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Difficulty with making decisions - Fact Sheet

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Cognitive effects

Difficulty with making decisions - Fact Sheet

This is common after a brain injury, according to Dr Andrew Bateman and Prof Jonathan Evans. 

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 through
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.


Self-awareness (insight)
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 behaviour.


In Goal Management Training, people learn to be clear on what they want to achieve, work out and keep in mind the steps needed, then
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 achieve?
  • 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
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.


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