Presentism (The Present Dominates Imagination)

The Science Behind Presentism (The Present Dominates Imagination)

Presentism, as explored by Harvard psychologist Daniel Gilbert in his landmark 2006 book 'Stumbling on Happiness,' refers to the tendency for our current emotional and physical state to dominate and distort how we imagine other states, whether past or future. When we feel good right now, we struggle to genuinely conjure what it felt like to be in pain. When we feel bad, we can barely remember what comfort felt like. Our minds don't function like neutral recording devices; they function like emotional filters, colouring every projection of the future with the pigment of the present.

Gilbert's research demonstrated that humans are surprisingly poor at what he calls 'affective forecasting', predicting how we will feel in the future. We consistently overestimate how long positive events will make us happy and underestimate how quickly we recover from negative ones. But the reverse also applies: when we are currently comfortable, we dramatically underestimate the likelihood and severity of future discomfort. The technical term for this is 'empathy gap,' a concept also developed in parallel by Carnegie Mellon economist George Loewenstein, who showed that people in a 'cold' state (calm, comfortable, pain-free) systematically fail to appreciate how they would behave or feel in a 'hot' state (stressed, uncomfortable, in pain).

For allied health practitioners, this cognitive glitch has profound practical consequences. A patient whose lower back is currently pain-free simply cannot, at a neurological level, fully access the memory of what it felt like to be unable to tie their shoes or sleep through the night. The emotional charge of that memory has faded. And because the future is built from the materials of our present experience, they also cannot imagine that pain returning with any genuine urgency. The maintenance appointment that seemed obviously sensible at the end of their last session now feels unnecessary, even indulgent.

This isn't laziness or ingratitude. It is a predictable, universal feature of human cognition. Research suggests that this present-state contamination of future imagination is stronger for visceral, physical states, including pain, than for almost any other category of experience. That makes your patients uniquely susceptible to presentism, and it means that standard reminder messages ('It's time for your check-up!') are fighting against a deeply wired psychological tendency. To win patients back, you need to do more than remind them you exist, you need to help them mentally time-travel.

The Research

How to Apply This in Your Practice

The first strategic shift is to stop sending reminders that live entirely in the present tense. A message like 'Hi Sarah, it's been three months since your last appointment, would you like to book?' asks Sarah to make a decision from her current comfortable state, which is precisely the state least likely to motivate action. Instead, your re-engagement communications need to anchor to a specific past pain experience before projecting forward. The structural formula is: recall the past state → acknowledge the current good feeling → connect today's comfort to past treatment → warn of future risk. Something like: 'Hi Sarah, you came to us in March with that lower back pain that was affecting your sleep. You've clearly done a great job maintaining things, but the research on lower back conditions shows that without periodic maintenance, most people experience a return of symptoms within six months. You feel well now. Let's keep it that way.'

The tactical execution involves equipping your front desk and your practitioners with what we might call 'memory anchors', specific, documented details about each patient's presenting complaint and its impact on their daily life. When a practitioner records notes, they should include not just clinical observations but functional impact statements: 'Patient reported being unable to participate in weekend football with his children' or 'Patient described difficulty sitting through work meetings for more than 20 minutes.' These details become the raw material for personalised re-engagement messages that bypass the empathy gap by reactivating the emotional specificity of the original pain experience.

For SMS and email workflows, timing matters enormously through the lens of presentism. The optimal window for a re-engagement message is just before the typical relapse period for that condition, not after symptoms have returned, and not so early that the patient still feels the glow of recent treatment. For lower back pain, research suggests that without maintenance, many patients begin to notice symptom recurrence between three and five months post-discharge. Sending a presentism-informed message at the ten to twelve week mark, before the patient is symptomatic again but close enough to the risk window, gives you the best chance of catching them while the warning is credible but the booking is still preventive. Your message should explicitly name this window: 'Most of our lower back patients find that around this time, without a check-in, old patterns start to creep back in. One session now is worth three sessions later.'

Finally, consider building presentism-countering language into your discharge process itself. Before a patient leaves their final scheduled session feeling great, help them prospectively experience the future discomfort. A practitioner might say: 'You feel really good right now, which is exactly what we wanted. I want you to close your eyes for a second and remember what it felt like in week one, when you couldn't get out of bed comfortably. That feeling is still possible if we don't stay on top of things. A maintenance session every eight to ten weeks is what keeps that version of your back in the past.' This in-clinic intervention creates a memory of the future that can survive the distortions of presentism better than any message sent three months later.

Seeing It in Action

Your Action Plan

1. 1Upgrade your clinical notes to include functional impact statements alongside clinical findings, document not just 'L4/L5 disc irritation' but 'patient unable to play with children on the floor or sleep more than four hours.' These become your re-engagement ammunition.
2. 2Map the typical relapse timeline for your most common presentations (lower back pain, cervicogenic headaches, plantar fasciitis, etc.) and set automated re-engagement triggers to fire two to three weeks before that window, not after symptoms return.
3. 3Rewrite your re-engagement message templates using the three-part presentism formula: name the past pain specifically → acknowledge current comfort → warn of the returning risk. Remove any message that exists only in the present tense.
4. 4Train your practitioners to deliver a verbal 'presentism inoculation' at discharge, ask patients to briefly recall their worst symptom moment before they leave, and explicitly connect today's improvement to the treatment they received, not just to time passing.
5. 5A/B test your re-engagement messages by comparing generic reminders against personalised, past-anchored messages that reference the patient's specific presenting complaint. Track rebooking rates over 90 days and use the data to continuously refine your copy.