Decisions, Decisions!

He was pleasant, in his fifties, graying at the temples, articulate,and pretty much burned out on the symptoms of an alleged schizo-affective disorder. Like many of the people I treat he had been involved with the Hollywood entertainment establishment years previously. Now he lived in a residence suitable for his situation, and told me there was nobody he could talk to; he hated it. He even produced a lovingly-constructed list of names of people who had been important to him in the past. He did not know where they were, had no intention of finding them, so it served no ostensible purpose, except maybe to help him live in the past, because he had no interest in his dull and frustrating present. He said he simply could not relate to anyone in the residence where he was. They had no words, in many cases were illiterate, and were of no interest to him because they would not converse. He said he was depressed, but it was clear this was not the kind of depression you medicate.

I called for his case manager, who told me he had been offered another placement where it was expected there would be more conversation;  not once, but twice. He had declined. The complaints I heard from him had been going on for years. I asked him what was going on. He told me, again quite articulate.

“I can’t decide. I’m like someone who stays in a marriage, even if they don’t love the other person. They just can’t change. I have tried, and I don’t think I can. Maybe people like you should leave me alone and stop trying to help me. I don’t think even a smart lady like you can do a good job of treating somebody who can’t make decisions.”

I was pretty shocked. I suggested everything imaginable, including therapy, which he did not want, and my old favorite that I have used myself, the “Benjamin Franklin Method.” You take a piece of paper, fold it in half vertically, make vertical lists of the reasons to do something and the reasons not to do it, and see which is longer. I have done this many times. He did not want to try. It would result in data which would “force” him to make a decision which he did not particularly want to make.

Sometimes classical arts and entertainment hit home in ways that science cannot. Perhaps that is why I thought of the movie which I dearly love, a golden oldie to be sure, “The Man Who Came to Dinner .”

The lovable showbiz character Banjo played by even more lovable Jimmy Durante sings (yelps??) the immortal “Did you ever have the feeling that you wanted to go/but still you had the feeling that you wanted to stay?” While sitting down at and jumping up from a piano bench and pounding the keyboard to the guffaws of the main character, I am
delighted to report that the scene (labelled as an homage to Harpo Marx??) is available on You-tube.

Great. Laughed at and immortalized and recognized as a block to happiness even by the patient who has it, who the hell knows how to treat this one??

I have a vivid memory of driving a lecturer who had visited my psychiatric training program to the airport, when I was early in training. She was an expert in mania. She asked me about my educational background, and I rattled off the eccentric sounding truths that make up my curriculum vitae, the academic story of my life. “You have made a lot of changes to move and change quite quickly,” she said, “could you have been manic; were they manicky decisions? Like to go to France or to join the Army?” “As a student of psychiatry, I checked myself for mania a million times, ” I told her, “and honestly, I do not have it. What I am is a creature of passions. I decide what I want to do and then I do it. I have a lifestyle that does not hold me back from making that kind of decision. If I have to go far away to do what I have to do, I do it. That’s all really..” We talked more, she agreed with me, and we parted respectful friends. Now I am married to a husband who feels the same way I do about life. We are frequently on the road changing our situation, and generally having more fun than any twenty or so people I know.

Even if I have trouble empathizing with indecision, as it obviously is not a major problem for me, I would love to treat it. It does plague friends as well as patients, who find themselves accustomed to a situation and do not wish to change, even though they may be a lot happier if they did.

Some simply call it “procrastination,” and formal academic psychological studies seem to be few. It seems to be more in the realm of “pop” psychology, people who relate personal experiences.

It seems to be related to anxiety, fear, and other emotions which may be quite treatable. As with a lot of existential problems, the problem is articulating it. Anxiety and fear are harder to talk about. Anyone who is “stuck” on this indecision level, I suggest what I ended up suggesting to this patient:

1. Talk, to a therapist is better, to anybody, friend or case manager, is better than nothing. Often, in talking to others, we become more articulate about our own problems and hear ourselves say things we did not know that we thought. Talking can lead to new thinking, even if there is not an appreciable response from the listener.

2. Try something. Anything. Most decisions are not as unilateral and irreversible as we think. I told him to visit other residences, see what they “felt” like. Could he stay where he was and do a day program that satisfied his social needs? If he tried some other residence and did not like it, could he return where he was?

3. Are there solutions he had not thought of yet? The old strategy of “brainstorming;” suspending criticism and listing possibilities, THEN looking at them more closely. More a tool from corporate problem solving than psychiatry, but still, perhaps relevant.

I told the patient all this in as loving a way as I could muster. I kept myself from saying “don’t just sit there; try something.” He laughed, said I was kind of fun, for a psychiatrist, and I had really gotten him thinking. Sometimes, that is enough. The first step on the path.