In 1964, Gerald Caplan, an American psychologist and the father of modern crisis intervention, proposed the concept of psychological crisis: he stated that when a person encounters a sudden or major life dilemma, previous crisis- handling patterns and support systems may be ineffective for coping with the present situation. As a result, the person develops a temporary psychological disorder and imbalance (Caplan, 1961, 1964; Kanel, 2003). Psychological crisis may lead to dysfunction in cognition and emotion, and behavior such as trembling, extreme nervousness, fearfulness, and escape from reality. It may also result in posttraumatic stress disorder, which can manifest as lifelong recurring traumatic memories and nightmares and intense psychological distress. Caplan recognized these deleterious effects of psychological crisis, and therefore proposed the concept of psychological crisis intervention (Caplan, 1964; Flannery & Everly, 2000). These interventions include therapeutic confrontation of feelings, exploring emotions, and challenging the maladaptive coping style (Ruchlewska, Kamperman, van der Gaag, Wierdsma, & Mulder, 2016; Wang, Chen, Yang, Liu, & Miao, 2010). Findings in a considerable body of subsequent research by psychologists show that such interventions help people to reestablish their mental equilibrium and to acquire new skills for mental-crisis prevention (Everly, Flannery, & Mitchell, 2000; Li, Liu, & Che, 2009). It is particularly important that people at risk of psychological crisis receive treatment early (Başoğlu, Salcıoğlu, & Livanou, 2007; Everly, Hamilton, Tyiska, & Ellers, 2008; Ruchlewska et al., 2016).

In recent years, several major natural disasters, including earthquakes, typhoons, floods, and debris flows, have occurred in China. They include a 2008 earthquake centered at Wenchuan in Sichuan Province, a 2010 debris flow in Zhouqu, Gansu Province, and a 2014 earthquake in Ludian County of Sichuan Province. Each of these natural disasters was either difficult or impossible to predict. Such disasters cause substantial economic losses and seriously threaten human physical and mental health, including causing psychological crisis. In several studies the researchers have shown that to prevent survivors of disasters suffering from posttraumatic stress disorder, it is vital that the government and professionals in related disciplines provide the victims and their families with early and appropriate psychological crisis interventions (Everly et al., 2008; Hu, Yang, Liu, & Liu, 2010; Zhang et al., 2012) and inform people of effective methods for managing emergency events (Acierno et al., 2007; Everly & Mitchell, 2000; Jin, Zuo, Luo, & Zheng, 2005). Indeed, when Becker (2009) studied the effect of psychosocial care for women survivors of a 2004 tsunami disaster in India, she found that receiving care effectively improved the women’s mental health scores. She suggested that such care should be an integral component of disaster response in resource-poor countries in which the effects of psychosocial care have been ignored in favor of resources.

A key feature of an effective response system is that first aid and psychological intervention systems are established before the natural disaster occurs (Xu, 2009). This is exemplified by several studies relating to the Wenchuan earthquake that occurred on May 12, 2008. Li et al. (2009) found that after this earthquake there was little psychological crisis intervention by professionals either immediately after the earthquake or later. As expected, when Xu (2009) assessed the cognition and response of the public to the earthquake, he found that people’s skills in coping with an earthquake, their earthquake knowledge, their emotional capacity, and the transmission of information were all poor. However, the people’s self-help and mutual-rescue abilities had become stronger. He concluded that the accuracy and depth of the public’s earthquake knowledge must be strengthened. Despite their usefulness, it should be noted that these studies on psychological crisis intervention in natural disaster emergency management in China are relatively narrow in scope: the authors discuss psychological intervention after a natural disaster in qualitative terms and there is a lack of empirical investigation of related problems.

Because there is a lack of relevant education and information, people in the disaster-prone areas are often unfamiliar with psychological crisis intervention. Furthermore, individuals’ cognition about, and attitude toward, postdisaster psychological crisis intervention can differ, and these differences can substantially affect their reactions toward psychological aid. To determine the cognition and attitude of the general public in China toward postdisaster psychological crisis intervention, we developed a survey. This is the first such instrument that has been developed either in China or in any other country as far as we know.

Method

This study was approved by the Ethics Committee of Shandong Normal University. All respondents in this study provided their written informed consent to participate in the study.

Scale Design

To obtain the scale items, we first developed an interview outline on the basis of several studies (Everly et al., 2008; Hu et al., 2010; Xu, Zhou, & Yu, 2010; Zhang et al., 2012). We then conducted a qualitative study. We conducted one-on-one semistructured interviews with 20 individuals who were representative of four types of people (five per type): experts involved in postdisaster psychological relief, general psychology professionals, nonpsychology professionals, and Sichuan disaster witnesses, for the purpose of examining their cognition and attitudes toward postdisaster psychological crisis intervention. The interviews were conducted according to the method of theme analysis. The items for the pilot scale were then derived from this interview information and also from the literature (Everly et al., 2008; Hu et al., 2010; Lin et al., 2014; Zhang et al., 2012). We analyzed the literature by performing an Internet search of the PubMed^® database with the terms “psychological crisis intervention” and “posttraumatic stress disorder.” The pilot scale consists of 46 items: 20 in the Cognition scale and 26 in the Attitude scale. All items were rated using a 5-point Likert scale, where 1 = strongly disagree, 2 = partially disagree, 3 = uncertain, 4 = partially agree, and 5 = strongly agree.

Pilot Survey

We named the scale the Chinese People’s Cognition and Attitude Toward Postdisaster Psychological Crisis Intervention Scale. We conducted a pilot test of the scale with 200 college students and 100 community members in Jinan and Dongying, China. We received valid responses from 290 of these respondents (the other ten individuals did not respond to all the items). To assess sampling adequacy we used the Kaiser–Meyer–Olkin (KMO) measure, with a cutoff of 0.5, and Bartlett’s Test of Sphericity, with a cutoff of p < .001 (Fu et al., 2013). Through item analysis, exploratory factor analysis (EFA), and internal reliability analysis, we then deleted items that had low discrimination (extreme grouping method, t ≤ 3) and those with factor loadings of < 0.35. In the EFA, one factor was one subscale. There were initially more subscales than in the final measure, and because the reliability of a subscale was < 0.60, all of its items were deleted. The resulting measure comprised a Cognition scale (15 items) and an Attitude scale (17 items).

Implementation of the Scale

We recruited 1,195 participants to test the scale, comprising 556 residents of Shandong Province and 639 residents of Sichuan Province; 661 college students, 17 middle-school students, 66 farmers, 74 factory workers, 169 soldiers, 97 state employees, 49 business service employees, and 27 engineers. Some data on demographic variables were missing. We performed a confirmatory factor analysis (CFA) to validate the theoretical model. Construct validity and goodness of fit were evaluated using fit indices.

Statistical Analysis

We calculated the mean and standard deviation of descriptive statistics. The possible score for each item ranged from one to five, with higher scores indicating a more positive attitude. We analyzed each item to measure its quality. We used the KMO measure of sampling adequacy, with a cutoff of 0.5 and Bartlett’s Test of Sphericity, with a cutoff of p < .001) to ensure the appropriateness of the dataset for EFA. We performed EFA using the principal component analysis method to explore the underlying structure of the instrument. Cronbach’s alpha coefficient ≥ 0.6 indicates adequate internal reliability. We performed a CFA to assess the factor structure identified using EFA. The goodness of fit for the competing models was evaluated using the fit indices of goodness-of-fit index (GFI), comparative fit index (CFI), adjusted goodness-of-fit index (AGFI), root mean square error of approximation (RMSEA), and minimum discrepancy divided by its degrees of freedom (CMIN/df; Paiva et al., 2014). We used SPSS 17.0 to analyze the descriptive statistics, items, to perform EFA, and to assess internal reliability. Amos 17.0 was used to perform the CFA.

Results

Cognition Scale

We performed item analysis of 20 items in the Cognition scale. Items 3, 10, 11, 16, and 17 (extreme grouping method, t ≤ 3) were then deleted from the Cognition scale. Using principal component EFA with varimax rotation to analyze the retained items, three factors with eigenvalues > 1 were extracted, as shown in Table 1. The KMO measure was 0.793, indicating sampling adequacy. Satisfactory variability in the data was confirmed using Bartlett’s Test of Sphericity (p < .001), confirming the validity of the data available for EFA. Three factors, the 15 items of which had rotated factor loadings exceeding 0.4, explained 52.92% of the total variance. Communalities ranged from 0.326 to 0.732.

According to each factor meaning, the cognition subscales were interpreted as (a) theoretical cognition, (b) professional cognition, and (c) objective cognition. The total scale and three subscales exhibited Cronbach’s alpha values > .6 (.807, .813, .741, and .619, respectively), indicating adequate internal consistency.

We performed a CFA (N = 1,195) to confirm the factor structure identified in the EFA. For the CFA, the model fit indices were: GFI = 0.94, CFI = 0.92, AGFI = 0.91 and RMSEA = .07, and CMIN/df was 7.17. These results show that the theoretical model was well suited to the data (Wen & Hou, 2008).

Attitude Scale

We performed item analysis with 26 items. Items 4, 6, and 7 (extreme grouping method, t ≤ 3) were deleted. Using principal component EFA with varimax rotation to analyze the retained items, six factors with eigenvalues > 1 were extracted. Item 22 was a one-item factor and was dropped from subsequent analysis. The fourth and fifth factors exhibited poor internal consistency (≤ 0.6) and were removed. The KMO measure was 0.842, indicating sampling adequacy. Satisfactory variability was confirmed using Bartlett’s Test of Sphericity (p < .001). There were three factors containing 17 items in all, for which the rotated factor loadings exceeded 0.4, and which explained 53.64% of the total variance. Communalities ranged from 0.496 to 0.801 (see Table 2).

The factors in the Attitude subscales were interpreted as (a) obligatory attitude, (a) constructive attitude, and (c) positive attitude, which all exhibited Cronbach’s alpha values > .7 (.806, .790, and .766, respectively), The Cronbach’s alpha coefficient for the total scale was .845, indicating adequate internal consistency. We performed a CFA (N = 1,195) to confirm the factor structure identified in EFA. For the CFA, the model fit indices were: GFI = 0.95, CFI = 0.92, AGFI = 0.92, RMSEA = .06, and CMIN/df = 5.78. Thus, the theoretical model was well suited to the data and the items had satisfactory construct validity (Wen & Hou, 2008).

Discussion

Our 46-item pilot scale was developed on the basis of our literature analysis and interviews with Chinese citizens (Everly & Mitchell, 2000; Li et al., 2009; Başoğlu et al., 2007). The results showed that the scale has adequate psychometric properties, and is currently the best option for the purpose of research on attitude toward, and cognition about, postdisaster psychological crisis intervention.

Characteristics of the Scale

We found that the measure has acceptable reliability and validity. The internal consistency reliability was considerably higher than the standard (Paiva et al., 2014). The fit indices demonstrated that the theoretical model was well suited to the data and the items had satisfactory construct validity (Wen & Hou, 2008). The development of this measure involved a number of features that we believe are likely to have substantially increased its validity. First, to account for regional differences, we recruited the participants from cities that have experienced major natural disasters, such as Beichuan and Mianyang in Sichuan Province, China. These were crucial survey locations for improving the reliability and validity of the measure. Second, before the development of the scale items, we collected qualitative information by obtaining respondents’ perspectives on existing psychological crisis interventions, and by combining the interview information with information from relevant literature for the design of the cognition and attitude items (Başoğlu et al, 2007; Everly & Mitchell, 2000; Liao, Li, Song, & Huang, 2009; Zhang, Liu, & Tang, 2011). Third, most aspects of psychological crisis intervention were considered when developing the survey items. In the Cognition scale we addressed the concepts of implementation of, precautions for, concerns addressed by, professional skills for, and cultural differences in psychological crisis intervention. In the Attitude scale we evaluated the status, necessity, and improvement of psychological crisis intervention (Becker, 2009; Flannery & Everly, 2000; Jin et al., 2005).

Contribution of the Scale

An advantage of the scale is that it is brief, consisting of just 32 items. In previous studies on Chinese disaster psychological crisis intervention the primary focus has been on qualitative descriptions of the mechanisms of psychological crisis intervention and current psychological rescue procedures (Hu et al., 2010; Liu, Wu, & Wang, 2011; Zhang et al., 2011). Thus, by using the scale it will be possible for the first time to make a quantitative assessment of people’s cognition and attitude toward psychological crisis intervention in China. This will provide new theoretical and practical perspectives on psychological crisis intervention.

References

Acierno, R., Ruggiero, K. J., Galea, S., Resnick, H. S., Koenen, K., Roitzsch, J., … Kilpatrick, D. G. (2007). Psychological sequelae resulting from the 2004 Florida hurricanes: Implications for postdisaster intervention. American Journal of Public Health, 97, S103–S108. http://doi.org/ctc6wr

Başoğlu, M., Salcıoğlu, E., & Livanou, M. (2007). A randomized controlled study of single-session behavioural treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator. Psychological Medicine, 37, 203–213. http://doi.org/d5h5nw

Becker, S. M. (2009). Psychosocial care for women survivors of the tsunami disaster in India. American Journal of Public Health, 99, 654–658. http://doi.org/d88ts5

Caplan, G. (1961). An approach to community mental health. New York, NY: Tavistock. Caplan, G. (1964). Principles of preventive psychiatry. Oxford, UK: Basic Books.

Everly, G. S., Jr., Flannery, R. B., Jr., & Mitchell, J. T. (2000). Critical incident stress management (Cism): A review of the literature. Aggression and Violent Behavior, 5, 23–40. http://doi.org/dsdhv5

Everly, G. S., Jr., Hamilton, S. E., Tyiska, C. G., & Ellers, K. (2008). Mental health response to disaster: Consensus recommendations: Early Psychological Intervention Subcommittee (EPI), National Volunteer Organizations Active in Disaster (NVOAD). Aggression and Violent Behavior, 13, 407–412. http://doi.org/cq6v5m

Everly, G. S., Jr., & Mitchell, J. T. (2000). The debriefing “controversy” and crisis intervention: A review of lexical and substantive issues. International Journal of Emergency Mental Health, 2, 211–225.

Flannery, R. B., Jr., & Everly, G. S., Jr. (2000). Crisis intervention: A review. International Journal of Emergency Mental Health, 2, 119–125.

Fu, S. N., Chin, W. Y., Wong, C. K. H., Yeung, V. T. F., Yiu, M. P., Tsui, H. Y., & Chan, K. H. (2013). Development and validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for primary care patients with Type 2 diabetes. PLoS ONE, 8, e78933. http://doi.org/bqnq

Hu, X., Yang, Y., Liu, L., & Liu, X. (2010). Early psychological intervention following a natural disaster: A study with a victim buried under rubble for 124 hours. Social Behavior and Personality: An international journal, 38, 71–74. http://doi.org/dvkwrz

Jin, N. N., Zuo, Y. R., Luo, M., & Zheng, P. (2005). Psychological crisis intervention for calamity [In Chinese]. Journal of Nursing Administration, 5, 35–38.

Kanel, K. (2003). A guide to crisis intervention. Pacific Grove, CA: Brooks Cole.

Li, X., Liu, Y. F., & Che, X. N. (2009). The psychological crisis intervention analysis of existing problems and countermeasures after the Wenchuan earthquake [In Chinese]. Modern Clinical Nursing, 8, 67–69.

Liao, X. M., Li, X. X., Song, Y. B., & Huang, B. (2009). Posttraumatic stress disorder (PTSD) and psychological relief after the Wenchuan earthquake [In Chinese]. China Modern Doctor, 47, 59–61.

Lin, Y.-H., Chang, L.-R., Lee, Y.-H., Tseng, H.-W., Kuo, T. B. J., & Chen, S.-H. (2014). Development and validation of the Smartphone Addiction Inventory (SPAI). PLoS ONE, 9, e98312. http://doi.org/bqnr

Liu, Z. K., Wu, K. K., & Wang, L. (2011). Psychological and behavioral research after a major disaster in China [In Chinese]. Advances in Psychological Science, 19, 1091–1098.

Paiva, P. C. P., de Paiva, H. N., de Oliveira-Filho, P. M., Lamounier, J. A., Ferreira e Ferreira, E., Ferreira, R. C., … Zarzar, P. M. (2014). Development and validation of a social capital questionnaire for adolescent students (SCQ-AS). PLoS ONE, 9, e103785. http://doi.org/bqns

Ruchlewska, A., Kamperman, A. M., van der Gaag, M., Wierdsma, A. I., & Mulder, N. C. L. (2016). Working alliance in patients with severe mental illness who need a crisis intervention plan. Community Mental Health Journal, 52, 102–108. http://doi.org/bqnt

Xu, C., Zhou, Q., & Yu, Y. (2010). Research on the public perception and responses to the disaster of the M_S8.0 Wenchuan earthquake-stricken area: A case study in Nanzheng in Southern Shanxi. Journal of Seismological Research, 33, 336–343.

Xu, F. (2009). The psychological damage emergency measures of the earthquake [In Chinese]. Journal of Clinical Emergency Treatment, 10, 127–128.

Wang, W., Chen, D., Yang, Y., Liu, X., & Miao, D. (2010). A study of psychological crisis intervention with family members of patients who died after emergency admission to hospital. Social Behavior and Personality: An international journal, 38, 469–478. http://doi.org/ds385t

Wen, Z. L., & Hou, J. T. (2008). Cut off values for testing: How great the difference between the true and the false makes them distinguishable? [In Chinese]. Acta Psychologica Sinica, 40, 119–124.

Zhang, J., Liu, W., & Tang, P. (2011). Postdisaster psychological crisis intervention status and optimization system [In Chinese]. Science of Social Psychology, 26, 583–587.

Zhang, L., Liu, X., Li, Y., Liu, Y., Liu, Z., Lin, J., … Liang, W. (2012). Emergency medical rescue efforts after a major earthquake: Lessons from the 2008 Wenchuan earthquake. The Lancet, 379, 853–861. http://doi.org/f2fgs6

Acierno, R., Ruggiero, K. J., Galea, S., Resnick, H. S., Koenen, K., Roitzsch, J., … Kilpatrick, D. G. (2007). Psychological sequelae resulting from the 2004 Florida hurricanes: Implications for postdisaster intervention. American Journal of Public Health, 97, S103–S108. http://doi.org/ctc6wr

Başoğlu, M., Salcıoğlu, E., & Livanou, M. (2007). A randomized controlled study of single-session behavioural treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator. Psychological Medicine, 37, 203–213. http://doi.org/d5h5nw

Becker, S. M. (2009). Psychosocial care for women survivors of the tsunami disaster in India. American Journal of Public Health, 99, 654–658. http://doi.org/d88ts5

Caplan, G. (1961). An approach to community mental health. New York, NY: Tavistock. Caplan, G. (1964). Principles of preventive psychiatry. Oxford, UK: Basic Books.

Everly, G. S., Jr., Flannery, R. B., Jr., & Mitchell, J. T. (2000). Critical incident stress management (Cism): A review of the literature. Aggression and Violent Behavior, 5, 23–40. http://doi.org/dsdhv5

Everly, G. S., Jr., Hamilton, S. E., Tyiska, C. G., & Ellers, K. (2008). Mental health response to disaster: Consensus recommendations: Early Psychological Intervention Subcommittee (EPI), National Volunteer Organizations Active in Disaster (NVOAD). Aggression and Violent Behavior, 13, 407–412. http://doi.org/cq6v5m

Everly, G. S., Jr., & Mitchell, J. T. (2000). The debriefing “controversy” and crisis intervention: A review of lexical and substantive issues. International Journal of Emergency Mental Health, 2, 211–225.

Flannery, R. B., Jr., & Everly, G. S., Jr. (2000). Crisis intervention: A review. International Journal of Emergency Mental Health, 2, 119–125.

Fu, S. N., Chin, W. Y., Wong, C. K. H., Yeung, V. T. F., Yiu, M. P., Tsui, H. Y., & Chan, K. H. (2013). Development and validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for primary care patients with Type 2 diabetes. PLoS ONE, 8, e78933. http://doi.org/bqnq

Hu, X., Yang, Y., Liu, L., & Liu, X. (2010). Early psychological intervention following a natural disaster: A study with a victim buried under rubble for 124 hours. Social Behavior and Personality: An international journal, 38, 71–74. http://doi.org/dvkwrz

Jin, N. N., Zuo, Y. R., Luo, M., & Zheng, P. (2005). Psychological crisis intervention for calamity [In Chinese]. Journal of Nursing Administration, 5, 35–38.

Kanel, K. (2003). A guide to crisis intervention. Pacific Grove, CA: Brooks Cole.

Li, X., Liu, Y. F., & Che, X. N. (2009). The psychological crisis intervention analysis of existing problems and countermeasures after the Wenchuan earthquake [In Chinese]. Modern Clinical Nursing, 8, 67–69.

Liao, X. M., Li, X. X., Song, Y. B., & Huang, B. (2009). Posttraumatic stress disorder (PTSD) and psychological relief after the Wenchuan earthquake [In Chinese]. China Modern Doctor, 47, 59–61.

Lin, Y.-H., Chang, L.-R., Lee, Y.-H., Tseng, H.-W., Kuo, T. B. J., & Chen, S.-H. (2014). Development and validation of the Smartphone Addiction Inventory (SPAI). PLoS ONE, 9, e98312. http://doi.org/bqnr

Liu, Z. K., Wu, K. K., & Wang, L. (2011). Psychological and behavioral research after a major disaster in China [In Chinese]. Advances in Psychological Science, 19, 1091–1098.

Paiva, P. C. P., de Paiva, H. N., de Oliveira-Filho, P. M., Lamounier, J. A., Ferreira e Ferreira, E., Ferreira, R. C., … Zarzar, P. M. (2014). Development and validation of a social capital questionnaire for adolescent students (SCQ-AS). PLoS ONE, 9, e103785. http://doi.org/bqns

Ruchlewska, A., Kamperman, A. M., van der Gaag, M., Wierdsma, A. I., & Mulder, N. C. L. (2016). Working alliance in patients with severe mental illness who need a crisis intervention plan. Community Mental Health Journal, 52, 102–108. http://doi.org/bqnt

Xu, C., Zhou, Q., & Yu, Y. (2010). Research on the public perception and responses to the disaster of the M_S8.0 Wenchuan earthquake-stricken area: A case study in Nanzheng in Southern Shanxi. Journal of Seismological Research, 33, 336–343.

Xu, F. (2009). The psychological damage emergency measures of the earthquake [In Chinese]. Journal of Clinical Emergency Treatment, 10, 127–128.

Wang, W., Chen, D., Yang, Y., Liu, X., & Miao, D. (2010). A study of psychological crisis intervention with family members of patients who died after emergency admission to hospital. Social Behavior and Personality: An international journal, 38, 469–478. http://doi.org/ds385t

Wen, Z. L., & Hou, J. T. (2008). Cut off values for testing: How great the difference between the true and the false makes them distinguishable? [In Chinese]. Acta Psychologica Sinica, 40, 119–124.

Zhang, J., Liu, W., & Tang, P. (2011). Postdisaster psychological crisis intervention status and optimization system [In Chinese]. Science of Social Psychology, 26, 583–587.

Zhang, L., Liu, X., Li, Y., Liu, Y., Liu, Z., Lin, J., … Liang, W. (2012). Emergency medical rescue efforts after a major earthquake: Lessons from the 2008 Wenchuan earthquake. The Lancet, 379, 853–861. http://doi.org/f2fgs6

Lihui Zhang or Fang Wang, College of Psychology, Shandong Normal University, Jinan 250358, People’s Republic of China. Email: [email protected] (Lihui Zhang) or [email protected] (Fang Wang).