Extremeness Aversion

The Science Behind Extremeness Aversion

Extremeness aversion is a well-documented cognitive bias describing our deep discomfort with choosing the most extreme option in any set of choices. When presented with a low, medium, and high option, whether that's a television, a bottle of wine, or a treatment package, the majority of people gravitate toward the middle. It isn't because the middle option is objectively superior. It's because choosing an extreme feels psychologically risky. The cheapest option signals low quality; the most expensive signals excess or recklessness. The middle option, by contrast, feels balanced, reasonable, and socially safe.

The principle was brought into sharp academic focus through the work of researchers studying what behavioural economists call 'compromise effects.' Itamar Simonson at Stanford University was among the earliest to formally study this phenomenon, demonstrating in a series of experiments during the early 1990s that simply adding a more extreme option to a choice set could dramatically increase the appeal of what was previously the 'expensive' option, because it had now become the middle. The implication was profound: you don't just choose based on what's in front of you, you choose based on how options relate to each other. Context isn't just background noise; it's the engine of the decision.

Richard Shotton, in his 2023 book 'The Illusion of Choice,' synthesises decades of this research and applies it to consumer behaviour. His central argument is that the structure of a choice set, how many options there are, and how they're positioned relative to one another, has an outsized influence on which option gets selected. Shotton highlights that marketers and business owners routinely underestimate this effect because they're focused on the merits of each individual option, when in reality consumers are evaluating options relationally. The middle option isn't just preferred; in many studies, it's selected at rates dramatically higher than chance would predict.

For allied health practices, this is both a cautionary tale and an opportunity. If you're currently offering patients a single rebooking option, or presenting your session packages in a way that makes your preferred option feel like the premium choice, you're likely losing patients at the decision point, not because of cost objections, but because of choice architecture failures. The good news is that restructuring your options to leverage extremeness aversion costs nothing to implement and can begin working from the very next patient interaction.

The Research

How to Apply This in Your Practice

The most direct application for your practice is in how you structure treatment package options when re-engaging lapsed patients. Rather than sending a generic 'we miss you, book an appointment' message, present patients with a clear, three-tiered rebooking offer where your preferred commitment level sits in the middle. A well-constructed example might look like this: 'We'd love to welcome you back. Choose the option that suits you best, a single session at $95, our popular 4-session recovery package at $340 (saving you $40), or our comprehensive 10-session plan at $800 (saving you $150).' The four-session package is your target: it's the commitment level that allows enough continuity to produce genuine clinical outcomes, and extremeness aversion will do the heavy lifting of steering patients toward it.

The framing of each option matters as much as the pricing itself. The lowest option should feel accessible but slightly bare, enough sessions to get started, but clearly not a complete course of care. The highest option should feel generous in value but represent a serious commitment that not everyone will feel ready for. The middle option should be named warmly and specifically, phrases like 'our most popular' or 'recommended for recovery' act as social proof cues that reinforce the compromise effect. Avoid language on the middle option that feels corporate or upselling; instead, anchor it to the clinical rationale: 'Four sessions gives us enough time to address the root cause, not just the symptoms.'

For SMS or email re-engagement campaigns, the kind that Routiq automates at scale, this three-option structure translates cleanly into a short message format. The key is clarity and brevity: patients won't read a wall of text, so each option should be communicated in a single line with the price and the primary benefit. You might also consider A/B testing which option you label as 'most popular,' since that social proof element can shift the distribution of choices even within a middle-anchored set. Track your conversion rates by tier across the first few months, and you'll quickly see whether your current middle option is correctly positioned.

Beyond re-engagement campaigns, consider applying this principle at every point in the patient journey where a choice is being made. Receptionists can be trained to present follow-up booking options in threes rather than open-endedly asking 'would you like to book again?' Initial treatment plan presentations can be structured with three care pathway options. Even appointment time slots can be offered as 'morning, midday, or afternoon' rather than an open-ended scheduling conversation that creates decision fatigue. Extremeness aversion is not a one-time tactic, it's a lens that, once adopted, reveals decision points throughout your practice where better choice architecture can quietly improve outcomes.

Seeing It in Action

Your Action Plan

1. 1Audit your current rebooking and re-engagement communications to identify every point where patients are asked to make a choice, and check whether you're currently offering one option (too little structure), two options (no middle), or an unanchored list of many options (decision fatigue).
2. 2Design a three-tier treatment package structure for your most common re-engagement scenarios, ensuring the package you most want patients to select, based on clinical outcomes and practice sustainability, is positioned clearly in the middle, with deliberate pricing gaps between the tiers.
3. 3Update your SMS and email re-engagement templates to present all three options in a single, scannable format, using warm social proof language ('our most popular,' 'recommended for recovery') on the middle option only, without applying it to the low or high options.
4. 4Brief your reception and clinical team on the principle of extremeness aversion, and role-play presenting three-option care pathways verbally, always naming the middle option first in conversation, then offering the alternatives on either side.
5. 5Track selection rates by tier across your next 90 days of re-engagement activity, and use that data to refine your pricing gaps and option labels, if fewer than 50% of converting patients are choosing the middle option, your tiers may not be sufficiently differentiated to activate the compromise effect.