Toward a Multidimensional Perspective on Wisdom and Health—An Analogy With Depression Intervention and Neurobiological Research

Toward a Multidimensional Perspective on Wisdom and Health—An Analogy With Depression Intervention and Neurobiological Research. Charles F. Reynolds III, Dan G. Blazer. JAMA Psychiatry, May 13, 2020. doi:10.1001/jamapsychiatry.2020.0642

The article by Lee and colleagues1 in this issue of JAMA Psychiatry explores 3 domains or components of wisdom: prosocial relations, emotional regulation, and spirituality. The authors’ basic hypothesis is that interventions may enhance these domains of wisdom (although they found no eligible studies that addressed wisdom as an inclusive or unitary construct). Interventions ranged widely, from mindfulness to emotional intelligence training. The literature contains many approaches to measuring wisdom as reviewed by the authors.1 One helpful distinction is between theoretical wisdom (understanding the deep nature of reality and humans’ place in it) and practical wisdom (also known as phronesis: making good decisions or doing the right thing, at the right time, for the right reasons), as delineated by Jeste and colleagues in a previous article.2 Both can be measured, yet practical wisdom is perhaps more easily captured via a questionnaire than theoretical wisdom. In the current study, the authors1 combine domains characterized as practical (prosocial behavior and emotional regulation) and theoretical (spirituality). They do not include other domains, such as decisiveness and the tolerance of and ability to deal with uncertainty, because of a dearth of intervention studies in these domains.3 Therefore, the reader should focus on the 3 domains examined as components of a much larger and more complex construct of wisdom, a construct that may be beyond the boundaries of empirical exploration or at least pose considerable challenges thereto.

Regardless, the 3 components measured have been studied frequently in the extant literature, and scales have been developed that provide a foundation for intervention trials. In other words, the data from these intervention trials are fair game for this meta-analysis. However, the serious reader must take advantage of the Supplement to gain a clear understanding of the range of studies included, the scales for measuring outcome, and the approaches to intervention.1 In this spirit, we offer the following perspective and address the importance of defining wisdom as a unitary construct.

In their meta-analysis of 57 published studies, the authors1 found that interventions can enhance prosocial behaviors, emotional regulation, and spirituality. Effect sizes did not vary by component, but for prosocial behaviors and spirituality, larger effect sizes were associated with older mean ages of participants. Estimates of benefits for prosocial behavior and spirituality survived correction for publication bias, but emotional regulation did not. Forty-seven percent of studies reported a significant improvement in one component or another, while the remaining studies did not. Only 40% of studies included an active control group, while many used a waiting list or another inactive control group. The authors suggest that the modern behavioral epidemics of social isolation, loneliness, suicide, and opioid abuse point to a growing need for wisdom-enhancing interventions that promote individual and societal well-being—a behavioral vaccine, as it were.

Part of the heuristic value of the study1 is that it raises important questions. Some pertain to the construct and predictive validity of the wisdom domains analyzed, others to concurrent validity, and still others to scalability and population outcomes. Regarding construct and predictive validity, the authors acknowledge a need to assess well-being and other health-associated measures by objective means (in addition to but not in place of self-reports), such as reports by close associates and hence to determine if enhancements in components of wisdom generalize to everyday life, over longer follow-up periods, to promote individual and population well-being. With respect to concurrent validity, neurobiological assessments with appropriate comparator conditions could examine if there is specific neurocircuitry activation for specific components of wisdom. Using interventional platforms, one could investigate whether there are brain-based mechanisms that mediate improvement in wisdom and/or in its specific components. If so, one could further investigate whether targeted neurostimulation techniques selectively activate neurocircuits associated with components of wisdom, facilitating adaptation as a result of specific, learning-based interventions. This approach bears analogy to emerging research testing the ability of behavioral and neurocognitive interventions to activate specific neurocircuits that in turn relieve depressive symptoms.4 Ultimately, one would like to know if interventions can be simplified, sustained, and scaled up—by analogy with depression, for example, through the use of lay counselors or digital platforms. As with depression, it may be that different interventions better fit the needs and values of individuals depending on sociodemographic, developmental, cultural, and clinical characteristics.

Now to revisit the basic question as to whether wisdom is a unitary construct with multiple components or dimensions: Lee and colleagues1 believe this to be the case and analogize wisdom to a syndrome, that is, a condition characterized by several medical signs and symptoms that more or less consistently occur together and are associated with a common entity (ie, a latent construct). The authors’ San Diego Wisdom Scale (SD-WISE) scale measures individual components, such as prosocial behaviors (empathy and compassion), emotional regulation, and self-reflection.3 In different samples, they have found that subscales of SD-WISE measuring these components correlate with the total composite SD-WISE score, and the total score correlates in cross-sectional studies with measures of overall well-being.1 In their search for the neurobiological correlates of individual components of wisdom (or their opposite, such as with antisocial personality or impulsivity, as in the case of Phineas Gage, or in cases of frontotemporal dementia), the authors have found evidence implicating prefrontal cortex and limbic striatum.5 This is certainly plausible, if relatively nonspecific.

The study1 thus prompts us to ask also which components of wisdom are most important for health and well-being. It is plausible that a combination of wisdom components is more likely to be associated with measures of health and well-being than any individual component. Which specific components should be considered in mechanistic studies to optimize the development of interventions? Our view is that adopting a multidimensional approach to ascertain associations between wisdom and health or well-being may provide greater, more nuanced information about risk for health than the considerations of individual components alone. We suggest another analogy with depression intervention research, where a combination of interventions is often needed to achieve and sustain optimal outcomes.6 Again, it may be that, as with depression treatment or prevention, one size does not fit all. Different interventions or combinations of interventions may better fit the needs of a person depending on sociodemographic, cultural, developmental, and clinical characteristics. By this logic, no single construct (such as prosocial behavior) should automatically be conflated with wisdom as a whole. Higher levels of spirituality, for example, may rate lower in interventions to promote practical wisdom. To be effective against the current epidemics of loneliness, social isolation, opiate addiction, and suicide, a multicomponent, so-called behavioral vaccine, as well as changes in the health care delivery system (to be more collaborative and integrated) may been needed.7

We concur with the authors1 that wisdom is a complex human characteristic with a number of specific components, such as those they have delineated using Delphi methods, resulting in a mixture of pragmatic and theoretical components. More than 1 component may be needed to optimize health effects and elucidate mechanisms of action and underlying neurobiology.

As the authors1 in their wisdom readily acknowledge, the science of wisdom is still at an early stage. Like them, we anticipate that more precise answers will emerge as empirical research, grounded in theory, deepens and widens.