• Unidimensional Model: A single general “drug evaluation” factor yielded very poor fit indices (e.g., Comparative Fit Index [CFI] < .65, Root Mean Square Error of Approximation [RMSEA] > .14), demonstrating that decisional balance cannot be conceptualized as a single bipolar dimension.
• Two-Factor Orthogonal Model: Specifying two uncorrelated latent constructs (Pros and Cons) produced acceptable fit, confirming substantial independence between perceived benefits and costs.
• Two-Factor Correlated (Oblique) Model: Allowing a slight-to-moderate negative correlation between Pros and Cons (typically r = -.15 to -.30) provided superior fit to the data across diverse cohorts (CFI > .92, Tucker-Lewis Index [TLI] > .91, RMSEA ≤ .058, Standardized Root Mean Square Residual [SRMR] ≤ .052).

In studies evaluating short-form inventories and measurement invariance across gender, age, and severity tiers (Ward, Velicer, & Rossi, 2004), multigroup CFA demonstrated strict metric and scalar invariance, confirming that the items function identically across demographic and clinical subpopulations.

10. Instrument / Measurement Tool

• Instrument Name: Drugs Decisional Balance Scales (DDBS)
• Alternative Names: Decisional Balance Scale for Drug Use; TTM Drug Decisional Balance Inventory
• Assessment Type: Quantitative self-report psychometric questionnaire
• Primary Application: Clinical addiction evaluation, readiness-to-change staging, treatment planning, cognitive monitoring, outcome evaluation
• Administration Format: Pen-and-paper self-administered, computerized clinical portal, or structured clinician-administered interview
• Time Required: Approximately 5 to 10 minutes to complete
• Target Population: Adolescents and adults (ages 12 and older) reporting active or recent illicit, prescription, or non-prescribed drug use
• Item Count: Exactly 20 items
• Subscale Breakdown:
  • Pros of Using Drugs Subscale: 10 items (Items 2, 4, 7, 9, 11, 14, 16, 17, 19, 20)
  • Cons of Using Drugs Subscale: 10 items (Items 1, 3, 5, 6, 8, 10, 12, 13, 15, 18)
• Response Scale: 5-point Likert-type scale rating the importance of each statement when making a decision about using drugs:
  • 1 = Not important at all
  • 2 = Slightly important
  • 3 = Moderately important
  • 4 = Very important
  • 5 = Extremely important
• Scoring Methodology:
  • Raw Subscale Scores: Sum or average the ratings for each 10-item subscale. Raw sums range from 10 to 50 for the Pros and 10 to 50 for the Cons (mean item scores range from 1.0 to 5.0).
  • T-Score Standardization: In clinical practice and TTM protocols, raw scores are frequently converted to standardized T-scores (Mean = 50, Standard Deviation = 10) based on population norms.
  • Decisional Balance Difference (Decisional Index): Calculated as Cons − Pros. A negative difference score (Pros > Cons) indicates Precontemplation; a difference score near zero indicates Contemplation/Ambivalence; a positive difference score (Cons > Pros) indicates Preparation, Action, or Maintenance.

11. Permissions & Fee and Test Year

The foundational research on decisional balance instruments within the Transtheoretical Model was published by Wayne F. Velicer, Carlo C. DiClemente, and James O. Prochaska beginning in 1985, with drug-specific adaptations formalizing in the 1990s and early 2000s (e.g., Werch & DiClemente, 1994; Prochaska et al., 1994; Velasquez et al., 2001). The Drugs Decisional Balance Scales were developed through federally funded academic research programs supported by the National Institutes of Health (NIH), including the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

In accordance with the open-science principles of the developers and public dissemination mandates, the scale is generally considered in the public domain for clinical, research, and non-commercial educational purposes. Researchers and practitioners may administer, reproduce, and score the instrument without royalty fees. However, clinical software vendors, commercial assessment platforms, or entities incorporating the instrument into proprietary commercial diagnostic packages must obtain express written licensing permission from the copyright holders or academic institutions (e.g., Habits Lab at UMBC, University of Maryland Baltimore County; Cancer Prevention Research Center, University of Rhode Island). Appropriate academic citation must accompany any use of the instrument.

12. References

• Carey, K. B., Maisto, S. A., Carey, M. P., & Purnine, D. M. (2001). Measuring readiness to change substance misuse among psychiatric outpatients: Reliability and validity of self-report measures. Journal of Studies on Alcohol, 62(1), 79–88. https://doi.org/10.15288/jsa.2001.62.79
• Collins, S. E., Carey, K. B., & Otto, J. M. (2009). A new decisional balance measure of motivation to change among at-risk college drinkers. Psychology of Addictive Behaviors, 23(3), 464–471. https://doi.org/10.1037/a0015841
• DiClemente, C. C., Nidecker, M., & Bellack, A. S. (2008). Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders. Journal of Substance Abuse Treatment, 34(1), 25–35. https://doi.org/10.1016/j.jsat.2007.01.005
• Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. Free Press.
• Nidecker, M., DiClemente, C. C., Bennett, M. E., & Bellack, A. S. (2008). Application of the Transtheoretical Model of change: Psychometric properties of leading measures in patients with co-occurring drug abuse and severe mental illness. Addictive Behaviors, 33(8), 1021–1030. https://doi.org/10.1016/j.addbeh.2008.03.011
• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390
• Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102–1114. https://doi.org/10.1037/0003-066X.47.9.1102
• Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., Fiore, C., Harlow, L. L., Redding, C. A., Rosenbloom, D., & Rossi, S. R. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39–46. https://doi.org/10.1037/0278-6133.13.1.39
• Velasquez, M. M., Maurer, G., Crouch, C., & DiClemente, C. C. (2001). Group treatment for substance abuse: A stages-of-change therapy manual. Guilford Press.
• Velicer, W. F., DiClemente, C. C., & Prochaska, J. O. (1985). Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology, 48(5), 1279–1289. https://doi.org/10.1037/0022-3514.48.5.1279
• Ward, R. M., Velicer, W. F., & Rossi, J. S. (2004). Factorial invariance and internal consistency for the decisional balance inventory – short form. Addictive Behaviors, 29(5), 953–958. https://doi.org/10.1016/j.addbeh.2004.02.049
• Werch, C. E., & DiClemente, C. C. (1994). A multi-component stage model for matching drug prevention strategies and messages to youth stage of use. Health Education Research, 9(1), 37–46. https://doi.org/10.1093/her/9.1.37

13. Items of the Scale (Questionnaire)