Patient-Reported Outcomes & Endpoints

How  Two Selves Theory Rectifies Patient-Reported Outcomes and Endpoint Assessments.

“How are you?” It’s a simple enough question. When asked by your physician, it deserves a good answer. The trouble is we really don’t know how to construct one.

Utilizing the underpinnings of behavioral economics theory (Epstein, 1973; Epstein, 2014; Kahneman, 2003), I’ve suggested (Pashko, 2016) our two basic choices involve using either percepts (experiential informational processing system) or concepts (rational-cognitive informational processing system). Using the perceptual approach, we would best answer by either describing our immediate sense-perceptions (somehow) and/or by indicating the limits of our physical abilities at that very moment. With the other approach, we would transform our sense-perceptions (somehow) into concepts and use them to make comparisons to how we think we should be, our theoretical optimum health state, or in relation to our health status at some time in the past. I put the parentheses around the word “somehow,” above, because one can never actually conceptualize any percept. For example, answer this question: “What is your subjective experience of the sound of middle ‘C’ on a piano or your feeling at the touch of a cleaning sponge?” I’ve used the word “somehow” to provide a sense of my own incredulity that anyone believes percepts could realistically and truthfully be represented by concepts. Do you remember how impossible it was for James (actor William Hurt), the teacher, to describe the sound of some music playing to Sarah (actor Marlee Matlin), a student who is deaf, in the 1986 film “Children of a Lesser God”? Though he moved well and pointed skyward along with the high notes, I still didn’t perceive music. Yet, many live with this mistaken belief and live their lives accordingly. Research from the behavioral economics literature strongly suggests answers about our health status significantly differ according depending on whether a predominately perceptual or a conceptual view is used.

Yet, even with this simple doctor’s question another problem arises, one seemingly more intractable than the first. It’s with the definition of “you,” the “me” who answers the doctor’s question. Which viewpoint do we choose for ourself, the conceptual or the perceptual me?

What? What do you mean, two of me?

The basics of behavioral economics demand and require a radical shift in our philosophy and psychology. Yes, the world exists simultaneously in two ways…and this includes us, our self-identity (Kahneman & Riis, 2005). This is the repair that psychology badly needs to make. It needs to accept and encourage these two competing yet complementary views of the realities of who we are. Because there has not been stronger support for these two views, many personal (e.g., anger, anxiety, stress, health) and societal problems (e.g., selfishness/ greed, corruption) continue on longer than they should (Epstein, 2014).

Though much of the focus on Freud’s work has been about id, ego and super ego, he acknowledged the ego’s counterpart in “Civilization and its Discontents,”but never named it. He describes a “more sharply demarcated feeling of ego-maturity,” which I take to relate to the rational-cognitive self of behavioral economics and “…a counterpart to it,” which his friend Romain Rolland continuously felt as “…a sensation of “eternity,” a feeling as of something limitless, unbounded- as if it were, ‘oceanic.’” It’s useful to note that Joseph Campbell has defined eternityas the breaking of the concept of time as opposed to it being an exceedingly long time period. And, of course, non-conceptual experiencing well describes the experiencing self of behavioral economics.

In 1781, Immanuel Kant described something similar to the two views of reality put forth by behavioral economists in his Critique of Pure Reason. His “noumenon” is a posited object or event that is known (if at all) without the use of ordinary sense-perception. By contrast, his “phenomenon” refers to anything that can be apprehended by, or is an objectof the senses. Over the years this has been interpreted to mean there are two aspects of one world (i.e., appearances are aspects of the same objects that also exist in themselves.) Here’s a helpful link to “Plato,” the Stanford Encyclopedia of Philosophy about Kant’s life and work.

Wayback, as early as the year 868, the Diamond Sutra(Soeng, 2000), “… in the words of the British Library, “the earliest complete survival of a dated printed book.” (Wikipedia, 2016), also can be read as offering a two selves theory. As I understand it, the first relates to any and every concept of a self whereas the second describes a “beingness” that is completely devoid of any conceptualization, including the term “beingness” itself. Note that I have used quotations around the word “beingness” in the previous sentence to bring the reader’s attention to the problem of language about how “something” can “be” without it existing conceptually. I believe this non-conceptual beingness(perceptual?) to be the heart of the question around the use of the term “no-self” (anatta)as it’s used in Eastern philosophy.

Neither the behavioral economicstwo-selves theory nor the Kantian notion of “two aspects of one world,” nor Eastern psychology’s notion of two selves (i.e., conceptual and non-conceptual) theory have yet substantially taken root in modern Western psychology. I’m not sure why. Perhaps what seems tangible and expressible, though erroneous, is preferred over the untransformed reality of the abstract. In my own writing, I’m suggested though “The rules of language and communication require a substitution[. But] blame can be placed on those who forget the transformation has occurred and willingly, though mistakenly, accept and psychologically exchange the concept for the percept.” (Pashko, 2016, p. 269).

In the simplest example, using the physical object we call a cup, most believe a cup is a “cup.” Consider how we have been taught. Teachers, parents and myriad others have shown us such objects and told us these were cups. However, “cupness” exists only as a mental concept about a class of objects. We were all shown physical examples of what reasonably constitutes “cupness.” Then we constructed our own personal mental classification scheme about it. Lastly, we continue to affirm or deny an object’s categorization based on our idealized organizing principle (e.g., holds too much volume, too skinny). It’s called a cup because it fits within our mental category of “cupness,” but a specific object is not a cluster of aspects that fit into a categorization. It’s a thing unto itself. As Bateson (1972, pp. 454– 455) suggests, “Always, the process of representation will filter it [reality] out so that the mental world is only maps of maps, ad-infinitum.” Conceptualization obscures reality because it’s representational. And with little needed in the way of deduction, we know a representation, like a map, is not the thing itself.*

With the physical object we mistakenly call a cup simply being an exemplar of our mental concept of “cupness,” where does this leave us when even the simplest of objects cannot be known? As before, the solution is offered via the truthfulness of sensory-perceptual reality, when objects are known through our sense-perceptions (i.e., shape and color by sight; temperature and rigidity by touch).

PROMIS screenshot 2018More difficult to comprehend than the example of a cup is what this dual view means for our self-identity, the one who answers questions about his/her health. Conceptual labels of identity, such as given and family names, gender, social role, type of work performed, etc. all can be used as frames of reference (i.e., identity viewpoints) for health status reporting. These conceptual labels, however, don’t define us fully. Further, these all change. As such, their use generates highly variable answers to health questions, such as those posed in patient-reported outcomes assessments during clinical research trials.

Let’s look to the previous solution, the perceptual, for an answer. Can you perceive and, of course, not say a word (conceptualize) about, your felt sense of beingness, consciousness and continuity over time? Is there anything actually wrong about having a self-identity that’s a percept, and not a concept, apart from the fact that you can’t say anything about “yourself?” I don’t believe so. Further, consider the upsides to a perceptual self-identity:

  • Enhanced freedom, from the constraint of inappropriate or discriminatory labels,
  • Decreased fear of pain, through the dissolution of any previously believed conceptual equivalence between self-identity and body-identity,
  • Increased sense of authenticity, through a perceivable continuous linkageto same person you have always been,
  • Enhanced resiliency to stress, from improved disinterestin overactive, ruminative thoughts (concepts),
  • Improved consistency with language (i.e., when you say “my body” now the body becomes rightfully possessed through a pointer to a continuously existing, never changing self-identity),
  • Acceptance of insights as valid, since percepts are processed equally as wellas concepts.

Rectifying clinical psychology’s fascination with a conceptual view of self-identity, including the terms “self-concept,” “ego,” “id,” “super ego,” “ideal self,” etc. can be addressed by acknowledging and accepting that which exists before words—and theinaccuracy arising from the labeling of “what is” (i.e., untransformed, perceptual reality). The origin of our surprise from the findings garnered from the behavioral economics research literature (Kahneman, 2012; Wirtz, et al., 2003) stem from having excluded perceptual reality from equal standing with that of a conceptualized reality. Full acknowledgement of perceptual beingness (self-identity?) also holds promise for a way to understand other confounding phenomena, such as courage in the face of grave bodily danger, acceptance in death and dying, as well as the origin of insights. It may even permit understanding and harnessing of the power of “response shift” and it’s allied phenomenon, placebo response (Pashko, 2014).

Changing the way we view ourselves has implications for how we interact within the world at large. To the point about improving patient-reported outcomes (PROs) assessments, personal and societal acceptance of a perceptual view of self-identity, as at least as valid as any conceptual view, has the capacity to re-shape our relationship to our health, how we appraise it and why we utilize health care resources.


Anatta(n.d). retrieved from Wikipedia, 5 August 2016.

Bateson, G. (1972). Steps to an ecology of mind. New York, NY: Ballantine Books.

Diamond Sutra(868). retrieved from Wikipedia, 5 August 2016.

Epstein, S. (1973). The self-concept revisited. Or a theory of a theory. American Psychologist, 28, 404–416.

Epstein, S. (2014). Cognitive-experiential theory. New York, NY: Oxford.

Freud, S. (2010). In J. Strachey (Trans.), Civilization and its discontents. New York, NY: Norton. (Original work published 1929)

Kahneman, D. (2003). Maps of bounded rationality: Psychology for behavioral economics. The American Economic Review, 93, 1449–1475.

Kahneman, D. (2012). Thinking, fast and slow. New York, NY: Farrar, Straus & Giroux.

Kahneman, D., & Riis, J. (2005). Living, and thinking about it: Two perspectives on life. In F. A. Huppert, N. Baylis, & B. Keverne (Eds.), The science of well-being(pp. 284 –304). Oxford, England: Oxford University Press.

Kant, I. (1781) Critique of Pure Reason. Retrieved from Project Guttenberg 5 August 2016. Link to book.

Pashko, S. (2014). Conceptual versus perceptual information processing: Implications for subjective reporting. Journal of Neuroscience, Psychology, and Economics, 7, 219–226. Link to paper.

Pashko, S. (2016). Implication of the differences between our perceptual and conceptual views.Psychology & Neuroscience, 9(2), 267-281. Link to paper.

Soeng, Mu. (2000). Diamond Sutra: Transforming the Way We Perceive the World.Wisdom Publications. p. 58.

Wirtz, D., Kruger, J. Scolion, C. N., & Diener, E. (2003). What to do on spring break?Psychological Science, 14, 520–524.


*(Even if, like the comedian Steven Wright said, “I have a map of the United States… Actual size. It says, ‘Scale: 1 mile = 1 mile.’ I spent last summer folding it. I also have a full-size map of the world. I hardly ever unroll it,” the representation seems a good approximation.) Retrieved from Wright House.

#PRO, #percept, #concept, #health, # outcomes, #behavioral economics

Copyright Steven Pashko, PhD (2016).