Decision-Making After Brain Injury

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Decisions run our lives. From the moment we wake up and decide to get out of bed to the moment we turn off the light and decide to sleep, we make decisions. Those who can make hard decisions are considered decisive, competent leaders; but little decisions require multiple mental processes, as well. Only after a brain injury do you discover how difficult making minor decisions is.

I faced that while standing in the grocery store over a decade ago, unable to decide how many apples to buy. Such an easy decision, yet impossible for my brain to compute.

As a healthy person, you consider the apples, pick the best ones, and place the quantity you need in your basket, all without much conscious thinking. After brain injury, this easy decision shifts from automatic with some conscious processing to fully conscious with little ability to process. For example, you may know which apple you crave, but will stumble if it's not available, fail to remember how many you eat in a week, fail to consider when you’re likely to eat them, or not recognize which apple is seasonal versus freshest.

Headway UK writes on post-brain injury decision-making difficulties:

“The ability to make decisions involves many different cognitive (thinking) skills. The mental skills that we use to make decisions are often referred to as ‘executive functions.’ … Memory is a particularly important cognitive skill when making decisions, as it allows us to hold information so that we can think things through, as well as reflecting on choices that we have previously made. … Emotions also help us to assess how important a decision is to us and how the possible outcomes will make us feel.”

When memory falters within seconds, an injured brain cannot think things through. Yet strategies, not treatments, are offered, such as:

• Impulsivity. Develop a habit of stopping to think before making a decision.
• Cycling. Give yourself a target date in the future to revisit the decision.
• Fatigue. Avoid making decisions when (more) tired.
• Emotional. Set aside the decision until feeling less emotional.
• Distractibility. Narrow down options. Find a quiet area to decide.
• Overwhelmed. Break larger decisions into small steps and use decision-making strategies such as SMART goals or SOLVE.
• Memory. Write down the decision to be made, choices, and related information.
• External Support. Seek advice that helps analyze the pros and cons but does not make the decision for you.

Two things these strategies lack:

1. Treating the damaged neurophysiology that underlies decision-making.
2. Acknowledging that a person with brain injury has lost an essential cognitive function for which strategies without external guidance cannot compensate.

Many health care professionals appear not to consider the first point nor understand the second. Although they acknowledge damage to multiple processes such as memory, emotions, impulsivity, and concentration affect decision-making, they still insist a person behave after brain injury as if the involved neural networks function normally and as if the mental process is behavioral not injured neurophysiology. Why do so many professionals neither treat the underlying injury nor provide effective methods?

I’ve had health-care professionals insult me, suggesting that my indecisiveness was a personality flaw. Prior to brain injury, the only time I struggled was when I decided not to pursue medical school but to enter the writing world. I wasn’t sure how to go about it. Still, I decided immediately on the first steps, which led to more steps I quickly decided on.

After brain injury, every decision became a mountain of indecision. This radical alteration in cognition felt foreign, discombobulating, and horrible. To be told that I needed to use strategies and not expect others to make the decision for me—for I had to learn to decide for myself—left me vulnerable, confused in a whirlpool of seemingly impossible choices, and angry.

Angry at losing my decision-making skill.

Angry at health-care professionals ascribing my damaged cognitive skill to personality or behavior.

Angry at having to seek treatments for neurophysiological damage outside of standard concussion care.

Angry at being left alone in a maelstrom of indecision that no number of strategies could lessen.

I recently talked with a person stuck in this kind of maelstrom. Within seconds, I gave them five short steps to get out of it. They’d been stuck in indecisiveness, despite multiple advice and strategies, for months. Since I know how unstable this makes you feel, I gave them the first steps out that aligned with their stated intentions.

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I have searched for studies on treating loss of decision-making after brain injury. Although I found research on underlying processes such as impulsivity or memory loss, I didn’t find studies on using neurostimulation, neuromodulation, or other similar treatments to target the damaged neurons, never mind studying the underlying brain activity in humans using qEEG.

As Wei-Chung Allen Lee, associate professor of neurobiology in the Blavatnik Institute at Harvard Medical School, has written, "the neural circuitry ... in brain areas that are important for decision-making isn’t well understood."

Instead, I found strategies masked as therapies, which relied on the assumption that people with brain injury retain habits. Habits are a learned experience. When brain injury affects the ability to learn and to create automaticity, how then can a person retain habits in the long term?

I discovered you can’t without external structure.

There isn't a lot of research on brain-injury effects on habit creation and retention over the long term and so further study is suggested.

What is it like to live with a brain whose damaged networks cannot execute decisions? The frustration, confusion, and vulnerability. The dependence on others yet isolation when people neither offer treatments nor provide actionable steps. Strategies failing to restore decision-making should lead clinics to offer neurostimulation and neuromodulation, which do restore damaged neural networks.

People with brain injury want to make their own decisions.

Damaged neurons and neural networks—not inherent indecisiveness or codependence or personality flaw—prevent them from doing so.

The answer is to heal the injury so that they can make their own decisions again.

Copyright ©2024 Shireen Anne Jeejeebhoy