Difficulty with making decisions - Fact Sheet
This is common after a brain injury,
according to Dr Andrew Bateman and Prof Jonathan
Decision-making is one element of a broader set of mental
skills that have been called 'executive functions' - these are
the skills needed to enable us to deal with problems that
arise in everyday life and to cope with new situations.
Everyday life is full of situations in which we have to make
decisions - some minor (which toothpaste will I buy, what will
I have for dinner tonight?) and some major (will I
stay in this relationship, will I change my job?).
Decision-making involves many different cognitive functions
working together - longterm memory (how have I dealt with
similar situations in the past?), working memory (holding
information in mind and thinking things through) and emotion
(how important is this decision to me, and how will the
possible outcomes make me feel?) are all involved.
Decision-making involves a lot of different processes so
brain disorders such as traumatic brain injury will
often affect this vital cognitive skill.
People are affected in different ways - some find it hard
to make a decision at all, finding that even what seem like
simple decisions, such as what toothpaste to buy,
become almost impossible. Some people become impulsive,
making hasty decisions, apparently acting without thinking
things through. Poor judgement in relationships, with money,
or in business, can have devastating consequences for the
individual and their family. All of us, with or without brain
injury, have difficulty making decisions from time to time,
but brain injury can make this much more frequent.
Decision-making & following
For some people, a decision about a plan of action might be
made, but it is difficult to follow 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 has
to be done has been completely forgotten, but rather that it
is difficult to keep the thing to be done in mind (e.g. take
medication, go to appointments, give someone a
message, carry out daily tasks, watch a favourite
TV program). This type of remembering is often called
'prospective remembering'. It requires alertness to the plans
for the day. Psychologists use the concept of a 'mental
blackboard' to describe how we keep things we intend to
do in mind (written on a mental blackboard). However, the
difficulty can be that for a person after brain injury things
are easily rubbed off a mental blackboard and temporarily
'forgotten'. Although the person may remember
their intention when reminded.
The cognitive problems that cause difficulties with
decision-making or prospective remembering may also make it
difficult for an individual to be aware of their problems.
This can be difficult for the person and his or
her family and friends, and cause conflict. The person
may show what may be considered by others as bad judgement,
and they may fail to achieve important tasks. However, they
may not be aware of these difficulties, or share
the opinion of those judging this as a difficulty.
So one of the first challenges to overcome is related to
the need for the individual to achieve a degree of
self-awareness and understanding of the problems they are
experiencing. This may require sensitive feedback from family,
friends or professionals, and for the individual to
want to learn about possible solutions.
It can be challenging working out how to improve
decision-making, problem-solving, planning, following through,
and remembering to do things after a traumatic brain
injury or similar brain disorder.
The first step in rehabilitation is understanding the
problem, but with something as complex as decision-making or
problemsolving this may not be straightforward. It may be
best done with the help of a professional such as an
occupational therapist or clinical psychologist.
For some people, learning to manage impulsivity is
important - developing a habit of often stopping and thinking,
even if just briefly, about what you are doing and what
you have to do can help to interrupt a tendency to act
without thinking. The idea is that people become better at
using 'self-talk' - regulating their own actions or
In Goal Management Training, people learn to be clear on
what they want to achieve, work out and keep in mind the steps
regularly check their mental blackboard to ensure important
tasks are kept in mind. A study by researchers in Cambridge
and Glasgow showed that Goal Management
Training, combined with text message reminders,
helped people to remember tasks (making a phone call to a
voicemail service) that had to be done four times a day.
Goal management involves these steps:
- GOAL: What are you trying to
- OBSTACLE: What is standing or could
stand in the way of you achieving the 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.
Also, electronic watches, mobile phones, pagers and
tablet computers can all be set to provide reminders and
cues to do 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.
References and further information
Thanks to the original authors, Dr Andrew Bateman
(Clinical Manager, Oliver Zangwill Centre for
Neuropsychological Rehabilitation, Ely UK) and Prof Jonathan
Evans (Professor of Applied Neuropsychology, University of
Glasgow, UK) for permission to reproduce this article.