Soc Psychiatry Psychiatr Epidemiol (2012) 47:1111–1119

DOI 10.1007/s00127-011-0416-2

ORIGINAL PAPER

A new psychological intervention: ‘‘512 Psychological Intervention

Model’’ used for military rescuers in Wenchuan Earthquake
in China
Shengjun Wu • Xia Zhu • Yinling Zhang •

Jie Liang • Xufeng Liu • Yebing Yang •

Hai Yang • Danmin Miao

Received: 10 January 2010 / Accepted: 9 July 2011 / Published online: 26 July 2011
Ó Springer-Verlag 2011

Abstract Conclusion ‘‘512 PIM’’ was an effective psychological

Objective We sought to compare the efficacy of the ‘‘512 intervention for military rescuers in reducing symptoms of
Psychological Intervention Model’’ (that is, ‘‘512 PIM’’, a PTSD, anxiety and depression after a crisis.
new psychological intervention) with debriefing on symp-
toms of post-traumatic stress disorder (PTSD), anxiety and Keywords Critical incident stress debriefing

depression of Chinese military rescuers in relation to a Post-traumatic stress disorder
Military personnel

control group that had no intervention. Rescuer
Method We conducted a randomized controlled trial with
2,368 military rescuers 1 month after this event and then at
follow-up 1, 2 and 4 months later to evaluate changes in Introduction
symptoms of PTSD, anxiety and depression based on
DSM-IV criteria, respectively. At 14:28 Beijing time (06:28 GMT), 12 May 2008, an
Results Baseline analysis suggested no significant dif- earthquake measuring 8.0 on the Richter scale struck
ferences between the study groups. Severity of PTSD, Wenchuan County, Sichuan Province, China. Up to 4
anxiety and depression decreased over time in all three August 2008, the total death toll in this disaster had
groups, with significant differences between the groups in reached 69,207, 374,468 were injured and 18,194 were lost
symptoms of PTSD (P \ 0.01). Compared with the [1]. There can be little doubt that such extreme disaster can
debriefing and control group, significant lower scores of intensify the effects of stress on individuals as specific
PTSD and positive efficacy in improving symptoms of re- types of stressor and engender a large-scale psychological
experiencing, avoidance and hyperarousal were found in morbidity. It has been realized that the notion of ‘‘victim’’
the ‘‘512 PIM’’ group. not only includes disaster survivals, but also is applied to
the disaster workers, rescue, medical or support staff
associated with disaster medicine, especially those
S. Wu, X. Zhu, Y. Zhang and J. Liang are the co-first authors. involved with the carrying, burying and identification of
human remains [2, 3]. All of them are at risk for acute and
S. Wu
X. Zhu
X. Liu
Y. Yang
H. Yang
D. Miao (&)
Department of Psychology, School of Aerospace Medicine, chronic post-traumatic stress disorder (PTSD). However,
Fourth Military Medical University, 169 West Changle Road, the incidence of mental disorder or PTSD after natural
Xi’an 710032, People’s Republic of China disaster varied [4–8]. The results of two empirical inves-
e-mail: [email protected]
tigations of emergency services personnel who participated
Y. Zhang in an earthquake rescue effort suggested that about 9% of
Department of Nursing Management, Fourth Military Medical the workers showed psychological symptoms at the same
University, Xi’an, People’s Republic of China level as an outpatient population diagnosed as having
PTSD [9, 10]. A study of body handlers found that 11%
J. Liang
XiJing Hospital of Digestive Diseases, Fourth Military Medical had symptoms of PTSD 3 months after the disaster work
University, Xi’an, People’s Republic of China [11]. The medical utilization and societal costs of PTSD

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are very high and the current treatment strategies for PTSD (3) Thought (participants talk about thoughts surrounding
are still controversial [12–15]. Therefore, the development the trauma, introducing some of the personal mean-
of successful prevention strategies may be of great ings that the event had for them)
importance in minimizing the risk of PTSD and in treating (4) Reaction (participants are encouraged to speak openly
anxiety and the affective conditions related to exposure to and freely about their emotions, focusing on extreme
traumatic events. fear or feelings that were unexpected or hard to
The close association of mental distress including PTSD accept)
and depression with natural disaster poses a challenge to (5) Symptoms (participants describe stress symptoms that
mental health service [6]. The attempts to develop suc- they experienced during or just after the event and
cessful preventive strategies during the past decades have currently)
led to greater interest in the efficacy of strategies such as (6) Teaching stage (participants are given information
debriefing. Psychological debriefing (PD) is a generic term about stress symptoms and post-traumatic stress
describing a variety of brief crisis intervention models with symptoms, and specific advice about ways of coping
the major aim of mitigating trauma-related psychopathol- with the trauma or the stress symptoms).
ogies, particularly that of PTSD [16, 17]. Within the genre (7) Re-entry (summary of all that has occurred and to
of PD models, the oldest and most enduring is Mitchell’s raise further issues if necessary).
critical incident stress debriefing (CISD) [18, 19], which
The greatest difference between ‘‘512 PIM’’ and
was designed to prevent or reduce the adverse psycholog-
debriefing is the cohesion training section. ‘‘512 PIM’’ was
ical consequences of traumatic events based in the group
first developed for the Wenchuan Earthquake field
work run with high-risk occupational groups [20]. Psy-
according to the practical principles and the facts of Chi-
chological debriefing has been used in various kinds of
nese military organization. ‘‘5’’ means that the model
trauma events with emergency workers, such as paramed-
includes five stages, ‘‘1’’ means that one interviewer per-
ics, police officers and firefighters [18], as well as with
formed the intervention, and ‘‘2’’ means that the duration
disaster workers, hostages, prisoners of war and soldiers
of intervention is approximately 2 h. The five stages
[21, 22]. Although debriefing has been widely used after
included in ‘‘512 PIM’’ were as follows.
traumatic events [23, 24], few randomized controlled trials
of debriefing have been reported. The lack of adequate (1) Introduction (explaining goals of the session and
control groups makes it difficult to judge the efficacy of developing a friendly and trustful atmosphere)
this type of intervention. Several nonrandomized but con- (2) Facts and thoughts (participants describe the facts of
trolled studies have concluded that various forms of the trauma as they see them, and then recall their first
debriefing had positive effects [25–27], but these are thoughts during the trauma)
countered by similarly designed studies that found neutral (3) Reaction and symptoms (participants reconstruct the
[28, 29] or negative [30–34] results. Another limitation is trauma and accompanying emotions in detail, and
that few trials on critical incident stress debriefing, as it then describe stress symptoms they experienced
was originally conceived by Mitchell and colleagues (i.e., during and just after the event, and currently)
as a group intervention for teams of emergency workers, (4) Stress management (tips and advice about ways of
military personnel or others who are used to working coping with the trauma or the stress symptoms)
together), or critical incident stress management met the (5) Training of cohesion (e.g., participants were
methodological inclusion criteria. As a consequence, we instructed to play games which need team coopera-
have a lack of evidence for practice in these situations. tion, participants were asked to tell in private or shout
Although many studies have explored the association in public the words they most want to say.).
between PTSD and military personnel, the prevalence of
The stages (1), (2), (3) and (4) referred to the principle
PTSD in Chinese troops has been largely missing [35–38].
of the CISD protocol originally designed by Mitchell [18,
In the present study, a new psychological intervention,
39]. Stage (5) focused on cohesion training.
‘‘512 Psychological Intervention Model’’ (512 PIM), was
Cohesion is defined as the ability of a unit to remain
developed based on the standard debriefing and unique
committed toward the same goal, utilizing the unit mem-
characteristics of Chinese military rescuers.
bers’ shared standards and support for each other. Cohesion
The debriefings were based on the CISD protocol and
in military groups is one of the vital factors for combat
consisted of seven stages:
effectiveness. Many studies have stressed the relationship
(1) Introduction (the outline of the CISD is explained) between cohesion and stress, PTSD and other mental health
(2) Facts (participants describe the facts of the trauma in military personnel [40–44]. Unit cohesion has been
they saw) shown to be the single most important sustaining and

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motivating force among troops, and psychiatric injuries are conducted based on the unit of company at that time. That
more prevalent in personnel who do not form close rela- is, each company was assigned to one group as a whole.
tionships within their unit [45]. Feeling isolated and lack of Randomization was carried out basically in the ratio of
unit cohesion is likely to have detrimental effects upon 1:1:1 among the three groups. Participants were not
psychological health and may also contribute to poorer masked to their intervention, but they were asked not to
relationships with the chain of command. It is suggested reveal this information to the research assistants who
that cohesion might have potential protective effects in conducted the assessments, as these assistants were masked
preventing stress [46–48]. Active treatment has been con- to the allocated interventions. Participants were invited to
firmed to be statistically and clinically superior to no- four assessments: a pre-intervention assessment (baseline)
treatment group on PTSD symptoms [49]. The efficacy of and three follow-up assessments, at 1, 2 and 4 months after
group psychological intervention has never been system- the intervention. Written informed consent was obtained
atically studied on Chinese military rescuers in crisis from all participants after full description of the study
before. protocol. The study protocol was approved by the Medical
In the present randomized controlled trial, two active Ethics Committee of the Fourth Military Medical Univer-
treatments were administered to Chinese military rescu- sity after we put forward our study plan after the
ers. The objective of this study was to evaluate the earthquake.
efficacy of 512 PIM and compare it with standard
debriefing in preventing symptoms of PTSD, anxiety and Study procedure
depression in relation to a control group that had no
intervention. Approximately, 1 month after experiencing the traumatic
incident (median 25 days, range 20–33), participants
received either the ‘‘512 PIM’’, debriefing or no debrief-
Methods ing (control). We based the nearly 1 month interval
between trauma and psychological intervention on medi-
Study population cal ethical considerations, as it was then assumed that an
early timing of the intervention contributed to harmful
The earliest time Chinese soldiers entered into the Beich- effect [25, 52].
uan County, the severest damaged region in this earth- The ‘‘512 PIM’’ was performed by ten clinical psy-
quake, was on 13 May 2008. All of them undertook the chologists and the general number of participants in each
most dangerous and heaviest rescue work such as searching intervention was ten (median 10, range 8–13).
for survivors, handling injured or bodies and so on. After The debriefings lasted about 1 h. Ten clinical psy-
nearly 2 weeks, their main tasks were to help victims to chologists performed ‘‘512 PIM’’ and eight clinical psy-
pitch tents, conduct epidemic prevention, transferring chologists performed the debriefing. All 18 interviewers
patients and other general work. Recruitment started from 5 were come from Chinese Military Psychological Inter-
to 25 June 2008. Collection of follow-up data was com- vention Group (CMPIG), which was set up years ago and
pleted before December 2008. based on the Department of Psychology, Fourth Military
Inclusion criteria were: (a) fulfilling the criterion A1 of Medical University. The primary task of such an organi-
the diagnosis of PTSD in the DSM–IV (American Psy- zation is to conduct psychological intervention for critical
chiatric Association, 2001); (b) age 18 years or older; events of the Chinese military group, and this group has
(c) proficiency in Chinese. Exclusion criteria were: also conducted many interventions for critical events of
(a) suicidal ideation; (b) already having received psycho- the Chinese Army successfully since it was set up. Each
logical intervention since the trauma; (c) fulfilling diag- year, all of the members in this group were summoned to
nostic criteria for a psychotic disorder, organic disorder, get a systematic training for 2–3 months. Therefore, when
substance abuse or chronic PTSD according to symptom the Wenchuan Earthquake occurred, the members in the
criteria used in DSM-IV [50], which is used in many group could be congregated in a very quick time, and all
studies worldwide [6, 37, 51]. of the members conducting the interview in our study
All participants were from 13 companies and each were trained 2 days by the authors in administering the
company had nearly 100 people. All of these participants intervention protocols. Then all of them were sent to
were randomly assigned to one of three groups: ‘‘512 Wenchuan as soon as possible. Protocol adherence was
PIM’’, debriefing or no intervention (control). To avoid the insured by supervision and was measured by a rating
intervention experience exchange among participants in system specifically designed for this study. In this rating
one unit, the randomization was based on the unit of system, we measured the occurrence of both desired and
company because the earthquake rescue work was undesired components in audio-taped sessions of both

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types of intervention, following the recommendations of Statistical analysis

Waltz et al. [53]. The rating system consisted of three
parts, i.e., general, proscribed and forbidden behaviors, Chi-square tests and independent t tests were used to
which were combined in an overall protocol adherence examine whether participants lost to follow-up differed
score. Raters were three clinical psychologists. A random from other participants. For the main outcomes, we used
sample of 43 briefings was independently scored by two repeated-measurement analyses to study the changes over
raters. Inter-rater reliability was good, with an intra-class time in SI-PTSD and HADS scores between the three
correlation coefficient of 0.81 (95% CI 0.54–0.86). groups. The mean score for each outcome was modeled as
According to the raters, 83% (range 62–100%) of the a function of the intervention given (three levels), time
desired protocol components occurred. since intervention (as a categorical variable with three
levels) and the pre-intervention measurement (continuous).
Measurements The interaction term between time and intervention was
added to the model to test whether trends over time differed
Severity of symptoms of PTSD, anxiety and depression for the three intervention groups. To determine whether
was assessed at baseline (pre-intervention assessment) and symptoms of acute psychological distress influence the
at all three intervention follow-up assessments (1, 2 and effect of the intervention, we added the following inter-
4 months after the intervention). Other 14 clinical psy- action terms to the model: re-experiencing, avoidance and
chologists conducted the assessments and they were not the hyperarousal at baseline (all into high and low).
ones who conducted the psychological interventions. All A two-tailed level of P = 0.05 was used to determine
assessments of one participant were performed by the same statistical significance. For all analyses, the Statistical
person. Package for the Social Sciences, version 11.0.1 for Win-
Symptoms were measured with the Chinese version of dows was used.
Structured Interview for PTSD (SI-PTSD) [54, 55], which
is a 17-item clinical interview that records the presence and
severity of the 17 DSM–IV diagnostic criteria for PTSD. Results
Each item is rated on a 0–4 scale; scores of 3 or higher
indicate the presence of that particular symptom. In Of the 1,341 respondents who were assessed for eligibility,
accordance with DSM–IV, interview items are clustered 1,267 were randomized (417 to ‘‘512 PIM’’ group, 421 to
into the three PTSD symptom groups: re-experiencing (5 debriefing group and 429 to control group). Another 74
symptoms), avoidance (7 symptoms) and hyperarousal (5 respondents were excluded, because they had reached the
symptoms). In the presence of at least one re-experiencing criteria for one of the DSM–IV disorders specified in
symptom, at least three avoidance symptoms and at least the exclusion criteria (n = 25, 1.9%), had not mastered the
two hyperarousal symptoms during 1 month, PTSD Chinese language (n = 7, 0.5%), had already received
according to DSM–IV may be diagnosed. The sum of the psychological intervention (n = 21, 1.6%) or refused
item scores results in a maximum continuous PTSD score (n = 5, 0.3%). Of the five soldiers who refused, three were
of 68. Higher scores indicate the presence of more symp- sick and were not capable of completing the study, and the
toms. In this study, we also used the baseline SI-PTSD other two refused for no reason. The numbers of partici-
scores to measure acute psychological distress. For that pants who were lost to the 1 month (n = 40, 3.2%),
purpose, re-experiencing, avoidance and hyperarousal 2 months (n = 83, 6.6%) and 4 months (n = 137, 10.8%)
scores were dichotomized into high and low using the follow-up were equally distributed across the study groups.
cutoffs for DSM–IV diagnosis. SI-PTSD scores correlate Finally, 21 participants (1.7%; 11 in ‘‘512 PIM’’ and 10 in
highly with clinicians’ ratings and with later other similar debriefing) did not receive the intervention (Fig. 1).
self-report PTSD instruments [54, 55]. For the Chinese Baseline characteristics are presented in Table 1. Chi-
version of the SI-PTSD, adequate internal consistency square tests and ANOVA tests showed no significant dif-
(Cronbach’s a = 0.91) and inter-rater reliability were ferences in baseline characteristics between the study
found (Cohen’s j = 0.88). groups.
States of anxiety and depression were measured with the The mean SI-PTSD and HADS anxiety and depression
Hospital Anxiety and Depression Scale (HADS) [56], a scores at the three follow-up assessments are shown in
well-established 14-item scale consisting of two sub-scales: Table 2.
HADS–A (anxiety, 7 items, range 0–21) and HADS–D The analysis on SI-PTSD total scores on all 1,267 par-
(depression, 7 items, range 0–21). Higher scores indicate ticipants showed that the severity of PTSD decreased over
more anxiety and/or depression. The Chinese version of the time in all three groups (P \ 0.01) and a significant main
HADS showed satisfactory reliability and validity [57]. effect of group (F = 4.53, df = 1,141, P \ 0.01) and no

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Fig. 1 Study protocol and flow

of participants throughout trial Excluded (n=74)
Enrollment Accessed for eligibility
Not meet inclusion criteria (n=53)
(n=1341) DSM-IV psychopathology (n=25)
No proficiency in Chinese (n=7)
Already intervened (n=21)
Refused (n=5)
Randomized (n=1267) Other reason (n=16)

Allocation

Referred to “521PIM” (n=417) Referred to debriefing (n=421)

Received “512 PIM” (n=406) Received debriefing (n=411) Control (n=429)
Did not receive “512 PIM” (n=11) Did not receive debriefing (n=10)

Follow-up
Measurement available: Measurement available: Measurement available:
1 month (n=395) 1 month (n=407) 1 month (n=425)
2 months (n=383) 2 months (n=389) 2 month (n=412)
4 months (n=367) 4 months (n=372) 4 months (n=391)

Table 1 Baseline characteristics of the study groups (n = 1,267)

Characteristics ‘‘512 PIM’’ (n = 417) Debriefing (n = 421) Control (n = 429) Chi-square ANOVA

Age, year, mean (s.d.) 19.8 (3.6) 20.1 (3.9) 20.2 (3.5) 1.35 (0.26)
Education, n (%) 0.46
Primary school 28 (6.7) 37 (8.8) 30 (7.0)
Secondary school 353 (84.7) 342 (81.2) 353 (82.3)
Undergraduate 36 (8.6) 42 (10.0) 46 (10.7)
Chinese ethnicity, n (%) 399 (95.7) 413 (98.1) 410 (95.6) 0.13
PTSD score (SI-PTSD): mean (s.d.) 34.2 (10.3) 34.8 (11.4) 35.4 (11.2) 1.26 (0.28)
Anxiety score (HADS): mean (s.d.) 8.1 (5.7) 7.9 (5.2) 8.2 (6.1) 0.31 (0.74)
Depression score (HADS): mean (s.d.) 7.4 (5.3) 7.3 (4.9) 7.6 (5.9) 0.34 (0.71)
PTSD Post-traumatic disorder, SI-PTSD structured interview for PTSD, HADS Hospital Anxiety and Depression Scale

Table 2 Main outcome measures (n = 1,267)

Psychopathology measure ‘‘512 PIM’’ Debriefing Control
n Mean (s.d.) n Mean (s.d.) n Mean (s.d.)

SI-PTSD
1 month 395 27.3 (12.2) 407 28.2 (10.1) 425 28.5 (9.7)
2 months 383 20.1 (8.7) 389 24.6 (9.4) 412 25.2 (10.2)
4 months 367 12.7 (9.3) 372 16.8 (10.2) 391 17.7 (9.3)
Anxiety (HADS)
1 month 395 5.8 (5.2) 407 6.8 (5.1) 425 7.1 (5.0)
2 months 383 4.3 (4.0) 389 5.6 (4.2) 412 6.0 (4.6)
4 months 367 3.1 (3.8) 372 4.9 (3.7) 391 5.3 (4.3)
Depression (HADS)
1 month 395 5.6 (4.6) 407 7.0 (4.6) 425 6.7 (4.1)
2 months 383 4.2 (4.4) 389 6.1 (3.7) 412 5.6 (4.2)
4 months 367 3.0 (3.1) 372 5.4 (3.2) 391 4.7 (3.6)
PTSD Post-traumatic disorder, SI-PTSD structured interview for PTSD, HADS Hospital Anxiety and Depression Scale

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significant time-by-group interaction (P = 0.21). Analysis group (95% CI 1.5–3.2), 1.6 in the debriefing group (95%
by follow-up time revealed that the SI-PTSD total scores CI 0.7–2.6) and 1.7 in the no intervention group (95% CI
were significantly lower in the ‘‘512 PIM’’ group than in 0.7–2.5).
the other two groups at 2 months (F = 33.79, df = 1,181, The analysis of HADS Depression Score also showed a
P \ 0.01) and at 4 months (F = 28.77, df = 1,127, significant main effect of time (P \ 0.001), a significant
P \ 0.01). The difference was no longer significant at the main effect of group (F = 2.06, df = 1,141, P \ 0.01) and
1 month follow-up (F = 1.38, df = 1,224, P = 0.25) no significant time-by-group interaction (P = 0.15). The
(Table 2). The estimated reduction between the 1- and mean reductions in HADS depression scores between the
4 month follow-up (adjusted for baseline) was 14.1 in the 1- and 4 month follow-up (adjusted for baseline) were
‘‘512 PIM’’ group (95% CI 9.3–18.9), 10.9 in the estimated as 2.3 in the ‘‘512 PIM’’ (95% CI 1.3–3.3), 1.4 in
debriefing group (95% CI 6.3–15.5) and 10.2 in the control the debriefing group (95% CI 0.5–2.3) and 1.8 in the
group (95% CI 6.1–14.3) (Fig. 2). Between the 1- and control (95% CI 0.8–2.8).
4 month follow-up, significant differences between ‘‘512 The analysis on Hospital Anxiety and Depression
PIM’’ and the other two groups were found in re-experi- revealed very similar results, showing significant differ-
encing (P \ 0.01), avoidance (P \ 0.01) or hyperarousal ence between ‘‘512 PIM’’ and the other groups (P \ 0.01)
(P \ 0.01). No significant difference was found between and no significant differences between debriefing and
the debriefing and control groups (P = 0.23) and no sig- control groups in re-experiencing (P = 0.10), avoidance
nificant differences between debriefing and control group (P = 0.27) or hyperarousal score (P = 0.44).
scores in re-experiencing (P = 0.12), avoidance (P = 0.32)
or hyperarousal score (P = 0.12). Subgroup analyses
At baseline, a total of 106 participants (8.4%) fulfilled
the diagnostic criteria for PTSD. At the 1 month follow-up, In the present study, to examine whether the effect of an
the disorder was diagnosed in 58 participants (4.6%), at the intervention interacted with acute psychological distress,
2 month follow-up in 42 participants (3.3%) and at the we added the following factors to our model: high versus
4 month follow-up in 33 participants (2.6%). No significant low re-experiencing, avoidance and hyperarousal at base-
differences between the three intervention groups in the line. Based on cutoff scores of one symptom present for
distribution of participants with and without the diagnosis re-experiencing, three for avoidance and two for hyper-
were found. arousal, 921 participants (72.7%) had high re-experiencing,
The analysis based on 1,267 participants showed that the 80 participants (6.3%) had high avoidance and 266 (21.0%)
HADS Anxiety Scores decreased over time in all three had high hyperarousal. Analyses based on all 1,267 par-
groups (P \ 0.01) and with a significant main effect of ticipants showed that there were significant differences in
group (F = 3.11, df = 1,141, P \ 0.01). No significant all of the subgroups. Participants in the ‘‘512 PIM’’ had
interaction between time and group (P = 0.24). The mean lower scores in re-experiencing, avoidance and hyper-
reductions between the 1- and 4 month follow-up (adjusted arousal than similar participants in the debriefing and
for baseline) were estimated as up to 2.5 in the ‘‘512 PIM’’ control groups at the 2- and 4 month follow-up. No sig-
nificant time-by-group interaction was found (P = 0.18).
30 These participants had significantly lower PTSD sub-
512 PIM Group
scale scores if they had received ‘‘512 PIM’’ than similar
25 Debriefing Group
participants in the other two groups at 2 and 4 months. No
Baseline PTSD Score

Control Group
significant interaction effect of time-by-group was found
20
(P = 0.37).
15

10
Discussion
5
The aim of the present randomized controlled trial was to
0 develop a new psychological intervention, which is ‘‘512
1 2 4
Time of Assessment (months) PIM’’, for military rescuers after Wenchuan Earthquake
and to compare its efficacy with the debriefing group and a
Fig. 2 Post-traumatic stress disorder (PTSD) scores measured by control group that received no intervention. The results
structured interview for PTSD in participants (n = 1,267) randomly
showed that in all groups, symptoms decreased signifi-
assigned to the ‘‘512 PIM’’, debriefing or control condition. Mean
(s.e.) values at baseline, list 1, 2 and 4 months from a repeated- cantly over the 4 month period, with a significant differ-
measurement model adjusting for baseline value of PTSD score ence between ‘‘512 PIM’’ and the other two groups. ‘‘512

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PIM’’ had positive effect on participants with symptoms of On the basis of current evidence, the ‘‘512 PIM’’ would
PTSD at 2 and 4 months. However, no significant differ- be a promising alternative intervention for military rescuers
ences between the debriefing and control groups were in critical incidents. Although the ‘‘512 PIM’’ proved to be
found. effective in the culture of Chinese military in this special
The results suggested that the ‘‘512 PIM’’ showed situation, it seems somewhat arbitrary to draw a conclusion
positive effects in subgroups of participants with symptoms that such psychological intervention would be effective in
of re-experiencing, avoidance and hyperarousal after first other non-military organization because too many differ-
controlling for baseline PTSD symptoms. The possible ences can be found between military and non-military
explanation might be that the ‘‘512 PIM’’ incorporates organizations. Further wide research should be conducted
protocol of CISD and cohesion training together. Some on this question whether ‘‘512 PIM’’ could be extended to
studies found the social support plays an important role in other non-military organizations. Another critical question
preventing mental disorders or recovery from traumatic is whether the ‘‘512 PIM’’ can be useful in non-Chinese
events [4, 58]. A previous study also found that cohesion cultures. Due to the limited comparative studies between
could attenuate the dose–response relationship between Chinese and non-Chinese cultures, such question remains
past stressor exposures and PTSD symptoms at relatively open, as a new door for further exploration.
moderate levels of exposure, and unit cohesion also could For the debriefing intervention, the absence of the effect
ameliorate stress-related symptoms [59]. Such a new psy- of debriefing in our overall study group was consistent with
chological intervention section was developed based on the previous studies and reviews, in which no differences were
actual organization of Chinese military rescuers. In the found between debriefed trauma rescuers and non-
mainland of China, military personnel undertake almost all debriefed rescuers [65–68]. A difference between our study
rescue tasks in both civil and nature critical incidents. Such and previous studies is that a lower rate of PTSD was found
organization of rescuers is different from police, firefight- across the three groups (mean 3.3% at 2 month and 2.6% at
ers and emergency workers. As military personnel, they 4 months) than that in previous studies (varying as 11% at
have a strict hierarchy and each one belongs to a specific 3 months and 13% at 10 months after the disaster) [3, 69].
squad, platoon and company. Therefore, the relationship The possible reason might be that the interval time of the
between them is much closer than other rescue groups and present study was shorter than previous studies.
group cohesion may play an important role in their mental Our trial had several strengths. Firstly, a new psycho-
health. Although the process of ‘‘512 PIM’’ referred to the logical intervention ‘‘512 PIM’’ was developed according
CISD protocol, the new and unique component included in to the actual characteristics of Chinese military rescuers
it is the stage (5), that is, training of cohesion. In the and the results showed its satisfactory effects. Secondly, we
training process, soldiers could experience the power of used randomization to assign participants to two interven-
team, and their sense of belonging will increase in training. tion groups and masked outcome assessment. Thirdly,
Such cohesion training may increase the level of social protocol adherence was systematically assessed, which to
support, which has been found to be an important protec- our knowledge has hardly been done before in debriefing
tive factor that may reduce stress and depression in general research. Fourthly, the number of participants was ade-
[60, 61]. Two meta-analyses have highlighted the impor- quate and the statistical results were reliable.
tance of social support as a predictor with great impact on There are some limitations in our study. The first limi-
PTSD after exposure to trauma [62, 63]. tation of our study was that the interval time was short and
After the intervention conducted by psychological it should be longer to obtain more information of assess-
interviewers, soldiers can practice such exercises in their ment. The second limitation was that our results were
own unit enhancing mutual trust and collaboration. By furthermore translated to other rescuers. This should be
conducting and practicing such training at a subsequent done with caution because ‘‘512 PIM’’ was developed
time, soldiers could try to cope with symptoms such as re- according to the characteristics of the Chinese army and the
experiencing, avoidance and hyperarousal together. results cannot be generalized to other rescue groups. The
Therefore, such cohesion training may play the role of third one is that the mechanism of unit cohesion training is
therapists in the subsequent days. With the passing of time, not totally clear and further research is needed to investi-
the effect of cohesion will be more and more important gate it in Chinese military rescuers. The fourth one is that
against mental disorder, i.e., fear, anxiety and depression. the subjects in our study were relatively young. Although
Some studies have also suggested that the team should age is found related to incidence of mental disorder
work on exercises together, thus aiding in cohesion prior to including PTSD [35, 51], the subjects in some studies are
deployment [64], and it would also give a valuable indi- as young as ours [32]. The fifth one is that the majority of
cation of the future cohesion utilization in military those soldiers were of Han ethnicity. Ethnicity plays an
personnel. important role in the prevalence of mental disorders

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1118 Soc Psychiatry Psychiatr Epidemiol (2012) 47:1111–1119

including depression [70–72] and anxiety [73]. Finally, 13. Greenberg PE, Sisitsky T, Kessler RC, Finkelstein SN, Berndt
based on medical–ethical considerations, we were not ER, Davidson JR, Ballenger JC, Fyer AJ (1999) The economic
burden of anxiety disorders in the 1900s. J Clin Psychiatry
allowed to offer the intervention until more than 1 month 60:427–435
after the traumatic experience, whereas in most instances 14. Kessler RC (2006) Posttraumatic stress disorder: the burden to
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In summary, our data suggested that ‘‘512 PIM’’ was an matic stress disorder. Croat Med J 49:459–475
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