Abstract
Multiple exposures to life-threatening events may lead to various mental health issues and indirectly affect the marriage of those affected. Very few studies have investigated trauma exposure, posttraumatic stress disorder (PTSD), depressive symptoms, and marital conflicts among firefighters, a group that faces such exposure occupationally. The present study explores the relationship between trauma exposure, PTSD, and depression in relation to marital conflicts among firefighters in Sarawak, adopting a cross-sectional research design. Different marital status reported significant PTSD and depressive symptoms. The widowed scored higher PTSD and depressive symptoms than the married and single groups. Firefighters with PTSD and depressive symptoms reported having more problems in aggression family history of distress, sexual dissatisfaction, and problem solving communication than those without. Regression analysis showed that problem solving communication (t (212) = 2.59, p = .01) and global distress scores (t (212) = 2.17, p < .05) in type of marital conflicts served as a significant predictor for depressive symptoms. The present study suggests that proper planning for treatment and intervention is needed to improve psychological well-being among firefighters and other high-risk professions following multiple exposures to traumatic events in carrying their job duty. Proper intervention programs also should be initiated for spouses of firefighters dealing with traumatized partners.
Introduction
Studies on marital conflicts and satisfaction are well-established (Hawkins et al., 2002; Li & Fung, 2011). Mutual understanding in communication, ability to resolve conflict, empathy with partner as well as cooperation between husband and wife in raising a family are especially important in marriage (Li & Fung, 2011). Particularly during crisis, providing emotional and financial aid and social and moral support to a spouse suffering from mental illness is crucial (Stone & Shackelford, 2007; Whisman, 2014). Traumatic experience can affect relationships. Any type of lifetime trauma can cause negative marital interaction except for natural disasters which have been shown to produce positive interaction (Whisman, 2014). Experiencing any type of trauma can result in the quality of marriage deteriorating over time (Stone & Shackelford, 2007; Torres et al., 2016; Whisman, 2014) especially among those in high-risk professions and their spouses (Riggs, 2014; Taft et al., 2011; Torres et al., 2016).
Posttraumatic stress disorder (PTSD) can increase marital conflict. Previous studies found that PTSD was “highly related with marital conflicts” (Whisman, 2014); “severe relationship problems, greater parenting problems, poorer family adjustment,” and poor communication with one’s partner (Cook et al., 2005); and discomfort sexual relationship with a partner (Riggs, 2014). Those suffering with PTSD were three to six times more likely to divorce than those without (Monson & Taft, 2005). The impact of trauma exposure and PTSD among firefighters does not only affect intimate relationships (Haddock et al., 2015), it also disrupts marital relationships as a result of emotional stresses following the trauma (Barnes, 2000; Torres et al., 2016). In Taiwan, 34.5% of firefighters experienced marital discorded as a result of suffering from PTSD (Chen et al., 2007). Similarly, Gagliano (2009) suggested that the divorce rate for firefighters is the highest rate in the United States and it is three times higher than the general population. Study on Malaysian firefighters’ mental health issue are limited. Scant literatures indicate that there is no study addressing issues related to marital conflict in relation to their mental health among our firefighters. The aim of this study was to establish the relationship between marital conflicts, trauma exposure, PTSD, and depressive symptoms.
Method
Design
A cross-sectional research design was adopted to examine the relationship between trauma exposure, PTSD symptoms, depressive symptoms, and marital conflicts. Cross-sectional design selects participants from the population at one time and provides the description of characteristics of a population in a specific time frame to examine the association among the variables involved in the study (Shaughnessy et al., 2012). By using cross-sectional design, the time span for this research is shorter and less expensive (Salkind, 2009).
Participant
According to the Fire and Rescue Department of Sarawak, there are 1262 firefighters in Sarawak. A minimum sample size of 233 was determined using Epi Info (version 7), based on a prevalence of PTSD in Sarawak of 7.1% (Ghazali et al., 2014), worst acceptable result of 5%, and confidence interval of 99.9%. A total of 282 firefighters (22.3%) were recruited, with only 258 included in the study. Ages ranged between 19 to 60 years old (Mage = 37.3, SD = 9.68), with 91.9% male and 8.1% female. The 24 firefighters excluded from the study did not fill out the instruments completely. The firefighters were recruited from 10 Fire and Rescue Stations in Sarawak.
Procedure
Firefighters were selected based on multi-stage sampling. The Fire and Rescue Department of Sarawak was contacted through the person in charge who agreed that 10 fire and rescue stations be selected for this study. The firefighters were approached shift by shift according to their shift schedule. Time and date of data collection were determined and scheduled based on their availability. During the data collection process, three to fifteen firefighters gathered in a meeting room per shift for a briefing. Issues of confidentiality, their rights to withdraw, and possible risks of the study were addressed. The firefighters were informed that they were required to answer four different instruments (for married firefighters) and three instruments for (unmarried firefighters) including their demographic background. All firefighters gave their permission to participate in the study with written consent obtained prior to data collection. This study was approved by the Research and Ethics Committee of the Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak and received permission from the Fire and Rescue Department of Sarawak. Letters of permission were sent to each fire and rescue station to seek approval from the station heads.
Measures
Socio-demographic characteristics questionnaire: This questionnaire measures all basic demographic data including age, gender, race, level of education, marital status, number of children, years of service, and name and location of their fire stations.
The life events checklists (LEC-5; Weathers et al., 2013): It was developed to measure potentially traumatic events experienced by an individual. The LEC-5 facilitates the diagnosis of PTSD by fulfilling the first PTSD criteria for traumatic event exposure. The LEC-5 consists of 22 items. It measures if an individual had any one of the stressful or traumatic events throughout their life. Firefighters were required to answer whether they have been exposed to traumatic events directly and/or indirectly and/or job-related traumatic events. The list of possible traumatic events includes natural disaster, fire or explosion, near drowning, motor-vehicle accident, other serious accident in workplace/home, exposure to toxic substances, physical assault, assault with a weapon, sexual assault, rape, war, captivity, robbery, death of close family, self-caused serious accident or death, divorce, childhood neglect, bullying in school/hostel, absence of parent, sudden death, sudden death caused by accident, and other trauma. Each item is coded as 0 for no and 1 for yes. The LEC showed sufficient temporal stability, good convergence, and was strongly associated with PTSD symptoms (Gray et al., 2004). For the full sample in the present study, the Cronbach’s alpha of this traumatic event checklist was α = .842.
The PTSD checklist for DSM-5 (PCL-5; Weathers et al., 2013): It consists of 20 self-report items that measure symptoms of PTSD in individuals. The PCL-5 corresponds to the DSM-5 symptoms criteria for PTSD. The rating scale for each symptom ranges between 0 to 4. Each scale is labeled as follows: (0) denotes “Not at all,” (1) denotes “a little bit,” (2) denotes “moderately,” (3) denotes “quite a bit,” and (4) denotes “extremely.” The degree of severity in PCL-5 is obtained by summing up all items, with possible scores ranging from 0 to 80. A cutoff score of 33 is used to determine individuals with PTSD symptoms. The PCL-5 is a well-validated measure, good in internal consistency (α = .96), test–retest validity (r = .84), and convergent validity (Bovin et al., 2016; Weathers et al., 2013). In the present study, the PCL-5 showed good internal consistency (α = .93).
The center for epidemiologic studies depression scale (CESD) (Radloff, 1977): This scale consists of 20 items measuring symptoms of depression that might disturb everyday functioning including feelings of guilt, worthlessness, helplessness, sleep disturbance, and depressed moods and feelings (Ghazali et al., 2014). It has been widely used as a good tool to measure depressive symptomatology in a general population (Radloff, 1977). The CESD was scored using a four-point Likert scale: (0) denotes absent, (1) denotes (rarely), (2) denotes sometimes, and (3) denotes always. The CESD total symptom severity score is obtained by adding the scores for all items, giving a range of 0 to 60. A recommended standardized cutoff score for a general population is 16 (Radloff, 1977); however, a cutoff score of 27 has been found to be more appropriate among Malaysian populations (Ghazali, et al., 2014) and was adopted for this study. The CESD possesses high internal consistency with Cronbach alpha ranging from .85 to .90 (Radloff, 1977).
Marital satisfaction inventory-revised (MSI-R) (Snyder, 1997): It was established to measure the nature and extent of relationship distress. The present study used 8 subscales in MSI-R comprising (i) Global distress–measures the overall dissatisfaction towards the relationship, (ii) Affective communication–evaluates over affective and understanding aspects in the relationship, (iii) Problem solving communication–measures the inability to resolve differences in the relationship, (iv) Aggression–evaluates the physical aggression experienced by the respondent from their partner, (v) Time together–measures couple companionship and time spent together, (vi) Disagreement about finance–evaluates relationship distress in finance management, (vii) sexual dissatisfaction–assesses the sexual displeasure in respondents towards their partner, and (viii) family history of distress–evaluates individual’s distress relationship in individual’s family. Yes or No responses were required in answering this scale. Relationship distress is measured by adding items in each subscale with the higher the scores indicating the higher the level of severity in the marital conflicts. The full scale of MSI-R possesses high level of both internal consistency (α = .70 to α = .93) and temporal stability (α = .74 to α = .88) (Snyder, 1997). In this study, the internal consistency of the instrument is α = .80.
Analysis
Data entry and analysis were done using IBM SPSS version 21. Prior to the analysis, data checking and data cleaning were performed. The frequency and percentage including the prevalence of trauma, depression, PTSD and marital conflicts, means and standard deviation for socio-demographic information were done using descriptive analysis. Two-ways analysis of variance analyses (ANOVA) were used to explore the significant difference between socio-demographic information associated with trauma exposure, PTSD symptoms, depressive symptoms, and marital conflicts. Pearson chi-square was used to explore the association between trauma exposure, depressive, and PTSD symptoms especially in relation to marital conflicts among firefighters. Multivariate ANOVA were run to explore the relationships between trauma exposures and marital conflicts domains among married and widowed firefighters. Further, multi-regression analyses were done to explore the predictive variables for marital conflicts and depressive symptoms among married and widowed firefighters. Threshold for statistical significance for all analyses was set at a p < .05.
Results
Demographic information
Descriptive Characteristics of Firefighters with Trauma Exposure based on Marital Status.
Marital conflicts among firefighters
Marital Conflicts Domains among Firefighters (N = 258).
Main analysis
Marital status in relation to PTSD and depressive symptoms
One-way analysis of variance (ANOVA) showed that there are statistically significant differences between groups of married, widowed, and unmarried firefighters reporting PTSD symptoms F (2, 255) = 3.089, p = .047 and depressive symptoms F (2, 255) = 9.87, p < .001. The widowed scored higher PTSD and depressive symptoms than the married and single groups (Table 2).
Marital conflicts and trauma exposure
Analysis of variance was used to determine whether trauma exposure has significant association with marital conflicts among the firefighters. A significant association was found between the number of trauma exposures and marital conflicts among married, divorced, and/or widowed firefighters, F(26,196) = 1.94, p = 0.006. There was also significant relationship between direct exposures to trauma (F(10, 49) = 2.101, p = .042) and job-related trauma (F(15, 49) = 2.243, p= .017) with marital conflicts. Multivariate analyses were also conducted to identify the effects and interaction between the marital conflict domain and trauma exposure. It was found that disagreement about finance (F(26, 196) = 1.828, p = .012), global distress (F(26, 196) = 1.828, p = .012), problem solving communication (F(26, 196) = 1.843, p = .01), and time together (F(26, 196) = 1.804, p = .013) have significant association with trauma exposure.
Marital conflict and PTSD symptoms
Marital Status in Relation to PTSD and Depressive Symptoms.
Marital conflict and depressive symptoms
Descriptive frequency analysis showed that 18.2% (n = 47) of firefighters reported depressive symptoms. Pearson chi-square analyses showed that firefighters with depressive symptoms scored significantly high in all marital conflict domains including disagreement about finances (31%, χ2 = 12.81, p = .002), aggression (33,3%, χ2 = 7.64, p = .022), family history of distress (7.1%, χ2 = 11.45, p = .003), affective communication (28.6%, χ2 = 14.73, p = .001), time together (14.3%, χ2 = 8.28, p = .016), sexual dissatisfaction (7.1%, χ2 = 15.27, p < .001), global distress (38.1%, χ2 = 18.31, p< .001), and problem solving communication (26.2%, χ2 = 20.6, p < .001) (Table 3). Clearly, firefighters with depressive symptoms exhibit more problems in marital conflict domains compared to those without.
Predictive factors of marital conflicts and depressive symptoms
Linear regression analysis was used to examine the predictive factors of depressive symptoms when related to marital conflict domains. The predictive factors included were affective communication, aggression, family history of distresses, disagreement about finances, global distress, problem solving communication, sexual dissatisfaction, and time together. The analysis accounts for 14.2% of the total variance (R = .42, R 2 = .17, R 2 adjusted = .14). This model is a significant predictor for depressive symptoms: F (8,213) = 5.57, p < .001. The predictive factors of depressive symptoms when related to marital conflicts among married and widowed firefighters were found to be problems solving communications (t (212) = 2.59, p = .01) and global distress (t (212) = 2.17, p < .05).
Discussion
Results showed that marital conflict is present among Malaysian firefighters. The present finding was consistent with previous studies (e.g., Amato & Hohmann-Marriott, 2007; Jackman-Cram et al., 2006) that aggression and dissatisfaction with spouse could significantly affect marriage. Stress and traumatic experiences faced on the job appear to correlate with significant aggressive behavior toward their spouse. Global distress was also included as the highest marital conflict reported in the present finding after aggression. Global distress and dissatisfaction towards partner such as having poor relationship quality has been shown to seriously affect individual marriages, presumably becoming the prominent reason to be disengaged in marriage for the firefighters (Amato & Hohmann-Marriott, 2007). Financial issues were also a prominent aspect of marital conflict in the present study. Arguments over finance usually end with disagreement and distress in the relationship, affect individual dissatisfaction about their relationship (Dew, 2008). Frequent unhealthy relationship as a result of frequent argument might cause disharmony in the marriage and perhaps eventually leads to divorce among the firefighters in the present study. Further study should also be conducted to see if financial distress can lead to divorce among firefighters. Problem solving communication and poor affective communication problem were also reported to be high in this study, which can lead to depressive symptoms among couples. Poor communication between couples together with depressive symptoms brings more harm in marriage (Harper & Sandberg, 2009). Despite the foregoing, sexual dissatisfaction and family history of distress were less likely to be reported by married and widowed firefighters in the present study.
Finding showed that the widowed scored higher PTSD and depressive symptoms than the married and single groups. In contrast to depressive symptoms, not many studies directly associate marital status with PTSD symptoms. A study of widowed Saudi firefighters found a significantly higher risk to develop PTSD symptoms in comparison to their married colleagues. It is speculated that widowed firefighters lack emotional support from their close family member (Alghamdi et al., 2017). Another study conducted among an Australian population revealed that the prevalence of PTSD was significantly higher among single, divorced, or widowed respondents (Creamer et al., 2001). However, firefighters who are single or not married in the present study did not report higher prevalence of PTSD and depressive symptoms. Rather, PTSD symptoms were lower among single or never married firefighters compared to the mean of widowed and married groups. Perhaps this is due to differences in how data were analyzed in the previous studies. While the current study analyzes data on married, divorced/widowed, and single firefighters separately, the previous studies grouped never married firefighters together with the divorced and widowed. The current findings also show that there is significant difference between married, widowed, and single firefighters in relation to depressive symptoms. The widowed are more prone to score higher in depressive symptoms compared to the married and single firefighters. Current findings support the notion that the widowed are much more vulnerable to suffer from depressive symptoms than the married and single (Jang et al., 2009; Kamiya et al., 2013; Zhang & Li, 2011). This indicates that divorced and widowed respondents tend to experience distress compared to married firefighters. A previous study on a general population in China also indicates that widowed, divorced, and unmarried individuals, especially among the elderly, were at higher risk of developing depression compared to married couples (Yan et al., 2011). The present study also found that divorced and widowed respondent mean scores on PTSD symptoms were significantly higher in marital conflicts than married firefighters based on their previous marital relationship. This indicates that divorced and widowed respondents were more prone to report distress in their previous marriage than married firefighters, perhaps because of the stressful experience they faced in marriage in the past, as divorce can be regarded as non-traumatic yet stressful experience for the divorcee which is consistent with the study conducted by Amato and colleagues (Amato & Hohmann-Marriott, 2007).
Trauma and PTSD were positively and significantly related with marital conflicts. There were also significant relationships between direct exposures to trauma and job-related trauma with marital conflicts. Those who had more trauma exposure regardless of source tend to report significantly higher marital conflicts. This result is supported by previous studies (Riggs, 2014; Whisman, 2014). A study among Vietnamese combat veterans with their spouses found that relationship distress was interrelated with the trauma experienced by one of the partners (Riggs, 2014). As a result of undergoing traumatic experience, couples might rate the marital relationship as less favorable (Dirkzwager et al., 2005) and the marital relationship between the spouses deteriorates over time (Whisman, 2014). While populations might differ across studies, they share support for the relationship between trauma exposures and marital conflicts. More systematic intervention can be proposed for marital conflicts among high-risk professions such as firefighters.
Problem solving communication was also found to be significantly correlated with trauma exposure. Poor communication during problem solving communication does contribute to the rapid destruction of marital relationships (Torres et al., 2016). During emotional distress (exposure to traumatic events and PTSD), individuals tend to confine in their own world and experienced emotional numbness (American Psychiatric Association, 2013). Many have difficulty to express their feelings. Some report frequent nightmares and severe emotional distress (Gerlock et al., 2014). Perhaps this is one reason firefighters reported high levels of poor communication with their spouses. However, previous literature has stressed that poor communication alone cannot be the only basis for arguments in marital conflict (Rogge et al., 2006). Poor communication in marital relationships might also be due to the manifestation of aggressive behavior as well as neuroticism (Javidi & Yadollahie, 2012). Studies have shown that many USA veterans report aggressive behavior upon their return from military service. Similarly, a majority of firefighters reported aggressive behavior as a result of exposure to traumatic events. This result highlights that good communication is an important key-predictor for marital satisfaction and happiness.
Marital conflict is positively and significantly correlated with PTSD symptoms. PTSD was reported to cause marital conflicts (Torres et al., 2016), worsening relationship problems (Cook et al., 2004), leads to hostile behavior and intimate partner violence, and divorce (Orcutt et al., 2003). PTSD symptoms were highly associated with aggression, families with history of distress, sexual dissatisfaction as well as problem solving communication. Marital conflict was found to positively and significantly correlate with PTSD symptoms in the present study. Several marital problems were linked with PTSD symptoms in contributing to overall marital dissatisfaction, specifically aggression, families with history of distress, sexual dissatisfaction, and poor problem-solving communication. These findings are well supported by existing literature among war-affected populations, in which PTSD symptoms were linked to marital problems of acts of hostility and aggression (Stone & Shackelford, 2007; Rogge et al., 2006), history of family dysfunction (Orcutt et al., 2003), sexual dissatisfaction (Riggs, 2014), and poor communication (Kamiya et al., 2013).Marital conflicts problems worsen when there are disagreements in communication between spouses (Kamiya et al., 2013).
The firefighters with depressive symptoms scored significantly high in all marital conflict domains including disagreement about finances, aggression, family history of distress, affective communication, time together, sexual dissatisfaction, global distress, and problem-solving communication. Those who reported more depressive symptoms exhibit more problems in marital conflicts domains compared to those without depressive symptoms, consistent with Fink and Shapiro (2013) and Kamiya et al. (2013).
Limitations of study
There are several limitations to this study. The sample size is limited among female firefighters, preventing comparisons between male and female firefighters. There are very few female firefighters in service across the globe. The use of retrospective reporting of trauma experiences may have led to under-reporting or recall bias by the participants. However, this is less likely to influence their job-related trauma exposure reporting as firefighters are typically exposed to numerous traumatic events throughout their years of service.
Conclusion
The present study suggests that there is significant association between lifetime trauma exposure, PTSD, and depression in relation to marital conflicts among firefighters in Sarawak. The most important finding is that some marital conflict domains served as risk factors for PTSD and depression. In making comparison between married and widowed groups, it is found that marital conflicts were mostly reported by widowed group. The current study cannot explain the causes of this finding, a qualitative study is recommended to understand this phenomenon. This study provides insights for future researchers, clinicians, counselors, and the Fire and Rescue Service Department of Malaysia itself in designing proper interventions, treatment, and counseling programs about the effect of trauma exposure on the psychological well-being of those in high-risk professions, specifically firefighters.
Footnotes
Acknowledgments
We thank the Research and Innovation Management Center (RIMC) of Universiti Malaysia Sarawak for supporting this study. Our sincere thanks to all participants who had given us their full cooperation during the data collection. Many thanks to Zayn Al-Abideen Gregory, Faculty of Built Environment, Universiti Malaysia Sarawak for assistance with editing and reviewing this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported and funded by Universiti Malaysian Sarawak (UNIMAS Short Term Grant), grant number and reference; UNIMAS/21/09-01.1 Jld 5 (37).
