Decision Making: A Major Life Challenge

Why do we suffer when faced with making a decision?

A beautiful sunriseI am grateful to have had the opportunity, during my residency in psychiatry at Harvard’s Massachusetts Mental Health Center in the 60’s, to learn from Dr. Elvin Semrad, the most influential teacher of the art of psychotherapy of his and subsequent generations. Semrad regularly conducted several weekly inpatient teaching conferences — meetings where one of us would “present a patient” to him and to the rest of us.   Dr. Semrad would spend some time interviewing the patient with the goal of clarifying what crisis had resulted in the patient’s having been admitted to the hospital. Many times, Semrad would learn and/or intuit that the patient had been avoiding making a life decision.  I remember him saying:

“The most important task of a human being is to make up his mind — what’s for him, and what’s not for him.”

” Major life decisions are best made with as clear a head and heart as possible.”

“Adults are most lonely when they learn to make their own decisions.”

Indeed, making one’s own decision is, by definition, something done alone.  I remember the first time I allowed my daughter, then about six or seven, to choose whether to stay on for a special overnight with her grandparents or to return home with us to go to the beach the following day.  I had never seen her more anguished.  She simply couldn’t choose. How much easier it would have been had I made the choice for her.  Then she could simply have been furious at me for having had to give up one of the options.

Decision-making both requires some capacity for being alone and is a potential building-block toward a more substantial sense of self.  Learning to make one’s peace with the consequences of one’s decision makes subsequent decision-making less fraught. Another of Elvin Semrad’s teachings has been useful in this regard.  He said,

 “Everything has a cost,”

“This is one of the eternal questions:  How much are you going to pay for what you get?”

“It takes a certain amount of time and exposure before you can make all the mistakes that are possible to be made.”

I have taken much comfort from this that Semrad addressed to us decades ago:

“Every time that you fall on your face and fail, if you learn something from it, you progress.  If you don’t, you go down the drain.  You’re all young, and maybe you have most of your failures still in the future.  None of us likes to look at the failures in our lives.”

“Is there any other way to learn than the hard way?”

Knowing that “making mistakes” and learning from the experience is an inevitable and valuable part of life discourages self-blame and encourages future decision-making.

The fact that decision-making always involves giving up other options in favor settling on one means that accepting the pain of some degree of sadness as an inevitable consequence.  Semrad spoke to this dilemma:

“As soon as you make a commitment, you put yourself in line for a lot of pain.  It means choosing a niche for yourself and giving up all those other possibilities.”

In working with our patients, it is helpful to appreciate that decision-making requires sufficient sense of self, sufficient capacity to be alone, sufficient capacity to accept the consequence of the choice without self-blame, and sufficient capacity to tolerate the sadness generated by relinquishing other options.  Compassionately and steadily investigating the specific details of these challenges as they present in the lives of our patients IS much of the work of psychotherapy.