Should I Do This or Should I Do That?: CBT for Indecision

Sue Schonberg, PhD, ABPP, Beck Institute CBT Certified Master Clinician

Beck Institute Faculty

What is Indecision?

Indecision can be defined as the inability or hesitancy to make a decision quickly, or experiencing difficulty making decisions. Decisions can be both small (e.g. what one orders in a restaurant, or what one chooses to wear) or large (e.g. what house one chooses to buy, what job one chooses to take).

Indecision can be problematic when an individual

• becomes overwhelmed by excessively gathering information;
• excessively weighs the pros and cons of a decision;
• experiences negative consequences from procrastination or avoidance of making decisions (often to escape the uncertainty of how a decision will unfold);
• feels a sense of angst when having to make many decisions, including smaller ones;
• consistently defers to others to make decisions which results in less desirable outcomes or feeling disempowered.

Indecision is commonly seen in individuals with generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), and depression.

Generalized Anxiety Disorder (GAD) and Indecision

A college student reports having tremendous difficulty choosing classes for his upcoming semester. This indecision results in increased anxiety affecting the clarity of his thinking and lowering his confidence in evaluating options. His hesitancy could be rooted in his fear of picking the wrong batch of courses. He thinks: “What if I make a mistake and pick bad classes? What if I wind up picking classes that I hate or are too hard? What if the professor is terrible? What if I do terribly in the class and my grade point average suffers? What if my parents get mad at me for my choices?” He might then procrastinate or altogether avoid making any decision in an effort to avoid these feared outcomes.

A woman in her 30s reports having great difficulty deciding whether to remain in a significant relationship that has been filled with tension. Perhaps this stems from fears of making the wrong decision, fears about being alone or fears of never meeting another partner. She may think: “What if I leave and find I didn’t realize how good I actually had it and later regret my decision? What if I regret my mistake and can’t forgive myself for making a stupid decision? What if I leave and can’t stand being alone? What if I never meet another decent person to be with?” She might put off making any decision and simply remain in a potentially unsatisfying relationship.

Cognitive restructuring is often beneficial when clients gain a more balanced perspective regarding their current cognitions. The college student deliberating which courses to choose might take his key automatic thoughts and look at how his thinking might be unhelpful or inaccurate. In response to the thought, “What if the class I pick is too hard, and my GPA suffers as a result?” he might remind himself that he has taken hard classes before and done reasonably well. He also might remind himself that one poor grade won’t ruin his entire grade average.

The woman who is deliberating whether to leave her relationship might look at her fear of making the wrong decision and not being able to tolerate the ensuing regret. She might remind herself of other decisions she had made in the past that didn’t lead to an ideal outcome. She might recall that she was able to sit with the discomfort of regret and see that it dissipated over time. Both individuals might remind themselves that the presence or absence of confidence is not necessarily indicative of whether they are capable of making a good decision. In contrast, facts and data are more reliable indicators.

Obsessive Compulsive Disorder (OCD) and Indecision

A woman in her 50s has great difficulty deciding which version of the COVID-19 vaccine to take, struggling between the Pfizer or Moderna vaccine. If this woman has health anxiety OCD, she may link her decision to the likelihood of getting infected with COVID-19 and becoming seriously ill. She may think: “What if I pick the wrong vaccine and get COVID? How can I sit with the uncertainty that I could get infected and become seriously ill?” This woman may resort to excessive internet research to lessen her anxiety, mentally review the pros and cons of each vaccine manufacturer repeatedly, or seek excessive reassurance from others in an effort to lessen her uncertainty and accompanying anxiety. These acts are considered rituals or compulsions and are likely to exacerbate her anxiety and further delay decision making.

A man in his mid-30s has great difficulty deciding which version of a work email to send to his superiors, fearing being less than perfect. The man worries that he will send the “wrong” email, angering his boss, and potentially getting himself fired. He might have the following automatic thoughts: “What if I made grammatical or spelling errors in one version that I didn’t catch? What if the content I’m sending in is way off base? What if my boss gets so angry that she wonders why she even hired me in the first place? What if she decides to fire me?” This man might resort to excessive checking of his emails– rereading them an unreasonable number of times or mentally reviewing them repeatedly before sending them. This same individual might also resort to reassurance seeking by asking multiple colleagues which email seems better. He might even defer to his wife and ask her which email looks best. The following actions are considered rituals or compulsions and will only likely exacerbate his anxiety and result in stalling any decision.

In contrast to clients with GAD where thought restructuring is helpful, this technique is not used with clients struggling with OCD who are experiencing indecision. When individuals with OCD are trying to ward off uncertainty, we identify the associated rituals/compulsions and work to lessen and ultimately eliminate them. Individuals are encouraged to face uncertainty head on and see that it is not dangerous and will not prevent them from making a reasonably informed decision.

The woman who is deliberating between taking one COVID vaccine over the other might significantly limit her internet searching and reassurance seeking from others and reduce her mental reviewing. This enables her to see that sitting with uncertainty is tolerable and that anxiety lessens over time. She might find it helpful to reflect on how she is able to successfully tolerate uncertainty in many other situations and make decisions despite uncertainty.

The man who is having great difficulty deciding which work email to send might be encouraged to lessen his excessive checking rituals to what would be considered reasonable (i.e., what a person who doesn’t have OCD would do). Additionally, he would be discouraged from seeking excessive reassurance from both his colleagues and wife.

Depression and Indecision

A woman in her 20s has great difficulty deciding what to do for the upcoming weekend. She may have been asked by one friend to simply spend time together at her house and by another friend to go for a short hike. She begins to experience high anxiety levels and has the following thoughts: “I don’t think I have the energy to do either. If I do go, one of my friends might notice my low mood, and decide to never spend time with me again. It’s not worth deciding right now.” She might then avoid making a decision, which could result in worsening of her depressed mood.

To address her indecision, she might conduct a behavioral experiment regarding the belief that she doesn’t have the energy to do either activity. Or she might examine her belief that either friend would be unaccepting of her low energy and mood. She might even recognize that doing things when indecisive and not confident in the result might still generate feelings of satisfaction and pride and could even lessen her depressed mood.

Additional Treatment Considerations

When working with clients experiencing indecision, additional techniques and strategies can be helpful. You could:

• do a cost/benefit analysis with the client, using their values as a guide;
• use acceptance techniques to help the client tolerate the fact that some decisions will not work out as well as hoped and uncertainty cannot be eliminated;
• help the client accept the possibility that a better decision could have been made;
• identify and address additional fears they may have about making decisions (e.g., fears that they will disappoint or anger others, that others might think they are incompetent, or that making a “wrong” decision could result in harm to themselves or others).

Cultural Considerations

An individual’s culture can impact their values and govern their decision making. One might see significant differences in the decision-making process in collectivist cultures (where more emphasis is placed on how others in the community are affected) vs. individualist cultures (where more emphasis is placed on how the individual is affected). Automatic thoughts arising in Collectivist cultures need to be recognized as possible outgrowths of cultural values and not inadvertently categorized as dysfunctional. That said, depending on the degree of distress engendered in decision making experienced by someone coming from a Collectivist culture, it might warrant revisiting their thinking or behavior to determine if some problematic element exists.