Received: 28 February 2017 Revised: 5 June 2017 Accepted: 29 June 2017

DOI: 10.1002/cpp.2116

RESEARCH ARTICLE

Ambivalence and guilt feelings: Two relevant variables for

understanding caregivers' depressive symptomatology
Andrés Losada1 | María Márquez‐González2 | Carlos Vara‐García1 |

Laura Gallego‐Alberto2 | Rosa Romero‐Moreno1 | Karl Pillemer3

1
Clinical Psychology Area, Universidad Rey
Juan Carlos, Madrid, Spain Providing care for a relative with dementia is considered to be a chronic stressor that has been
2
Department of Biological and Clinical linked to negative mental health consequences for caregivers. A theoretical model was developed
Psychology, Universidad Autónoma de Madrid, and tested to assess the degree to which ambivalence and guilt feelings contribute to caregivers'
Madrid, Spain
depressive symptomatology. Participants included 212 dementia family caregivers. In addition to
3
Department of Human Development, Cornell
ambivalence and guilt feelings, sociodemographic characteristics, behavioural and psychological
University, Ithaca, NY, USA
symptoms of dementia, and depressive symptomatology were assessed. Hypotheses derived
Correspondence
Andrés Losada Baltar, Facultad de Ciencias de from the stress and coping model were tested using path analysis. The analysed model showed
la Salud, Universidad Rey Juan Carlos, an excellent fit to the data. In total, 35% of the variance in depressive symptomatology was
Departamental II, Avda de Atenas s/n 28922 explained by the assessed variables. Although significant correlations were obtained between fre-
Alcorcón, Spain.
Email: andres.losada@urjc.es
quency and appraisal of behavioural and psychological symptoms of dementia and depression,
the obtained model suggests that this effect was mediated through ambivalence. In addition,
ambivalence had an indirect effect on depression. The association of ambivalence with depres-
Funding information
Spanish Ministry of Economy and Competi- sion was explained through feelings of guilt; that is, respondents who reported ambivalent feel-
tiveness, Grant/Award Number: PSI2015‐ ings were more likely to experience guilt, leading in turn to greater depressive symptomatology.
65152‐C2‐1‐R and PSI2012‐31293; U. S.
The findings suggest that dementia caregivers' ambivalence and guilt feelings are relevant for
National Institute on Aging, Grant/Award
Number: P30AG022845 understanding their depressive symptomatology. These factors should be addressed in psycho-
logical interventions with caregivers.

KEY W ORDS

Alzheimer's disease, depression, disruptive behaviours, mediation, stress and coping

1 | I N T RO D U CT I O N contribute significantly to caregivers' level of depression, with disrup-

Providing care for a relative with dementia is considered to be a
chronic stressor (Robinson‐Whelen, Tada, MacCallum, McGuire, &
Kiecolt‐Glaser, 2001) that has been linked to negative mental health
consequences for caregivers (Pinquart & Sörensen, 2003). One of the
most studied consequences of caregiving is depressive symptomatol-
ogy. Research suggests that over one third of caregivers suffer from
clinical depression (Sallim, Sayampanathan, Cuttilan, & Ho, 2015).
Several theoretical models, such as the stress and coping model
(Haley, Levine, Brown, & Bartolucci, 1987), have received strong empir-
ical confirmation as explanatory models for caregivers' emotional dis-
tress. These models point to the pathways by which cultural,
contextual, or personal factors and stressors affect caregivers' mental
and physical health. According to this model, stressors such as care
recipients' behavioural and psychological symptoms of dementia
tive behaviours such as aggression among the most distressing (Fauth
& Gibbons, 2014). However, although most caregivers face stressful sit-
uations, not all of them suffer negative outcomes to the same degree.
An underexplored variable that may contribute to caregivers' depres-
sive symptoms is feelings of guilt. Guilt has been described as “the dys-
phoric feeling associated with the recognition that one has violated a
personally relevant moral or social standard” (Kugler & Jones, 1992; p.
318). Studies have found that guilt feelings among caregivers to older per-
sons are associated with depressive symptoms (Gonyea, Paris, & de Saxe
Zerden, 2008) and frequency of or reaction to care‐recipients disruptive
behaviours (Feast, Orrell, Russell, Charlesworth, & Moniz‐Cook, 2017;
Losada, Márquez‐González, Peñacoba, & Romero‐Moreno, 2010). Similar
findings have been found in other caregiving populations. For example,
guilt has been found to be associated with long‐term reports of distress
among relatives of patients with schizophrenia (Boye, Bentsen, & Malt,

Clin Psychol Psychother. 2017;1–6. wileyonlinelibrary.com/journal/cpp Copyright © 2017 John Wiley & Sons, Ltd. 1
2 LOSADA A.
2002), and with psychological distress and mental, social, and physical
functioning among caregivers of cancer survivors (Spillers, Wellisch, Kim,
Matthews, & Baker, 2008). Although research on guilt feelings among
dementia caregivers has increased in recent years (Feast et al., 2017;
Gallego‐Alberto, Losada, Márquez‐González, Romero‐Moreno, & Vara,
2016; Roach, Laidlaw, Gillanders, & Quinn, 2013; You & Tak, 2014), few
studies have analysed potential predictors of guilt or the mechanisms
through which guilt may affect caregiver distress.
A possible source of guilt may be specific emotional experiences. In
this article, we examine the relationship between the experience of
ambivalence and guilt feelings. In the caregiving context, ambivalence
is defined as the simultaneous experience of positive and negative feel-
ings toward the care recipient (Fingerman, Pitzer, Lefkowitz, Birditt, &
Mroczek, 2008; Willson, Shuey, & Elder, 2003). Research has focused
almost exclusively on caregivers' negative feelings or (to a lesser extent)
positive feelings, rather than on co‐occurrence of both types (Cohen,
Colantonio, & Vernich, 2002). However, it is not uncommon to find
caregivers who report experiencing positive and negative feelings
simultaneously, an internal conflict that is typically perceived as aver-
sive by the individual (Pillemer et al., 2007). Ambivalence is especially
likely when disruptive behaviours by the person with dementia are fre-
quent and stressful for the caregiver (Pillemer & Suitor, 2005).
Although the existence of ambivalent feelings among caregivers
has been recognized (Shim, Barroso, & Davis, 2012), few studies have
explored this construct among caregivers. Further, most existing
research is qualitative (Harding & Higginson, 2001; Shim et al., 2012),
although several quantitative studies exist that have measured ambiv-
alence indirectly by assessing positive and negative feelings toward the
care recipient separately, and then calculating an ambivalence score by
combining both dimensions (Iecovich, 2014; Willson et al., 2003).
Recently, Losada, Pillemer, Márquez‐González, Romero‐Moreno,
and Gallego‐Alberto (2016) developed and tested the Caregiving
Ambivalence Scale. Using a sample of 401 dementia caregivers, the
investigators found that ambivalent feelings (e.g., feeling both satisfac-
tion and resentment due to caregiving) contributed significantly to
caregivers' depressive and anxious symptoms, controlling for other rel-
evant dimensions of stress and coping. However, their study did not
examine the specific mechanisms through which ambivalent feelings
may contribute to caregivers' distress.
The aim of this study was to analyse the role of ambivalent and guilt
feelings in depressive symptomatology, using theoretical framework
based on stress and coping model, The hypotheses were the following:
(a) Caring for a loved one with high disruptive behaviours will be associ-
ated with a increased reporting of ambivalent feelings; (b) reporting
simultaneous positive and negative feelings toward the care recipient will
be associated with increased feelings of guilt; and (c) guilt feelings will in
turn be associated with increased reports of depressive symptoms.
2 | METHODS
2.1 | Participants
In‐person interviews were conducted with 212 dementia family care-
givers. All respondents were recruited through social agencies and
ET AL.
Key Practitioner Message
• Care‐recipients' disruptive behaviours increase
caregivers' ambivalent feelings.
• Having ambivalent feelings in turn leads to stronger guilt
feelings in caregivers.
• This process appears to significantly contribute to
caregivers' depressive symptomatology.
healthcare centres in Madrid, Spain. In order to be eligible for participa-
tion in the study, individuals were required to meet several criteria in
order to ensure that the caregiving role has been established: (a) iden-
tify themselves as the principal person taking care of a relative diag-
nosed with dementia; (b) devote at least 1 hr a day to the care of the
relative; and (c) have provided care for at least 3 months to that
relative.
These criteria are similar to those used in other studies analysing
caregivers, such as those considered by Perlick, Hohenstein, Clarkin,
Kaczynski, and Rosenbheck (2005), who consider as primary caregivers
those who satisfy at least three of the following criteria: Is the spouse,
parent, or spouse equivalent; has the most frequent contact with the
patient; helps to support the care‐recipient financially; has most fre-
quently been a collateral in the care‐recipients' treatment; and is
contacted by treatment staff in case of emergency. All of the partici-
pants gave their consent to participate in the study, which was
approved by the Spanish Ministry of Economy and Competitiveness
and the Ethics Committee of the Universidad Rey Juan Carlos.
2.2 | Variables and instruments
2.2.1 | Sociodemographic variables
Caregivers' gender, age, relationship to the care‐recipient, time since
beginning caregiving, and daily hours devoted to caregiving were
assessed.
2.2.2 | Disruptive behaviours
The frequency of occurrence of disruptive behaviours and the degree
to which these behaviours were rated as stressful by the caregivers
were assessed through the 8‐item disruptive behaviours frequency
and reaction subscales of the Revised Memory and Behaviour Prob-
lems Checklist (Teri et al., 1992). The internal consistency (Cronbach's
α) for the frequency and appraisal subscales in this sample was .67 for
each subscale.
2.2.3 | Ambivalence
Caregivers' ambivalent feelings were assessed through the Caregiving
Ambivalence Scale (Losada et al., 2016). This 5‐item scale assesses
the degree to which caregivers' attitudes and feelings toward their rel-
atives are mixed or conflicted (e.g., “I have mixed feelings toward my
relative (tenderness‐rage; love‐hate, etc).”). The answers are rated on
a Likert‐type scale that ranges from 0 (never) to 3 (always). The internal
consistency (Cronbach's α) for this scale in this study was .87.
LOSADA A. ET AL. 3

2.2.4 | Guilt
The Caregiver Guilt Questionnaire (Losada et al., 2010) was used to
assess caregivers' feelings of guilt. It is a 22‐item scale (e.g., “I have felt
guilty about the way I've sometimes behaved with my relative”) with
response options ranging from 0 (never) to 4 (always or almost always).
In this study, the internal consistency for this scale (Cronbach's α)
was .92.
2.2.5 | Depressive symptomatology
Caregivers' depressive symptoms were measured by the Center for
Epidemiologic Studies—Depression Scale (Radloff, 1977). The Center
for Epidemiologic Studies—Depression is a 20‐item scale that assesses
the frequency of depressive symptomatology during the past week
(e.g., “I felt that everything I did was an effort”). Response options range
from 0 (rarely or none of the time) to 3 (most or all of the time). The internal
consistency (Cronbach's α) for this scale in this study was .89.
2.3 | Data analyses
(41%) or a parent (49.1%). Participants were either taking care of a rel-
ative with Alzheimer disease (71.1%) or related disorder (29.9%) and
had been providing care for a mean of 3.73 years (SD = 2.91), devoting
on average 13.19 daily hours to caregiving (SD = 8.30).
3.2 | Correlations
The associations between the assessed variables are shown in Table 1.
As hypothesized, caregivers who reported higher frequency and reac-
tion to disruptive behaviours reported higher ambivalent feelings
(Hypothesis 1), those who reported higher ambivalence scores also
reported high guilt scores (Hypothesis 2), and high scores on ambiva-
lence and guilt were associated with higher scores in depressive symp-
tomatology (Hypothesis 3). Other significant correlations were found
between daily hours spent caring and frequency and reaction to dis-
ruptive behaviours and guilt and depressive symptomatology. In addi-
tion, being younger and caring for parents were associated with
higher ambivalent feelings and guilt, and female caregivers showed
higher scores on ambivalent feelings and depressive symptomatology.

Descriptive data (mean, standard deviations, ranges, and frequencies)

were calculated for the assessed variables. To analyse the relationship 3.3 | Path analysis
between variables, correlation analyses were conducted.
As shown in Figure 1, when all the assessed variables were considered,
Path analysis was employed to determine the goodness‐of‐fit of
being female, being older, more daily hours devoted to caregiving, and
the model testing the degree to which ambivalent and guilt feelings
having guilt feelings were directly associated with caregivers' depres-
are related to depressive symptomatology. Based on the stress and
sive symptomatology.
coping model adapted to caregiving (e.g., Haley et al., 1987), the fol-
The direct associations between frequency of and reaction to dis-
lowing dimensions of the model were considered: contextual variables
ruptive behaviours and ambivalent feelings with depressive symptom-
(caregivers' age, gender, and kinship), demands or stressors (frequency
atology, which were significant in the correlational analysis, were no
of disruptive behaviours), appraisal of demands as stressful (reaction to
longer significant once all the assessed variables were considered in
disruptive behaviours), and potential mediators between appraisals
the model. The results of the bootstrap analysis for testing mediation
and distress (ambivalence and guilt). The dependent variable was
showed that the indirect effect of frequency of disruptive behaviours
depressive symptomatology.
(standardized indirect effect = .08; p < .01; SE = .018; 95% CI = 0.05–
As a first step, all the associations between variables that were
0.11) and reaction to disruptive behaviours (standardized indirect
found to be significant in the correlation analyses were established.
effect = .10; p < .01; SE = .021; 95% CI = 0.06–0.14) on depressive
Next, following the model‐generating strategy (Joreskog, 1993), only
symptomatology were significant. These findings suggest that
those significant associations between variables that were observed
reporting a higher number of disruptive behaviours was associated
once the model was run were included in the final model. In addition
with the chances of perceiving them as stressful, and both factors were
to the chi‐square (χ2) statistic, the chi‐square value divided by the
related to the experience of ambivalent feelings and guilt by the care-
degrees of freedom (χ2/df) was considered, with values under or near
givers. These links were significantly associated with higher scores in
3 indicating good model fit (Bollen, 1989). The root mean square error
depressive symptomatology.
of approximation (RMSEA), the comparative fit index (CFI), and the
Regarding the specific effect of ambivalent feelings on depressive
Tucker–Lewis index (TLI) were also assessed, considering Hu and
symptomatology, the results of the bootstrap analysis for testing medi-
Bentler's (1998) indications of values under .06 (RMSEA) and over
ation suggest that the indirect effect of ambivalent feelings on depres-
.95 (CFI and TLI) as indicating excellent fit of the data to the model.
sive symptomatology through guilt was significant (standardized
Mediation analysis following Preacher and Hayes's (2004) recom-
indirect effect = .23; p < .01; SE = .037; 95% CI = 0.17–0.29). Thus, it
mended bootstrapping approach was conducted, using 1,000 boot-
appears that the association of ambivalent feelings with depressive
strap samples.
symptoms was not direct. More intense ambivalent feelings were asso-
ciated with higher guilt feelings, and this link was associated with care-
givers' levels of depressive symptomatology.
3 | RESULTS
The obtained model explained 18% of the variance of ambivalent
feelings, 41% of guilt feelings, and 35% of caregivers' depressive symp-
3.1 | Descriptive data tomatology. The obtained fit indexes suggest an excellent fit of the
The study sample had a mean age of 61.40 years (SD = 14.36) and model to the data (χ2 = 39.72; p = .11; χ2/df = 1.32; RMSEA = .039;
included mostly women (77.6%). Most participants cared for a spouse CFI = .986, and TLI = .979).
4 LOSADA A. ET AL.

TABLE 1 Correlation matrix and means, standard deviations, and ranges of the assessed variables
1 2 3 4 5 6 7 8 9 10

1—Gender (1 = female)
2—Caregiver age −.19**
3—Caring for parents (1 = yes) .19** −.65**
4—Time since being a caregiver .01 .20** −.15*
5—Daily hours caring −.04 .45** −.38** .00
6—Frequency disruptive behaviours .17* −.06 .08 .31** −.04
7—Reaction to disruptive behaviours .17* −.09 .14* .20** −.07 .83**
8—Guilt .07 −.27** .33** −.02 −.18* .25** .29**
9—Ambivalent feelings .18** −.15* .15* −.01 −.07 .32** .43** .62**
10—Depressive symptomatology .29** .13 −.05 .00 .29** .24** .23** .32** .30**
Mean 61.40 3.73 13.19 6.97 5.51 25.05 4.83 21.63
SD 14.36 2.91 8.30 5.52 5.16 14.17 3.51 12.20
Range 21–88 0.3–20 1–24 0–27 0–25 0–65 0–15 1–48

*p < .05;
**p < .01.

FIGURE 1 Path analysis testing the role of

ambivalence and guilt in the caregiving
process. Note. All associations are significant
(p < .05). The errors have been omitted for
ease of presentation

4 | DISCUSSION (e.g., disruptive behaviours) on caregiving consequences vary depend-

The goal of this study was to analyse the role of ambivalence and guilt
feelings as contributors to caregivers' depressive symptomatology.
Although the associations between depressive symptoms and ambiva-
lence (Losada et al., 2016) and guilt feelings (Losada et al., 2010; Roach
et al., 2013) have been reported in previous research, this study offers
the first evidence of the pathways through which they are linked with
caregivers' depressive symptomatology. Specifically, we found that the
significant correlation between frequency of and reaction to disruptive
behaviours with caregivers' depressive symptomatology became insig-
nificant when other variables (ambivalence and guilt feelings) were
controlled. These results suggest that the association between these
variables is indirect, mediated through ambivalence and guilt. That is,
caregivers' ambivalent feelings are higher when caregivers face disrup-
tive behaviours (Hypothesis 1), and, in turn, having ambivalent feelings
is related to stronger guilt feelings in caregivers (Hypothesis 2). This
process is significantly associated with caregivers' depressive symp-
tomatology (Hypothesis 3). The findings provide support for the stress
and coping model, which postulates that the relationship of stressors
ing on resource variables (e.g., Haley et al., 1987).
Moderate to strong associations were found between disruptive
behaviours, ambivalence, guilt, and depressive symptomatology, sug-
gesting that the contribution of ambivalence and guilt to understand-
ing caregivers' distress is significant. A significant percentage of
variance of ambivalence, guilt, and depressive symptomatology was
explained through the variables included in the tested model.
Consistent with previous research, our results show that being
female and providing a higher number of hours of care per day are asso-
ciated with higher depressive symptoms (Covinsky et al., 2003; Pinquart
& Sörensen, 2006). In addition, compared with individuals caring for
spouses, younger caregivers (Spillers et al., 2008) and those caring for
parents show higher levels of guilt (Romero‐Moreno et al., 2014) and
ambivalence. Interestingly, those providing care for more hours daily
reported lower guilt scores but higher depressive symptomatology. Indi-
viduals providing more hours of care may perceive that they are behav-
ing consistently with their values that families should provide as much
care as possible. Nevertheless, they may also feel more depressed due
to the activity restriction resulting from the time spent providing care.
LOSADA A. ET AL.
These results have several implications for practice. Of particular
note is the finding that care recipients' disruptive behaviours are associ-
ated with caregivers' ambivalent feelings. Although most caregivers will-
ingly provide care to a loved one, the occurrence of disruptive behaviours
may also generate negative feelings such as rejection, shame, or anger.
Such feelings are uncomfortable and distressing for caregivers. However,
they typically emerge that in the context of a close relationship, positive
affect and love toward the person with dementia are also present. The
co‐occurrence of negative feelings toward the care recipient because
of these disruptive behaviours and the positive feelings associated with
long‐standing bonds and attachment produce the experience of ambiva-
lence. In turn, caregivers experience guilt about the experience of such
mixed (rather than positive) feelings.
The inclusion of strategies for addressing and managing ambiva-
lence and guilt feelings in interventions for caregivers may increase
the effects of available interventions for reducing caregivers' levels of
distress (e.g., Logsdon, McCurry, & Teri, 2007; Losada et al., 2015).
Therapeutic strategies that focused on compassion (Gilbert, 2009),
both for others and for self (self‐compassion), may also be useful inter-
ventions to reduce guilt feelings and ambivalence.
Several limitations of the study should be mentioned. First, the
cross‐sectional design does not allow for causal inferences to be made.
We cannot reject the possibility that the direction of the observed asso-
ciations may be reversed. For example, it is possible that caregivers'
depressive symptomatology increases the reporting of ambivalence and
guilt feelings. Second, although the sample size of the study is acceptable
(bearing in mind the difficulties in accessing this population), it does not
allow us to test the influence of specific variables that have been shown
to play a significant role in similar studies of caregivers. For example, kin-
ship affects caregivers' distress (e.g., Romero‐Moreno et al., 2014; Viñas‐
Diez et al., 2017), but this variable has not been controlled in this study.
Similarly, in this study, data were available from the disruptive behav-
iours subscale of the Revised Memory and Behaviour Problems Checklist
(Teri et al., 1992), which measures the symptoms that are most
distressing for the caregivers (Fauth & Gibbons, 2014). Future studies
should analyse if the obtained results are also valid for other behavioural
and psychological symptoms of dementia such as depressive symptoms
or memory problems. In addition, dementia family caregivers also show
low levels of quality of life (Coen, O'Boyle, Coakley, & Lawlor, 2002)
and high levels of anxiety (Joling et al., 2015). Further, emotion‐regulation
variables have been found to influence in caregivers' anxiety levels, such
as emotional intelligence (Weaving, Orgeta, Orrell, & Petrides, 2014) and
rumination (Romero‐Moreno, Losada, Márquez‐González, & Mausbach,
2016). Future studies should also analyse the association between
ambivalence, guilt feelings, and emotion‐regulation variables in dementia
family caregivers. In addition, it has been suggested that guilt has a salient
impact on expressed emotion (e.g., emotional overinvolvement; Cherry,
Taylor, Brown, Rigby, & Sellwood, 2017), and expressed emotion appears
to predict negative care recipients' behaviours over time (Vitaliano,
Young, Russo, Romano, & Magana‐Amato, 1993). Therefore, analysing
the impact of guilt, ambivalence, and expressed emotion in the caregiving
process may provide useful information regarding the design and imple-
mentation of interventions for caregivers.
Despite these limitations, this first study to analyse the association
of caregivers' ambivalence and guilt feelings with depressive
5
symptomatology supports a potential etiological pathway for the relation-
ship between these variables and depression. The results suggest that
ambivalence and guilt feelings are relevant variables for understanding
caregivers' distress and may be important targets for interventions aimed
at helping caregivers to cope with caring for a relative with dementia.
ACKNOWLEDGEMENTS
We thank all the caregivers for their participation in the study and also
the following centres for collaborating with us in the project: Centros
de día SARquavitae, Fundación María Wolff, Centro de Salud General
Ricardos, Centro de Salud García Noblejas, Centro de Salud Benita
de Ávila, Centro de Salud Vicente Muzas, Centro Reina Sofía de Cruz
Roja, Unidad de Memoria de Cantoblanco, Asociación de Familiares
de Alzheimer de Alcorcón, and Centro de Psicología Aplicada de la
Universidad Autónoma de Madrid.
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How to cite this article: Losada A, Márquez‐González M, Vara‐
García C, Gallego‐Alberto L, Romero‐Moreno R, Pillemer K.
Ambivalence and guilt feelings: Two relevant variables for under-
standing caregivers' depressive symptomatology. Clin Psychol
Psychother. 2017;1–7. https://doi.org/10.1002/cpp.2116