Difficulty with making decisions

Decision-making ranges from minor decisions, such as what to have for dinner, to major life-changing ones, such as changing careers. It involves many different cognitive functions working together: 

• long-term memory (how I have dealt with these situations in the past?)  
• working memory (holding information in mind and thinking things through) 
• emotion (how important is this decision to me, and how will the possible outcomes make me feel?). 

A traumatic brain injury or other brain disorder can disrupt the complex process of decision-making. People are affected in different ways and some find seemingly simple decisions almost impossible, while others become impulsive, making hasty decisions without thinking them through. 

Poor judgement in relationships, with money, or in business, can have devastating consequences for the individual and their family. We all have difficulty making decisions from time to time, but brain injury can make this much more frequent. 

Some people may be able to decide on a plan of actions to take but will struggle following through with the plan.  It is as if a person’s intention, or goal, becomes neglected. This can sometimes be because the person becomes distracted by other tasks or activities. The person ‘forgets’ to do things, not because what they have planned to do has been completely forgotten.  Rather, it is difficult to keep planned activities in mind (e.g. going to an appointment). 

This is often called ‘prospective remembering’, as a person needs to be alert to all elements of their plans for the day. Psychologists describe this ability to keep a list of actions in mind as having a ‘mental blackboard’. For people with brain injury, items are easily rubbed off the mental blackboard and temporarily forgotten, although the person may remember their planned intention when prompted.

The cognitive problems that affect decision-making can also affect a person’s ability to recognise their own difficulties. A person might appear to have poor judgement and may fail to achieve important tasks. This can be a challenge for family and friends and even become a source of conflict. However, it is important to keep in mind that the person may not be aware of these difficulties, or share the opinion of those judging it as a problem.  

The first step is to help the person achieve a degree of self-awareness and gain an understanding of the problems they are experiencing. This may need sensitive feedback from family, friends or professionals, and requires that the individual has a desire to learn about possible solutions.

The first step in rehabilitation is to understand the problem. This is easier said than done because of the complex process involved in decision-making or problem solving.  It may be best done with the help of a professional such as an occupational therapist or clinical psychologist. 

For many, learning to manage impulsivity is an important step. This involves developing the habit of stopping to think, even just briefly, about what you are doing and what you have to do. This interrupts a person’s tendency to act without thinking. The idea is that people become better at using ‘self-talk’ to regulate their own actions or behaviour. 

Goal Management Training is another way to help people stay focused on what they want to achieve. It involves the following steps: 

Goal: what are you trying to achieve? 

Obstacle: what is standing, or could stand in the way of you achieving your goal? 

Plan: what do you need to do, and do you need help for any one of the steps? 

Prediction: how well do you think you will do? How many can you get done? 

Do: implement the plan. 

Review: What worked? What didn’t work? Why or why not? 

External aids such as diaries, notebooks, wall charts and calendars are invaluable for people with memory impairment. Devices such as mobile phones, tablets and electronic watches can all be set to provide reminders and cues about specific tasks, or to check a daily planner. It isn’t always easy for someone with memory difficulties to use these aids so the help of a relative, carer or occupational therapist may be needed.