Too Good to be Liked? When and How Prosocial Others are Disliked

Too Good to be Liked? When and How Prosocial Others are Disliked. Lucia L.-A. Boileau, David J. Grüning and Herbert Bless. Front. Psychol., August 19 2021. https://doi.org/10.3389/fpsyg.2021.701689

Abstract: Outstandingly prosocial individuals may not always be valued and admired, but sometimes depreciated and rejected. While prior research has mainly focused on devaluation of highly competent or successful individuals, comparable research in the domain of prosociality is scarce. The present research suggests two mechanisms why devaluation of extreme prosocial individuals may occur: they may (a) constitute very high comparison standards for observers, and may (b) be perceived as communal narcissists. Two experiments test these assumptions. We confronted participants with an extreme prosocial or an ordinary control target and manipulated comparative aspects of the situation (salient vs. non-salient comparison, Experiment 1), and narcissistic aspects of the target (showing off vs. being modest, Experiment 2). Consistent with our assumptions, the extreme prosocial target was liked less than the control target, and even more so when the comparison situation was salient (Experiment 1), and when the target showed off with her good deeds (Experiment 2). Implications that prosociality does not always breed more liking are discussed.

General Discussion

The present research demonstrates that individuals who perform an outstanding degree of prosocial behaviors may be devaluated—due to their prosocial behaviors. Specifically, across two experiments, the prosocial target was liked less than the control target. This consistent pattern is unlikely to be due to participants' perception that the displayed behaviors did not unambiguously reflect prosocial behavior: When explicitly evaluating prosociality, the prosocial target was clearly perceived as prosocial (and more so than the control target). The finding that prosocial behaviors may decrease rather than increase liking seems rather surprising at first glance. Past research suggests that liking and perceptions of prosociality in others are in fact very highly correlated (Imhoff and Koch, 2017). However, the observed devaluation is in line with prior empirical research suggesting that superior prosocial others are indeed sometimes devaluated through rejection and dislike (Fisher et al., 1982; Herrmann et al., 2008; Parks and Stone, 2010; Pleasant and Barclay, 2018).

The present research goes beyond prior research that has similarly demonstrated a possible disliking of prosocial targets by suggesting and investigating two possible underlying processes. Thus, it responds to the call that mediating mechanisms for the dislike of very prosocial targets are yet to be investigated (Parks et al., 2013).

First, the reduced liking of the prosocial target was more pronounced when comparisons between the target and the observers were induced by the information that observers would first evaluate the target and then themselves on the very same items. Eliciting such a comparison expectation increased disliking of the prosocial target. Presumably, in this situation, the extremely prosocial target constituted a very high comparison standard, and this high standard would have negative consequences for participants' evaluations of themselves (Mussweiler, 2003; Bless and Schwarz, 2010; Morina, 2021). This conclusion extends indirect evidence by Parks and Stone (2010) by providing an experimental manipulation of the assumed comparison component.

Second, as predicted, the dislike of the prosocial target was increased when perceptions of communal narcissism (Gebauer et al., 2012; Nehrlich et al., 2019) were elicited by informing participants that the target actively sought to let others know about her prosocial behaviors. This finding suggests that a target's prosocial behavior will not turn into more liking but backfire when that target is perceived as someone who exerts “excessive self-enhancement” in the domain of prosociality and who is showing off with her good deeds (Rentzsch and Gebauer, 2019; p. 1373).

Interestingly, the two proposed accounts (comparison processes, and communal narcissism) may in fact be related. The perception that an individual competes for higher status on the communal dimension (Gebauer et al., 2012) might elicit social comparison processes just as a situation in which comparison is made salient. Communal narcissists do show-off because they want to outperform others—which inevitably entails a comparison. In case the comparison is not only given on the side of the prosocial target but also on the side of the perceiver, one might speculate that we manipulated comparative aspects of the situation in Experiment 1 and comparative aspects of the target in Experiment 2. Such speculation may explain why assessed communal narcissism in Experiment 1 was strongly related to disliking the prosocial target. In turn, eliciting social comparison via the situation might increase perceptions of communal narcissism as a form of target devaluation (cf. Monin, 2007). Note, however, that we did not find a significant interaction effect of target type and comparison salience on perceptions of communal narcissism in Experiment 1.

In combination, the present research provides first evidence on two potential mechanisms to explain the devaluation of very prosocial others. The findings thus provide a first, yet important step, for investigating the processes that lead to the devaluation of prosocial targets.

Open Issues and Caveats

Although the present research offers new insights into the potential devaluation of prosocial others, it is important to address several open issues and caveats. First, one may speculate about the degree of prosocial behavior that is necessary to elicit a dislike of the target (in combination with the comparison component). Of course, prosocial behavior does not necessarily lead to disliking. In this respect, it is important to point out that our target was very outstanding with respect to prosocial behavior. Thus, to elicit devaluation, the target might have to be perceived as “too good” or “too perfect” (note that self-devaluation tends to be elicited when the outstanding other is perceived as unreachable; Lockwood and Kunda, 1997). Evidence in this respect has been reported for the ability domain demonstrating that a superior target was liked more than an average person—if the superior target displayed some imperfections in other domains (Aronson et al., 1966). Further research is needed to address this issue systematically in the prosocial domain.

Second, our conclusion on the crucial role of comparison processes for the dislike of outstanding prosocial targets matches with research on the devaluation of targets that outperform others in the domain of performance and abilities (Pleban and Tesser, 1981; Salovey and Rodin, 1984; Alicke et al., 1997; Alicke, 2000; Lassiter and Munhall, 2001). The present findings thus suggest that similar processes may cause devaluation of both oustandingly capable, and outstandingly prosocial individuals (for a discussion of different, yet overlapping conceptualizations of ability vs. prosociality, see, e.g., Fiske et al., 2007; Gebauer et al., 2014; Abele et al., 2016). Similarly, these processes may also cause devaluation of outstandingly moral individuals (e.g., Monin et al., 2008; Minson and Monin, 2012). Importantly, despite some overlaps, prosociality and morality are not the same. Morality comprises being loyal, fair, law-abiding, and pure (Graham et al., 2013)—aspects that are at least partly independent of prosociality. However, given the similar patterns of dislike observed for superior targets in these various domains, it seems worthwhile to investigate communalities and differences between prosociality and morality in their underlying mechanisms.

Third, we did not find complementary patterns for perceived communal narcissism vs. perceived modesty in Experiment 2. The obtained findings do not allow for an answer to this issue. With respect to the concept of narcissism it might be interesting to investigate whether narcissism and modesty are located on different sides of the same dimension or whether the two concepts are at least partly unrelated to each other (for a discussion of the humility and grandiose narcissism dimension, see Miller et al., 2012; Gebauer and Sedikides, 2019). This relation might also depend on whether narcissism and modesty are measured via self-reports or other-reports. Interestingly, while self-rated communal narcissism has been conceptualized and investigated (Gebauer et al., 2012; Nehrlich et al., 2019), the perception of communal narcissism in others has so far received little systematic investigation (Rentzsch and Gebauer, 2019).

Fourth, the crucial interaction of target type and communal narcissism (i.e., show-off vs. modest condition) in Experiment 2 did not reach the conventional level of significance when tested two-sided. We readily acknowledge this aspect. Note, however, that we pre-registered our study so that one-sided tests statistics could potentially be applied. Due to the unexpected drop out (due to the attention check, see above) the conducted analyses were presumably underpowered, which constitutes a common problem in the field of psychological research (Maxwell, 2004).

Fifth, the reduced liking of the outstandingly prosocial target reflects a contrast effect. General models on context effects in social judgment (cf. Bless and Schwarz, 2010) hold that—under specified conditions—contrast effects may turn in assimilation effects. We readily subscribe to this possibility. One condition that might apply to the present research could rest in the perceived similarity between target and perceiver. In case perceivers assume a high overlap between themselves and the target, they may derive positive implications for themselves rather than devaluating the target (e.g., basking in the reflected glory, Cialdini and DeNicholas, 1989; see also Brown et al., 1992; for an overview on assimilation vs. contrast effects, see Bless and Schwarz, 2010).

Sixth, our sample predominantly consisted of females. As our target was female as well, this might have influenced our results (e.g., see Espinosa and Kovárík, 2015), for gender differences in prosocial behavior). To address this issue, further research needs to test potential gender differences in the evaluation of outstandingly prosocial others.

Finally, it needs to be pointed out that we minimized the potential ambiguity of the prosocial behavior. One could speculate that other devaluation mechanisms (i.e., denying prosociality, ascribing lower competence, etc.) might be at work when the prosocial behavior is more ambiguous and more open to interpretations.

Outlook

While readily acknowledging the open issues addressed above, we strongly believe that the present research addresses important issues. We consistently demonstrated that performing prosocial behaviors may lead to reduced liking. Moreover, we showed that the reduced liking of prosocial individuals is triggered by both comparison processes and perceptions of communal narcissism. The present set of studies therefore show, to our knowledge, the first direct evidence on underlying mechanisms in the devaluation of very prosocial others and provide a basis for future research.

Leaving the laboratory situation, the obtained findings suggest that performing prosocial behaviors is no guarantee to be liked. In fact, in some instances, individuals may be disliked because of their prosocial behaviors. This observation is in line with the ambiguously connoted term “do-gooder,” which on the one hand describes the target's “desire and effort to help people” but on the other hand, points out to potential evaluations of the target's behavior as “wrong,” or “annoying” (see Merriam-Webster, n.d.). We assume that the ambivalence of the term “do-gooder” is rather widespread. If so, research needs to pay more attention to the devaluation of prosocial others, as it might constitute a potential obstacle to individuals' motivation for prosocial behavior.

The warm glow of recycling can make us more wasteful; such potential ‘wasteful contribution’ effects need to be considered in assessing the benefits of certain recycling initiatives

The warm glow of recycling can make us more wasteful. Jenny van Doorn, Tim Kurz. Journal of Environmental Psychology, August 19 2021, 101672. https://doi.org/10.1016/j.jenvp.2021.101672

Highlights

• Initiatives that involve recycling waste into something useful are gaining popularity.

• These initiatives potentially increase waste rather than preventing it.

• People may frame their waste as a contribution to the collective good that elicits a warm glow.

Abstract: Laudable initiatives designed to limit the environmental damage associated with consumption, such as the recycling of plastic packaging into clothing or unused bread into beer, have become increasingly popular. In three experiments, we show how such initiatives can potentially increase waste rather than preventing it. Specifically, we show that when presented with such options people may come to psychologically frame their waste creation as a contribution to the collective good that makes them feel good about themselves (i.e. eliciting a warm-glow effect). We argue that such potential ‘wasteful contribution’ effects need to be considered in assessing the true sustainability benefits of certain recycling initiatives.

Keywords: RecyclingWarm glowWasteWaste hierarchyFoodPlastic

Women were substantially more likely to wear painful, restricting or distracting clothing than men, clothing that requires ongoing monitoring or adjusting

These Boots Weren’t Made for Walking: Gendered Discrepancies in Wearing Painful, Restricting, or Distracting Clothing. Renee Engeln & Anne Zola. Sex Roles, Aug 19 2021. https://rd.springer.com/article/10.1007/s11199-021-01230-9

Abstract: Using the framework of objectification theory (Fredrickson & Roberts in Psychology of Women Quarterly 21(2): 173–206, 1997), the current studies explored how often women (vs. men) reported wearing clothing that is painful, distracting, and/or restricting (PDR clothing). Additionally, we examined differences in body surveillance (i.e., chronically monitoring the appearance of one’s body) and body appreciation between those who reported wearing various types of PDR clothing and those who did not. In both a sample of U.S. college students (n = 545) and a broader sample of U.S. adults (n = 252), results indicated that women were substantially more likely to wear PDR clothing than men. Across both samples, the largest differences between men and women were in wearing uncomfortable or painful shoes and in wearing clothing that is distracting because it requires ongoing monitoring or adjusting. Women and men with higher body surveillance were more likely to report wearing PDR clothing. Though some findings pointed toward a negative association between body appreciation and wearing PDR clothing, these results were inconsistent. Overall, results were consistent with the notion that the gendered nature of clothing might reflect and provoke chronic vigilance of the body’s appearance. Gendered differences in the extent to which clothing promotes comfort and movement vs. discomfort and distraction has clear implications for women’s quality of life.

Discussion

Once again, we found that women were substantially more likely to wear PDR clothing than men. Wearing PDR clothing was linked to greater body surveillance among both women and men. In general, there was no pattern to suggest that body appreciation differed significantly between those who do and do not wear PDR clothing.

Coding of themes in the open-ended responses to the question about why participants wore PDR clothing suggested two areas of gender discrepancy. Consistent with evidence that women score higher than men on measures of the salience of appearance in their lives (Cash et al., 2004), and with arguments that women face more rigid appearance ideals than men (Buote et al., 2011), women who wore PDR clothing were more likely than men who wore PDR clothing to indicate that they did so in order to appear more attractive. On the other hand, men were more likely than women to indicate that when they wore PDR clothing, they did so because it was a workplace requirement (e.g., wearing a tie or suit jacket). This finding was somewhat surprising given the attention in both popular media and legal settings to sexist workplace apparel requirements (e.g., requiring women to wear heels or skimpy uniforms; Aamodt, 2017). It is possible that for some men, PDR clothing in the workplace (e.g., wearing a tie or blazer) can be a means of projecting power and financial success, both of which are tied to masculinity pressures (Berdahl et al., 2018). However, a more parsimonious explanation for this pattern (and one that is consistent with objectification theory), is that for women, the pressure to “look good” extends across all settings. In other words, if one’s reason for wearing PDR clothing is to look attractive to others, that reason might supersede any specific reference to work or particular social settings. Unfortunately, the brief responses to this exploratory, open-ended question did not provide us with enough detail to more fully examine these possibilities.

General Discussion

Across two studies, we demonstrated that women are significantly more likely than men to wear clothing that is painful, distracts, or restricts movement. Additionally, results revealed that overall, men and women who wear PDR clothing engage in more body surveillance than men and women who do not wear this type of clothing. Finally, we found that when they wear PDR clothing, women are more likely to indicate that their reason for doing so is to look attractive to others, whereas men were more likely to indicate that they do so out of a workplace obligation. This descriptive, exploratory research is the first we are aware of that directly examines how often men vs. women wear PDR clothing.

These results may appear obvious to many readers. One would need only a passing familiarity with women’s fashions to ascertain that they regularly show little regard for comfort or function. As just one example, consider widespread popular media coverage of the claim that the lack of pockets in women’s clothing is an issue of gender equality (Basu, 2014), and that designers leave useful pockets off women’s clothing primarily because pockets are viewed as unflattering to the lower body. Despite how easy it may be to casually observe the gender difference in wearing PDR clothing, documenting this pattern is a necessary first step in building an understanding of how often individuals wear PDR clothing, the psychological (or practical) factors involved in decisions to wear such clothing, and the psychological outcomes that follow.

Certainly, men’s clothing can fall under the umbrella of painful, distracting, or restricting as well. For example, neckties are a common source of fashion-related discomfort for men. However, as workplaces become more casual, fewer men are required to wear ties on a regular basis. A 2007 Gallup poll found that two in three men never wear a tie to work and only nine percent wear a tie most days (Carroll, 2007). Rates are likely substantially lower today.

Though men in the current studies were less likely than women to wear PDR clothing, men and women who wore PDR clothing tended to have greater body surveillance than those who did not wear such clothing. The link between body surveillance and wearing PDR clothing could be conceptualized as moving in two directions. Some types of PDR clothing literally require body surveillance (e.g., clothing that must be adjusted/monitored in order to avoid showing more of your body than you mean to). For example, if a woman wears a low-cut blouse but does not wish to expose her breasts, that blouse will cause her to monitor her body in order to determine how much of it is visible to other people. Other types of PDR clothing may be more of a reflection of ongoing body surveillance. For example, women may wear “shapewear” in part because they are sensitive to how the shape of their body appears to others. Of course, these effects could also act in a feedback loop, where trait levels of body surveillance prompt a person to choose PDR clothing, and the PDR clothing itself then draws more of that person’s attention to the appearance of their body.

The chronic appearance monitoring assessed by the measure of body surveillance used in these studies is strongly linked to self-objectification (Calogero, 2012). Self-objectification has negative psychological outcomes for men as well as women (e.g., Hebl et al., 2004; Martins et al., 2007), suggesting that the potential psychological toll of body surveillance is relevant regardless of gender. However, because women report wearing PDR clothing substantially more frequently than men do, PDR clothing can be conceptualized as a factor that may partially explain the gender gap in rates of self-objectification (with women consistently reporting higher levels; Frederick et al., 2007).

Because one component of body appreciation is a focus on and appreciation for the functions of one’s body (Tylka & Wood-Barcalow, 2015), and because many types of PDR clothing can limit some of the body’s functions (e.g., comfortable movement, taking deep breaths), we anticipated that wearing PDR clothing would be negatively associated with body appreciation. However, we found inconsistent support for this prediction. This may be because appreciation for the body’s functionality is only one of several components of body appreciation. Other components (e.g., body acceptance and rejecting unhealthy or rigid appearance ideals; (Tylka & Wood-Barcalow, 2015) may be less relevant to decisions around PDR clothing. An alternative explanation for the inconsistency of results regarding the link between PDR clothing and body appreciation is the complicating factor of choice. Regardless of whether you freely choose to wear PDR clothing or are required to do so (by a workplace, for example), body surveillance is a logical outcome of PDR clothing if it draws your attention to how you look. On the other hand, one can imagine a person with high levels of body appreciation who wears PDR clothing out of obligation. In this case, there is no reason to suspect that wearing PDR clothing would necessarily lower one’s body appreciation.

The pattern of gender differences across these two studies with respect to how often men vs. women wear PDR clothing was clear: women wear such clothing more often. However, some categories of PDR clothing showed larger and more consistent gender differences. Across both studies, some of the largest differences between men and women were in wearing shoes that cause pain/blisters and wearing shoes that limit the time one can comfortably stand. The findings regarding shoes may speak to gender differences in taking a functional perspective on one’s body (Alleva & Tylka, 2021). When it comes to facilitating movement, shoes are arguably the single most important article of clothing. Shoes affect how quickly and confidently one can walk and how long one can stand without breaks. Though men’s shoes vary to some extent in terms of how comfortable they are (e.g., dress shoes vs. running shoes), only in women’s fashion do we see the dominance of a type of shoe (the high heel) that clearly impedes movement (Jeffreys, 2015). Previous research has found that women report wearing high heels in order to look sexy (Smolak et al., 2014), suggesting that shoes may be a key area where women negotiate trade-offs between comfort and appearance pressures. Consistent with this argument, across both studies, those who reported wearing shoes that cause pain/blisters or limited the time they could comfortably stand scored significantly higher on body surveillance.

A second area of notable gender differences was in wearing clothing that requires adjusting or monitoring throughout the day: women were much more likely to indicate that they wore this type of clothing. This finding is consistent with Fredrickson and Roberts (1997) argument that certain women’s fashions require women to be “chronically vigilant” of their bodies (p. 182). Monitoring your clothing provides ample opportunity to bring your attention back to your appearance. Interestingly, this type of PDR clothing was the only one to show a significant link with body appreciation across both studies. Men and women who indicated they wore clothing that requires this type of ongoing monitoring reported lower body appreciation.

One of several questions the current research leaves unanswered is the extent to which women freely choose to wear PDR clothing. This is a complicated question to tackle. In a culture in which women are taught that their primary form of social currency is their appearance (Fredrickson & Roberts, 1997), the behaviors women engage in in order to appear attractive or sexy are at best viewed as constrained choices. Some women in Study 2 directly stated that they choose to endure fashion-related pain and discomfort because that is what it takes to look sexy. Even in settings where specific types of apparel are not explicitly required, social pressures to follow fashion trends can be fierce. A norm-enforced unofficial dress code (e.g., wearing tight, short dresses in order to gain entry to a trendy bar or wearing heels for an important work presentation) can still exert a substantial pull on behavior.

An important point of difference between men’s and women’s PDR clothing is that for women, PDR clothing is often revealing (e.g., tight, short, or low-cut clothing; Goodin et al., 2011), not just distracting or uncomfortable. In other words, much of women’s PDR clothing seems intended to draw the (potentially sexually objectifying) gaze of others, whereas men’s PDR clothing is often intended to signal competence or power (e.g., a suit coat and tie). Consistent with this trend, in the current studies, the only PDR clothing type men were more likely than women to report wearing at least once a week was clothing that makes one too hot or too covered for weather conditions (Study 1). This difference between revealing and non-revealing PDR clothing likely matters in terms of the subjective experience of wearing such clothing. A suit can hide perceived bodily flaws and make a person feel (and be perceived as) more powerful (Kraus & Mendes, 2014); highly revealing clothing can prompt body consciousness and make a person more likely to be perceived as a sexual object (Gray et al., 2011).

Limitations and Future Research Directions

The current studies were primarily exploratory and cannot provide conclusive evidence about the direction of the association between wearing PDR clothing and body surveillance. Additionally, the limited data about reasons why men and women wear PDR clothing suggests that a more thorough analysis on this topic is warranted. Some reasons for wearing PDR clothing (e.g., to look good) seem to indicate free (or at least, somewhat free) choice. Other responses suggest bowing to social norms or following explicit guidelines for different work/social settings. Many participants listed both types of reasons. Future work on this topic should include a more nuanced set of questions about when, why, and how often men and women wear PDR clothing. This is especially important given the relatively informal process by which the list of PDR clothing types used in these studies was generated. Future researchers could consider using these initial data to inform the development of a formal measure of behaviors and attitudes around PDR clothing. The general categories of PDR clothing examined in these studies could also be used as a starting point for a more detailed analysis of specific articles of clothing and their psychological effects. For example, researchers could examine what types of clothing participants are thinking of when they respond to questions about clothing that leaves welts or makes it difficult to breathe. Of particular interest would be any gender differences in the extent to which PDR categories are capturing rarely worn types of clothing (e.g., formalwear) vs. more everyday types of clothing (e.g., undergarments, shoes).

We recommend that future work examining reasons why individuals wear PDR clothing employ focus groups or semi-structured interviews in order to more carefully interrogate how people make decisions around PDR clothing. Though many participants in the current study indicated that they wore PDR clothing to be more attractive to others, we were not able to explore how (or to what extent) men and women understood these choices in terms of gender roles or gendered sociocultural appearance ideals. In addition to this type of qualitative work, researchers should consider using experimental methods to test the extent to which wearing PDR clothing might lead to trade-offs between momentary boosts in self-esteem (e.g., feeling sexy or confident while wearing heels) and disruptions in the ability to focus (e.g., when one’s attention is drawn to foot pain or the need to adjust one’s clothing).

The current studies are also limited by their reliance on participants’ memory and on participants’ rough estimates of how often they wear different types of apparel. Additionally, our online survey did not include attention checks (beyond evaluating the open-ended responses in Study 2). Observational or field studies could provide more detailed data on the types of PDR clothing men and women wear in their everyday lives and how PDR clothing choices vary by setting or context. Some researchers have argued that those whose bodies least resemble cultural body ideals (typically people in marginalized bodies) may feel the greatest pressure to engage in appearance surveillance (Frederick et al., 2007). Relatedly, others have pointed to appearance management behaviors as a means for women who are poor to attempt to improve their status or financial situation (Edmonds, 2007). Together, these findings suggest that the links between social status and choices around PDR clothing would be a rich area for future research.

The current studies were not designed in a way to allow for a rigorous examination of how age (or the interaction between age and gender) might be related to wearing PDR clothing. However, there are numerous reasons that this could be an interesting area for future work. There are theoretical and empirical reasons to predict that women may be less likely to wear PDR clothing as they age. For example, Fredrickson and Roberts (1997) argued that because older women tend to receive less sexualized attention from their culture, women may find themselves more able to “step out of the objectification limelight,” (p. 195) as they age. To the extent that they do so, they may feel less pressure to wear PDR clothing. This possibility would be consistent with evidence that older women report lower levels of self-objectification than young women (Tiggemann & Lynch, 2001).

On the other hand, (Tiggemann, 2004) argued that, unlike age-related body changes, appearance management behaviors like clothing choices remain largely under one’s control as one ages. For that reason, clothing choices designed to maximize attractiveness may become more important for women as they age. This perspective suggests that PDR clothing could be more common among older women.

Practice Implications

Therapists and other practitioners working with individuals who struggle with body image-related issues might consider clothing choices as a worthwhile topic to address. Previous research has suggested that a more functional approach to understanding one’s body can help reduce body image disturbance (Alleva et al., 2015). To the extent that more comfortable clothing choices allow one to focus more on how one’s body moves and how it feels, opting out of PDR clothing could be a healing choice for some (assuming they have the freedom and means to do so). This may be particularly true for women, both because women are more likely than men to wear PDR clothing and because women tend to engage in more body surveillance than men. Of course, practitioners should take care to avoid shaming people over any clothing choices, instead considering how one might select apparel that is both confidence-inducing and allows for comfortable freedom of movement and less distraction. Activists working in this space can continue to push fashion designers and clothing manufacturers to provide comfortable clothing that does not require monitoring and adjustment throughout the day – and insist that such options be available to all genders and all body shapes and sizes.

Paradoxical intention has been considered an evidence-based treatment for insomnia since the 1990s; it seems to result in great reductions in sleep-related performance anxiety & marked clinical improvements

Paradoxical intention for insomnia: A systematic review and meta-analysis. Markus Jansson-Fröjmark, Sven Alfonsson, Benjamin Bohman, Alexander Rozental, Annika Norell-Clarke. Journal of Sleep Research, August 17 2021. https://doi.org/10.1111/jsr.13464

Summary: Paradoxical intention (PI) has been considered an evidence-based treatment for insomnia since the 1990s, but it has not been evaluated with modern review techniques such as meta-analysis. The present study aimed to conduct the first systematic review and meta-analysis of studies that explore the effectiveness of PI for insomnia on insomnia symptomatology and theory-derived processes. A systematic review and meta-analysis was conducted by searching for eligible articles or dissertations in six online bibliographic databases. Randomised controlled trials and experimental studies comparing PI for insomnia to active and passive comparators and assessing insomnia symptoms as outcomes were included. A random effects model was estimated to determine the standardised mean difference Hedge’s g at post-treatment. Test for heterogeneity was performed, fail-safe N was calculated, and study quality was assessed. The study was pre-registered at International Prospective Register of Systematic Reviews (PROSPERO, CRD42019137357). A total of 10 trials were identified. Compared to passive comparators, PI led to large improvements in key insomnia symptoms. Relative to active comparators, the improvements were smaller, but still moderate for several central outcomes. Compared to passive comparators, PI resulted in great reductions in sleep-related performance anxiety, one of several proposed mechanisms of change for PI. PI for insomnia resulted in marked clinical improvements, large relative to passive comparators and moderate compared to active comparators. However, methodologically stronger studies are needed before more firm conclusions can be drawn.

4 DISCUSSION

4.1 Summary of main results

The present study is the first comprehensive systematic review and meta-analysis of the effectiveness of PI for insomnia. Relative to passive comparators, PI resulted in large improvements in several central insomnia symptoms. Although the effectiveness of PI was smaller compared to active comparators, the effects were still moderate for several key outcomes. Relative to previous reviews, the present study extends the quantitative assessment of PI as an evidence-based intervention in that it compared PI with passive versus active comparators and included both night-time and daytime symptoms (Jansson-Fröjmark & Norell-Clarke, 2018; Morin et al., ,1999, 2006). A unique finding was support for great reductions in sleep-related performance anxiety by PI. This finding strengthens the notion that decreased performance anxiety is a mechanism through which PI might work.

Cumming and Finch (2001) have recommended that effect sizes should be compared to other relevant estimates in the literature to grasp their significance. In one of the largest and more recent meta-analysis, cognitive and behavioural interventions (e.g. CBT-I, relaxation, stimulus control, psychoeducation, and sleep restriction) were compared with passive comparators (van Straten et al., 2018). Comparing the effect sizes from van Straten et al., (2018) for cognitive and behavioural therapies with the present study’s effect sizes for PI relative to passive comparators, the effects were larger in the present study for PI on SOL (0.57 versus 0.82), NAW (0.28 versus 1.10), and TST (0.16 versus 0.51), and smaller on SE (0.71 versus 0.00). Although inferences from comparisons of this sort are difficult to draw from a methodological viewpoint, a reasonable conclusion would be to state that PI tentatively has a similar effectiveness as other cognitive and behavioural interventions. At the same time, this conclusion is hampered by several limitations in the trials exploring the effectiveness of PI. The relatively few studies, limited number of study participants, and other methodological characteristics of the studies makes an overall conclusion about effectiveness and generalisability of PI uncertain.

4.2 Methodological considerations and quality of evidence

The present review identified 10 studies that evaluated the effectiveness of PI. There were a number of notable methodological limitations of the studies. The study quality assessment showed that the quality of the 10 studies ranged from 15 to 20 points out of 26, implying a moderate study quality. The methodological quality was particularly weak in two areas. First, no studies reported using blinding of subjects, even though it appeared as if this would have been possible. Second, it was uncommon that studies appeared to have sufficient power to detect group differences. While some of these limitations were noted in the study quality assessment, others will be underscored more specifically below.

Across the 10 studies, there was diversity concerning the design. In nine trials, PI was compared with a passive comparator, which means that non-specific factors (e.g. therapist contact) were not controlled for in the estimations comparing PI with passive comparators. Concerning design, it is also worth underscoring that the aggregation of various active comparators into one active comparator category was based on that they provided study participants with active treatment content. This aggregation could, however, have resulted in that comparators with differing effects were combined, so that the comparison between PI and active comparators becomes uncertain.

Another limitation regards the patient characteristics. The total sample size was limited to <400 participants, and none of the trials reported that power calculations were made prior to study start. In all, Type 2 errors are likely, particularly when active treatments were compared. Further, all participants were recruited from the community, which might make the present findings less generalisable to health settings, as patients in clinical settings tend to display elevated symptoms (Davidson et al., 2009). Another observation is that, in almost all of the studies, we categorised the participants as meeting criteria for sleep-onset insomnia or primary insomnia. Therefore, it is uncertain whether PI should be viewed as an effective intervention for other types of insomnia, such as comorbid insomnia. It is also worth noting that there might be specific insomnia profiles that are particularly susceptible to PI. For example, Espie et al., (2006) have proposed that PI might be specifically suited for patients with psychophysiological insomnia, as this profile of patients are believed to be characterised by attentional bias, preoccupation with sleep, and using several strategies to avoid sleeplessness. In future research, the study of PI and the effectiveness for different insomnia profiles might also be based on recent empirical attempts to subtype insomnia (Blanken et al., 2019). On a related note, we observed that comorbidity was not formally assessed in the included studies. Although several studies used certain criteria to assess and/or exclude comorbidity, the lack of validated assessments of psychiatric and somatic conditions limits generalisability. As comorbid problems are more common than “pure” insomnia (Stepanski & Rybarczyk, 2006), the lack of assessing comorbid conditions and exclusion of participants with comorbid problems are problematic.

Another issue of methodological uncertainty concerns the administration of PI. There were slight variations concerning several features of the delivery. The rationale and instructions varied across studies, although the original approach by Ascher and Efran (1978) was most commonly employed. Also, the delivery format was mixed, with individual, self-help, and group formats identified. Further, in several treatment-related parameters, it was rare that sufficient information was provided; this concerned whether a treatment manual was used, who delivered PI, whether the therapists were trained and/or supervised, and whether treatment integrity was assessed. Also, the dose of PI varied across studies. Often, PI was delivered across 2–4 weeks, but longer treatment periods were also identified. Based on the limited number of studies in the present review, we were unable to investigate whether certain formats of delivery of PI was more effective than others. During the review process, we also noted that none of the studies assessed treatment-relevant domains that might have importance for the interpretation of findings, such as acceptability, adherence, credibility and expectancy ratings, and perceived usefulness of PI. It should also be emphasised that worsened sleep after PI has been reported in the research literature (Espie & Lindsay, 1985). As none of the included studies in the present review reported on adverse events or deterioration, more research is warranted to examine whether PI produces negative effects among patients with insomnia in general or in subgroups of patients.

An inclusion criterion for the present review was that trials must report insomnia-related outcomes (i.e. night-time and/or daytime symptoms). Across studies, it was less common to index objective sleep outcomes, daytime symptoms, theory-derived processes, and global insomnia symptoms [e.g. with the Insomnia Severity Index; (Bastien et al., 2001)]. Due to the lack of studies assessing several outcome domains, all meta-analytical estimations were based on sleep diary or questionnaire data assessing sleep performance anxiety. As a result, we can only draw conclusions for PI concerning sleep diary-assessed night-time symptoms and, to a lesser extent, sleep performance anxiety. A related limitation is that estimations of effectiveness for PI was not possible to assess in the longer term, as there were not sufficient data for such calculations.

A further limitation is that sensitivity and moderator analyses were not employed due to the limited number of studies. For example, it would have been interesting to explore the effects of the addition or removal of lower quality studies and, to examine whether insomnia symptomatology at baseline and PI administration might moderate the effectiveness of PI. A final limitation is that it was required that the included studies were published in English, thereby introducing a possible language bias.

4.3 Putative mechanisms

In the present study, we identified three studies that assessed sleep-related performance anxiety as a putative mechanism, and no trial indexing other potential mechanisms (e.g. sleep intention). As a whole, performance anxiety was reduced to a large degree after PI in the included trials. However, it is important to emphasise that this does not imply that performance anxiety has been demonstrated to act as a putative mechanism. As all trials in the present review analysed sleep-related performance anxiety only as pre- to post-treatment changes, future research might design studies so that mediational analyses become possible. In such studies, repeated assessment of mediators is necessary, and then analysing whether change in mediators precede improvements in insomnia symptoms. This would pave the way for evidence-based explanations for how PI produces improvements (Kazdin, 2007).

Another important methodological aspect of the research literature on performance anxiety is that the self-report scales used in the three studies have not been systematically validated in psychometric terms (Broomfield & Espie, 2003; Buchanan, 1988; Fogle & Dyal, 1983). As a result, it is uncertain whether the construct validity of the self-report scales is sufficiently captured, so that conclusions about sleep performance anxiety can be drawn in the present review. Concerning the measurement of sleep performance anxiety, it should be noted that validated self-report scales are available, such as the Glasgow Sleep Effort Scale (Broomfield & Espie, 2005; Meia-Via et al., 2016; Vand et al., 2020), and such instruments are recommended for future research. The use of validated measures in future trials would enable stronger conclusions about the effectiveness of PI on sleep performance anxiety as well as the possibility to examine mediation in a more rigorous way and explore moderation (e.g. whether PI is particularly effective among insomnia patients with elevated sleep performance anxiety).

One should note that sleep-related performance anxiety is not the only candidate as a putative mechanism for PI. First, PI could be viewed as an intervention that exposes patients to learned, feared stimuli in the bed or bedroom (Lundh, 1998), which enables extinction and the formation of new learning (Craske et al., 2014). However, this notion has not yet been articulated in detail in the research literature and not examined empirically. A second putative mechanistic pathway is described in the attention–intention–effort model (Espie et al., 2006). Although the pathway by Espie et al., (2006) appears to have high face validity, the model has not, to our knowledge, been explicitly tested in its full complexity in the realm of PI treatment.

4.4 Future directions

There are several important areas that future research could focus on to enhance the understanding of PI. Following from the limitations and uncertainties described above, we recommend future research to use active comparators, sample sizes based on power calculation, samples from clinical settings, a variety of insomnia types (including insomnia disorder), formal assessments of comorbidity, different delivery formats, broad assessments of insomnia symptoms and correlates as outcomes, and different mediators to examine mechanistic pathways.

One unknown dimension of PI is the optimal dosing and administration. Although PI has commonly been implemented by patients during a 2–4-week period, it could be argued that shorter administration of PI could be beneficial as well. Based on the theoretical rationale; that is, breaking a vicious cycle of sleep intention and associated performance anxiety, PI could potentially also be delivered as a behavioural experiment, during which patients test their predictions (e.g. “If I do not try to fall asleep, I will remain awake all night”), followed by testing PI for a limited number of nights. Another topic for future research is the optimal treatment rationale and instructions for PI. Based on two studies included in the present review (Ascher & Turner, 1980; Ott et al., 1983), it appears likely that PI with a desensitisation rationale or with feedback is less beneficial than the original approach by Ascher and Efran (1978). Beyond that, the ideal rationale and instructions remains unknown when delivering PI.

Based on the findings in the present review, the notion of how PI should be used warrants reflection. On the one hand, we believe that CBT-I should still be regarded as the first-line intervention for insomnia disorder (Riemann et al., 2017). On the other hand, PI might play a role in some cases. For example, if a patient remains unimproved after CBT-I, PI could be one option. Also, if the patient reports high sleep-related performance anxiety, and this appears as the primary maintaining factor, PI could be used in isolation or in combination with other efficacious CBT-I components, such as sleep restriction (Miller et al., 2014). To date, current CBT manuals do not include PI as a treatment component (van Straten et al., 2018). Whether the addition of PI could add efficacy to CBT-I is currently unknown. Future research could explore the notion of combining PI with CBT-I to explore potential additive effects, but also whether there are subgroups of patients who benefit more from PI.