Wisdom-related attitudes in psychosomatic patients and in a convenience sample

Abstract Wisdom can be understood as a complex capacity to solve unsolvable problems. Wise persons are better in coping with difficult life situations. People with mental disorders often have problems coping with difficult life situations. This study examines whether a convenience sample from the general population and psychosomatic rehabilitation patients (dis)agree similarly or differently with global sentences representing wisdom-related attitudes. A total of 209 persons from a convenience sample (lecture visitors, M = 32 years of age) and 207 patients with mental disorders (M = 49 years of age) were given a short case vignette of a seemingly unjust situation. They were then asked to which degree they agree to different wisdom-related attitudes (12-WD Scale) regarding the example situation. Results: Patients judged the situation as more unjust, and they identified more strongly with the victim. There were no differences between the two groups concerning agreement to the wisdom ideas, except that the convenience sample was more likely to agree with the wisdom idea change of perspective. This finding of similar wisdom attitudes in patients and others is a validity support for wisdom being a capacity, which may be independent from psychopathology. Wisdom trainings for health promotion potentially do not need to distinguish between patients and general population persons. As the scale asks for wisdom-related attitudes for problem solving, it may be the case that coping with concrete situations (i.e. wise behavior) would be different.


Introduction
In everyday life, there are many ambiguous situations in which there is no definitive right or wrong.Do you stay at home with your sick child or rather go to work because of an important meeting?Do you engage in an argument with a colleague for getting your right at this moment, or do you ABOUT THE AUTHORS Anne Meier-Credner is PhD student and psychological psychotherapist in behaviour therapy.Michael Linden is medical specialist in psychosomatics and psychotherapy and senior researcher.He is director of the Research Group Psychosomatic Rehabilitation at Charité Berlin, and the Institute of Behaviour Therapy Berlin.Beate Muschalla is senior researcher, psychological psychotherapist (behaviour therapy) and supervisor.She is director of the psychotherapy and diagnostics unit and outpatient clinic at Technische Universitaet Braunschweig.rather stand back under a long-term perspective?There are also severe problems that cannot be undone or where there is no solution at all.Workers are fired despite having sacrificed themselves for their jobs, a person learns after the death of the partner that s/he engaged in infidelity, and people can experience major injustice or humiliation.The question is what one needs to "solve" such unsolvable problems.
The psychological capacity that helps to cope with such dilemmas (i.e.situations in which any decision has dis/advantages) is wisdom.Wisdom is a complex psychological capacity, besides others (Molodynski et al., 2013).There are several different wisdom concepts (e.g.Ardelt, 2003;Baltes & Smith, 1990;Baltes & Staudinger, 2000;Bluck & Glück, 2005;Grossmann, Dorfman, et al., 2020;Kunzmann & Baltes, 2005;Sternberg, 1998).Wisdom definitions were found to be similar across cultural and geographic boundaries (Jeste & Vahia, 2008;Meeks & Jeste, 2009).Various researchers attempted to identify commonalities among the different wisdom concepts.Bangen et al. (2013) conducted a review of peer-reviewed articles on wisdom and identified the following commonly cited components of wisdom: A deep insight in life, sound judgment, the ability to reflect in an unbiased way, a philanthropic attitude, knowledge of life, prosocial values, selfunderstanding, acknowledgment of uncertainty, emotional homeostasis, tolerance, openness, spirituality, and sense of humor.A few years ago, Grossmann, Weststrate, et al. (2020) conducted a survey of empirically oriented wisdom scientists around the world.The scientists showed substantial agreement about the central elements of wisdom and Grossmann et al. proposed a common psychological wisdom model.According to their model, wisdom is defined as "morallygrounded excellence in social-cognitive processing" (p.64).Morally grounding means "a set of inter-related aspirational goals: balance of self-and other-oriented interests, pursuit of truth (vs.dishonesty), and orientation toward shared humanity."(p.64).Excellence in social-cognitive processing means context-adaptability, perspectivism, dialectical and reflective thinking and epistemic humility (p.64) as metacognitions for problem solving.Simultaneously, B. Baumann et al. (2004), K. Baumann and Linden (2008) and Linden et al. (2019) proposed an integrative wisdom model for use in practice to promote psychosocial functioning.Summarizing the many concepts of wisdom, it includes 12 wisdom dimensions, largely reflecting the components identified by Bangen et al. (2013) and those identified by Grossmann, Weststrate, et al. (2020): factual and procedural knowledge, contextualism, value relativism, change of perspective, empathy, relativization of problems and aspirations, self-relativization, selfdistance, perception and acceptance of emotions, emotional serenity and humor, uncertainty tolerance, and long-term perspective (Linden et al., 2019).This model is especially common as the theoretical basis of wisdom therapy to promote wisdom as a complex capacity.In a randomized controlled therapy study (Linden et al., 2011), wisdom therapy appeared to be a successful approach to treat patients in psychosomatic rehabilitation.Developing wisdom trainings to strengthen mental health and to cope with life events would be a promising approach for rehabilitation of mental disorders as well.Additionally, with the 12-WD scale (Linden et al., 2019), a self-report measure of general wisdom-related attitudes is available.This scale is used in the current study.
Research on folk conceptions of wisdom has shown that people in general know very well, or at least can recognize, what would be wise to do (e.g.Baltes et al., 1995;Glück & Bluck, 2011;Hershey & Farrell, 1997;Jason et al., 2001;Sowarka, 1989).People can identify wisdom in others, as several nomination studies show (Baltes et al., 1995;Jason et al., 2001;Sowarka, 1989).Individuals nominated as wise performed better on a wisdom task than a control group of "older" persons (aged 60 and 80 years) with comparable levels of education (Baltes et al., 1995).Glück and Bluck (2011) got nearly 2000 laypeople to rate items on their importance for wisdom.They showed that laypeople agreed moderately to strongly with the wisdom items.However, applying wise behavior is difficult.Psychosomatic patients often have difficulties in coping with life problems as compared with the general population (Ebrahimi et al., 2017;Vitaliano et al., 1990).Previous research has shown that wisdom is positively linked to mental health (van Patten et al., 2019;Webster et al., 2014), fewer mental health problems (Roháriková et al., 2013) more joy and optimism (Jeste et al., 2020;Vásquez et al., 2020), less depression (Chen et al., 2021), and less experience of loneliness (Jeste et al., 2020).In Roháriková et al. (2013) study of 26 patients with psychosomatic conditions and 20 control subjects, the psychiatric patients scored lower in wisdom than the control subjects on Ardelt's Three-Dimensional Wisdom Scale and Levenson's Adult Self-Transcendence Inventory.
In the research literature, little attention has been paid to the distinction between outwardly observable wise behavior on the one hand or wise reasoning and wise attitudes that are not directly observable on the other hand.An essential prerequisite for wise behavior is wisdomrelated attitudes.These are assumptions, judgements, and basic beliefs about life (Ardelt, 2004;Baltes & Smith, 1990;Leung et al., 2002) which are rather stable across the lifespan.The degree to which attitudes have an impact on or are identical with behavior is a broadly discussed psychological problem.It is a long-known phenomenon that attitudes and behavior can be different (Ajzen & Fishbein, 1977;Bickman, 1972;Corey, 1937;Darley & Batson, 1973;Himelstein & Moore, 1963).Wisdom-related attitudes are beliefs that people hold and must be discriminated from wise behavior in a specific situation.Wisdom-related attitudes indicate whether a person is wiseminded, a prerequisite to act wisely.It depends on individual, contextual, and social factors whether a person has an intention to act (Ajzen, 1991).Action occurs when a person commands about the necessary capacities, is convinced of the positive effect of the behavior, and when the behavior is compatible with the subjective norms (Ershler et al., 1989).
One explanation for psychosomatic patients having more difficulty coping wisely with life problems could be that psychosomatic patients have a lack of wisdom-related attitudes (Linden et al., 2019).This could make them more vulnerable to suffering in critical life situations.There could also be problems to understand or recall wise attitudes due to mental health impairment.If there is already a difference at the level of wisdom-related attitudes, this would be an important finding for the design of wisdom interventions.An even stronger focus than before (Linden et al., 2011) could be directed toward the development of wisdom-related attitudes.In contrast, if it turns out that there is no difference at the level of wisdom-related attitudes, and this existing level is quite high, wisdom interventions could focus on training of concrete wise behavior.

Research question
In this first exploratory study, we investigate whether psychosomatic patients and persons from a general population convenience sample are similar or different at the level of wisdom-related attitudes.To our knowledge, this is the first study to compare wisdom attitudes of a larger sample of psychosomatic patients and control subjects.
Based on the 12 wisdom dimensions of the integrative wisdom model, Linden et al. (2019) developed the 12-Wisdom Dimensions self-rating Scale (12-WD Scale) to measure wisdom-related attitudes.The 12-WD Scale consists of 12 statements, each representing one of the twelve wisdom dimensions.The scale measures to which degree people agree that these wisdom ideas are helpful for problem solving.The wisdom dimensions with descriptions and the corresponding wisdom-related attitudes of the 12-WD Scale (Table 1) are translated from the original German version (Linden et al., 2019):

Participants
A convenience sample of psychosomatic patients (ps) was recruited in a day care psychosomatic hospital.A total of 207 patients participated.Their age was 20 to 79 (M = 49.0;SD = 10.6)years, and 60.4% were female.This corresponds to the composition and average age of the psychosomatic patients of the hospital group (Median, n.d.).The most common main diagnosis is (recurrent) depressive disorders (60%), followed by reactions to severe stress and adjustment disorders (14%) and somatoform disorders (8%) (Median, n.d.).Participants from the general population convenience sample (gp) were recruited at a public lecture on "Wisdom" at the local university, as well as via postings on social networks.A total of 209 persons participated.Their age was 18 to 84 (M = 32.1;SD = 15.8)years, and 66.5% were female.Participants were asked to provide information on their age, gender, and educational level.Sociodemographic data on participants in both samples is provided in Table 2.
There was a similar rate of females between the two samples (ps: 60.4%, gs: 66.5%), but patients were older on average and less likely to have had a university education.

Self-relativization:
The ability to accept that one is not always the most important individual and that most things do not follow one's own will or are not oriented towards one's own interests.
7. As far as possible I try not to take myself so important.

Self-distance:
The ability to identify and understand the perception and evaluation of oneself from the perspective of other people.
8. I cannot expect others to like me if I do not behave accordingly.

Perception and acceptance of emotions:
The ability to recognize and accept one's own feelings.
9. I cannot demand to be always in a good mood.

Emotional serenity and humor:
The ability to emotional balance, control one's own emotions according to situations, as well as the ability to look at oneself and one's own difficulties with humor.
10.If possible, I try not to get upset, because there is nothing to gain by getting upset myself.
11. Uncertainty tolerance: Knowledge and acceptance of the fact that future developments can never be predicted or controlled reliably.
11.I am one of those people who say that things happen as they happen.
12. Long-term perspective: Knowledge about short-and long-term consequences, which can contradict each other.
12. I always see crises also as an opportunity for the future.

Case vignette
To study wisdom, Smith and Baltes (1990) used case vignettes and asked participants what one could consider and do in the described situation.Case vignettes are also used in wisdom therapy to train wisdom capacities (K.Baumann & Linden, 2008;Linden et al., 2011).
Following Smith and Baltes (1990) methodological approach, we gave a concrete example of a dilemma situation to the participants, for which they have a concrete situation in mind to which they give their ratings.Thus, participants were first given a brief description of a dilemma taken from a set of validated dilemmata (K.Baumann & Linden, 2008) and then asked to fill in the 12-WD Scale: "You have successfully managed a department for 25 years.After a longer stay in hospital due to an accident at work, you lose your management function.Your new boss is a young university graduate."To check whether this situation was experienced as unfair, participants were asked to indicate: "How unfair do you perceive the situation to be? Please rate on a scale from 0 (not at all) to 10 (very much)." In addition, they were asked to indicate how well they were able to identify themselves with the situation: "How well could you put yourself in the situation?Please rate on a scale from 0 (not at all) to 10 (very much)."

Wisdom-related attitudes (12-WD scale)
Wisdom-related attitudes were then measured with the 12-WD Scale (Linden et al., 2019).The 12-WD Scale covers 12 wisdom dimensions, each represented by one item.Participants were asked to indicate on 12 self-rating items to which extent they agreed with the wisdom ideas when they thought about the situation in the presented dilemma: "In the following you will find very different statements and attitudes on how people can react to enormous difficulties and significant life stresses.Please think of the situation just presented.Decide for each statement to what extent it makes sense for you personally in this situation or not."Answers were given on a Likert scale from 0 (do not agree at all) to 10 (agree exactly).Since Linden et al. ( 2019) had observed a general tendency to agree with the items, we adjusted the original scale (Linden et al., 2019) from 1 to 6 to a scale from 0 to 10 to differentiate more precisely on the upper scale points.A global average wisdom score can be calculated across all items.Completing the questionnaire took about 20 minutes.
The study material is available upon request to interested researchers.

Ethics
The study was reviewed and approved by the Ethics Committee of the Faculty of Life Sciences (identification number FV 2019 10) of the Technische Universität Braunschweig.All participants gave written informed consent.

Statistical analysis
Answers of patients and convenience sample were compared by using welch-tests.To counteract the risk of alpha error accumulation in multiple testing, Bonferroni correction was applied.Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0.

Power analysis
An a priori power analysis was conducted using G*Power version 3.1.9.7 (Faul et al., 2007) to determine the expected statistical effect.The expected effect size is small to medium according to Cohen's (1988) criteria.With a significance criterion of α = .05and power = .80,the minimum effect size needed with a sample size of n = 200 per group is d = 0.28 for welch-tests.

Results
As manipulation check showed, the presented situation was seen as very unjust (a value of 6 or higher on the injustice rating), by 71.3% of the psychosomatic and 68.7% of the convenience sample.In regard to the identification with the situation described in the vignette, 69.1% of patients and 66.3% of the convenience sample had a rating of 6 or higher.Patients perceived the situation more unjust, t = 2.349; p = .019;d = .23,and perceived themselves more able to put themselves in the situation, t = 2.016; p = .045;d = .20.
Regarding the cued wisdom ratings, the scores of the 12-WD Scale in the patient sample and the convenience sample did not differ significantly.An exception is change of perspective, t = −3.630;p adjusted = .004;d = −.36.(see Table 3).
Participants in both groups mostly agreed (rating ≥6) with almost all items on the 12-WD Scale (ps: M = 6.60;SD = 1.51 and gp: M = 6.82;SD = 1.26; as shown in Figure 1).The strongest agreements were found for factual and procedural knowledge, perception and acceptance of emotions, value relativism, and relativization of problems and aspirations.The weakest agreement was found for self-relativization and uncertainty tolerance.The distribution of the global wisdom score is right part (ps: skewness = −.72;gp: skewness = −.46), and approximately normally distributed in both samples, as assessed by visual inspection of Q-Q plots and histograms.Regarding single items, the convenience sample had a tendency to slightly higher wisdom ratings across most items, which is only statistically significant for change of perspective.There is a trend for higher rates of persons with low wisdom attitudes (sum score of <6) in the patient sample (26.1%) as compared to the convenience sample (19.8%).The responses of psychosomatic patients vary more.Compared to the convenience sample,   3).No significant correlations were found between the cued global wisdom score and age, gender, or educational level.

Discussion
The data show that psychosomatic patients and a convenience sample from the general population agree to a similar extent with wisdom-related attitudes regarding a given fictitious dilemma situation.This indicates that there are no overall fundamental differences at the level of wisdomrelated attitudes, except in one out of twelve wisdom dimensions (change of perspective).
Results showed almost no differences at the level of wisdom-related attitudes between psychosomatic patients and the convenience sample.This finding is in line with previous research that people are basically good at recognizing what would be wise (e.g.Baltes et al., 1995;Glück & Bluck, 2011;Hershey & Farrell, 1997;Jason et al., 2001;Sowarka, 1989).The results contradict the findings of Roháriková et al. (2013) on their small sample (N = 46) that psychiatric patients had lower wisdom scores than a control group.
One difference emerged regarding change of perspective: the convenience sample agreed more than psychosomatic patients.This is consistent with other findings; for example, in a systematic review of psychological interventions for people with bipolar disorder, Davenport et al. (2019) found change of perspective as a key intervention element.Greve et al. (2021) found in people who are not explicitly mentally ill that change of perspective plays an important role in coping with stressful life situations and correlates with psychological well-being.This finding fits to the fact that perspective change is an important method in current wisdom therapy (K.Baumann & Linden, 2008, 2011;B. Baumann et al., 2004).Perspective change is practiced in various ways, in order to gain awareness of the perspectives of others involved in a situation, and also to expand one's own scope of action.The fact that the psychosomatic patients rated the given situation as more unfair and indicated higher ratings than the general population on the question how well they could place themselves in the situation is interesting.An explanation can be that the psychosomatic patients are more prone to perceive unfairness or have a more sensitive perception or interpretation of events.
Situations for perspective change tests or trainings may be introduced with variation in the instruction: Individuals who were asked to think about a challenging interpersonal situation from the grammatical third-person perspective developed wiser thoughts than those who thought about it from the first-person perspective (Grossmann & Kross, 2014;Grossmann et al., 2021).Thus, distanced reflection may be a useful method in wisdom trainings because it expands the focus on the whole situation, beyond the narrow self-focus.
Here, investigated people had a general tendency towards agreement, with higher mean agreement scores across all items of the 12-WD scale.In an earlier study in psychosomatic patients, a similarly right part distribution was found for the global 12-WD score (Linden et al., 2019).The results of the current study cannot be directly compared with earlier data from other studies, as we used a cued method and a scale with endpoints 0 and 10.Furthermore, participants in our study should not indicate how they would react in general, but what would make sense to them if they were confronted with the situation in the case vignette.
Given a fictitious vignette which describes a possibly unjust event, both samples identify with the affected person in the vignette and perceive the situation as unfair.Nonetheless, patients gave higher scores, indicating that they resonate more intensely with the imagination of negative life events.This suggests that psychosomatic patients are more prone to respond to critical life events, and they are more prone to feel injustice.As a result, they may more often experience situations as unfair and feel confronted with more injustice overall, which can mean a stronger experience of strain.
The 12-WD Scale asks for wisdom-related attitudes.It is easy to agree that it is decent to listen to the wishes of other persons or behave humble.Building on these findings, wisdom-related attitudes are generally present or at least easily understood.The question is how this corresponds to considerate and humble behavior.Therefore, wisdom trainings should target concrete wise behavior.The idea is that wisdom as a complex capacity helps maintaining or recovering psychosocial functioning and coping with life challenges.As such, wisdom trainings can be a valuable approach to psychosomatic rehabilitation (Linden et al., 2011).
Limitations of the present study are that we did not collect data on the participants' living situation or their general success in life, or how long they had been in treatment before participating in the study, and we did not observe their behavior in critical situations.We had no specific information on the intensity and type of psychosomatic disorder.It may be that there are differences in wisdomrelated attitudes depending on psychopathology, like worrying or embitterment, and between different disorders, like personality or adjustment disorders (B.Baumann et al., 2004).
In other studies, some social desirability was observed in wisdom self-rating questionnaires (Brienza et al., 2018;Glück et al., 2013;Taylor et al., 2011).This may also be true in this present study.The psychosomatic patients may have been exposed to wise attitudes in therapy sessions before, and the convenience lecture audience may have heard there what attitudes would be wise.It is unclear to what extent the wisdom attitudes are internalized as intrinsic motivation.
The case vignette task included the challenge to imagine oneself in a fictitious situation and to assess to what extent the attitudes presented made sense.While most individuals indicated that they were able to place themselves in the given situation, it still was a cognitive challenge, and we are not able to verify how well they would have succeeded in real life.In addition, it must be taken into account that, due to their young age or previous professional career, they may not have had the experience to empathize emotionally adequately with the situations described.
We did not actively check subjects' attention while completing the questionnaire but assumed that the diverse questionnaire (reading the case vignette, empathizing, and noting thoughts, and then answering the 12 items of the wisdom scale) was sufficiently rich in variety.
For a more precise differentiation of responses on the 12-WD wisdom scale, we used a rating scale from 0 to 10 instead of the original scale from 1 to 6.However, this change of the rating scale contradicts a direct comparison with data from previous studies with the 12-WD scale.
Our control sample represents a selective sample from the general population who might be interested in wisdom or life issues and were, on average, younger and more academically educated than the psychosomatic sample, and the average general population.In comparison, the average age of the population in Germany was 44.6 years (Statista, 2021), the proportion of academics was just under 20% (Statistisches Bundesamt Destatis [German Federal Statistical Office], 2021) and 50.7% were female (Bundeszentrale für politische Bildung [German Federal Agency for Civic Education], 2020).The psychosomatic sample was recruited from a single hospital and differs significantly in age and level of education from the control sample.Both samples are not representative.Accordingly, the results must be considered preliminarily.
The fact that there were hardly any differences in the wisdom-related attitudes can be interpreted as underlining the universality of wisdom-related attitudes.Further research is needed to examine whether the observed similarities and the difference can be replicated, in situations from other life domains.It could incorporate additional information on coping and psychopathology in psychosomatic patients.Given the questionnaire length of about 20 minutes, it may be considered to include items that test whether attention is maintained.Future samples should also be heterogenous in terms of age and level of education and include a broader range of the general population, and psychosomatic patients could be recruited from different hospitals.Moreover, it would be insightful to examine to what extent there might be differences in wise behavior despite similar wisdom attitudes in everyday life.
In conclusion, a convenience sample and patients with mental disorders agreed similarly with global wisdom-related principles, except change of perspective where the general population convenience sample agreed more strongly.As the scale asks for wisdom-related attitudes for problem solving, it may be the case that coping with concrete situations (i.e.wise behavior) may be different.This finding provides an initial basis for designing programs to promote wisdom as a complex capacity which are especially important in rehabilitation of mental disorders.Due to the mentioned limitations, the finding should be validated in further research.
patients are more likely to tick high and low agreement values.The global score of the cued 12-WD scale in the patient sample and the convenience sample are not significantly different (see Table

Figure
Figure Distribution of the frequency of dis/agreement of the participants per item of the 12-WD Scale in regard to the case vignette.Ps = psychosomatic patients, gp = general population sample.

Table 1 .
Wisdom dimensions of Linden et al. (2019) integrative wisdom model with descriptions and corresponding wisdom items of the 12-WD Scale (Table 1)

Wisdom dimensions according to Linden et al. (2019) Corresponding items for wisdom-related attitudes of the 12-WD Scale
6. Relativization of problems and aspirations:The ability to be humble and accept that one's own problems may not be as important in comparison with many problems in the world.6.If you are satisfied with what you have, you are better off than if you cry over what you do not have.

Table 2 . Sociodemographic data and check of manipulation effectiveness, number of included cases (n), means (M), standard deviations (SD), medians (Md), test statistics (t-and χ 2 -values) with degrees of freedom and effect sizes are reported
*= sign.with an error probability of alpha = .05.

Table 3 . 12-WD Scale scores: group comparisons via welch-tests, number of included cases (n), means (M) and standard deviations (SD), t-values (t) with degrees of freedom (df), p-values (p), p-values after Bonferroni-Correction for 12 tests (p-adjusted), and effect sizes (d) are reported Psychosomatic patients n = 191 to 199 General population convenience sample n = 204 to 208 Welch-test p two-tailed and Bonferroni-adjusted for 12 tests Wisdom dimensions
* = sign.after Bonferroni-Correction, error probability of alpha = .05.