International Psychogeriatrics (2010), 22:4, 650–660 

C International Psychogeriatric Association 2010

doi:10.1017/S1041610210000074

Development and validation of the Caregiver

Guilt Questionnaire
.........................................................................................................................................................................................................................................................................................................................................................................

Andrés Losada,1 Marı́a Márquez-González,2 Cecilia Peñacoba1

and Rosa Romero-Moreno1
1
Psychology Department, Universidad Rey Juan Carlos, Madrid, Spain
2
Clinical and Health Psychology Department, Universidad Autónoma de Madrid, Madrid, Spain

ABSTRACT

Background: Family care of frail elderly people has been linked to significant negative consequences for
caregivers’ mental health. Although outcome variables such as burden and depression have been widely
analyzed in this population, guilt, an emotion frequently observed in caregivers, has not received sufficient
attention in the research literature.
Methods: Face-to-face interviews were carried out with 288 dementia caregivers. Guilt was measured using
the Caregiver Guilt Questionnaire (CGQ).
Results: Using principal components analysis, 22 items were retained and five factors were obtained which
explained 59.25% of the variance. These factors were labeled: guilt about doing wrong by the care recipient,
guilt about not rising to the occasion as caregivers, guilt about self-care, guilt about neglecting other relatives,
and guilt about having negative feelings towards other people. Acceptable reliability indexes were found, and
significant associations between the CGQ and its factors and the Zarit Burden Interview guilt factor were
also found. Caregivers with higher scores on the CGQ also scored higher in depression, anxiety, frequency
and appraisal of behavioral problems. Negative associations between the CGQ and its factors and frequency
of/and satisfaction with leisure and social support were also found. Being female and caring for a parent were
associated with higher scores on the CGQ.
Conclusions: Feelings of guilt are significantly related to caregiver distress. The CGQ may be a useful measure
for acknowledging feelings of guilt in caregivers; moreover, it can be used as an outcome variable for
psychoeducational interventions aimed at reducing caregiver distress.

Key words: anxiety, assessment, behavioral problems, burden, dementia, depression, leisure, social support

Introduction Cooper et al., 2008). There remain, however, some

emotions, such as guilt, which have not received
Family care of frail elderly people has been linked
adequate attention in the research literature, even
to significant negative consequences for caregivers’
though they are frequently observed in caregivers
mental health. Outcome variables such as burden
(Yaffe, 1988).
and depression have been widely analyzed, with
Guilt has been described as “the dysphoric
many research studies demonstrating that caregivers
feeling associated with the recognition that one
as a group, especially if they are caring for relatives
has violated a personally relevant moral or
with Alzheimer’s disease and other dementias, show
social standard” (Kugler and Jones, 1992). Guilt
higher scores on depression and stress than non-
has also been suggested as a factor potentially
caregivers (e.g. Pinquart and Sörensen, 2003).
contributing to depression and distress in non-
Other negative emotional outcomes in caregiving,
dementia caregivers (Boye et al., 2002; Spillers
such as anger or anxiety, have received more
et al., 2008) and non-caregiving samples (Ghatavi
attention in recent years (Coon et al., 2003;
et al., 2002) and some research considers it as a
Correspondence should be addressed to: Andrés Losada-Baltar, Facultad de main emotion for caregivers, which may exacerbate
Ciencias de la Salud. Departamento de Psicologı́a, Edificio Departamental II. their burden (e.g. Brodaty, 2007). The association
Avda. de Atenas, s/n. 28922 Alcorcón, Madrid, Spain. Phone: + 34 914888941. between guilt and burden or depression may be
Email: andres.losada@urjc.es. Received 30 Sep 2009; revision requested 26 Oct
2009; revised version received 4 Jan 2010; accepted 5 Jan 2010. First published either direct or indirect, that is, mediated or
online 22 February 2010. moderated by other relevant variables in caregiving,

such as social support or frequency of and
satisfaction with leisure or pleasant activities.
Despite the fact that researchers have called for
the analysis of guilt in both community and long-
term care (e.g. Hamel, 1995; Ankri et al., 2005),
the number of studies analyzing guilt in dementia
caregiving remains small.
Gonyea et al. (2008) analyzed guilt by rating
answers to an open-ended question posed to 66
caregivers of elderly relatives (“Some women tell
us that they feel guilty about their caregiving: how
guilty would you say you feel about it?”). Drawing
upon the stress and coping model, these authors
found that guilt contributed to the explanation of a
significant proportion of burden, even when other
significant variables were controlled for (e.g. basic
and instrumental activities of daily living).
Guilt has also been analyzed in dementia
caregiving as one of the components (factors) of
burden. Through principal component analysis of
the Zarit Burden Interview (ZBI; Zarit et al.,
1980), Ankri et al. (2005) obtained a factor made
up of four items, which they called “guilt”, as
most of these items assessed a general sense of
inadequacy as a caregiver (e.g. “Do you feel that
you should be doing more for your relative?”
or “Do you feel you could do a better job
in caring for your relative”). They found this
subscale to be significantly related to the patient’s
behavioral problems (e.g. verbal aggressiveness and
sadness). In a study with caregivers of children
with intellectual disabilities, Gallagher et al. (2008)
found that guilt, as assessed with the ZBI, was the
strongest predictor of caregiver anxiety. However,
even though the ZBI’s guilt factor may function
as a good indicator of a general sense of guilt
in caregivers, we consider this feeling to be a
rather complex one, since as well as this general
feeling of inadequacy as a caregiver there may
be different types of guilt specifically associated
with different sources or situations potentially
affecting a caregiver’s emotional state; for example,
interactions with the care recipient, role conflict,
devoting time to themselves, etc. The analysis of
the specific type of guilt or the diverse sources
contributing to the generation of this emotion may
be very helpful for clinicians working with the
population in question.
To our knowledge, there is only one instrument
that has been specifically developed for measuring
guilt in dementia caregivers, namely, the Caring
Guilt Scale developed by Martin et al. (2006).
This scale focuses on feelings of regret and sense
of responsibility (e.g. “If I did not spend my
time caring for my relative I know I would feel
deep regret”). Martin et al. (2006) analyzed the
relationship between guilt and depression in a
Caregiver Guilt Questionnaire 651
sample of 70 dementia caregivers, finding no
significant association between the two variables. It
is important to note, however, that the six items
making up the Caring Guilt Scale are written in
conditional terms (e.g., “I would worry about my
relative if I did not care for them as I do”), so that the
answers may be reflecting not the current situation,
but rather an imagined one. Also, the psychometric
data the authors provided for the scale were scarce.
Considering that (a) guilt is an important feeling
for caregivers, (b) improving our knowledge about
this variable will increase our ability to understand
the factors contributing to caregiver distress, and
(c) there are few instruments available for
measuring this construct, the aim of this study is to
develop a measure for assessing guilt in dementia
caregivers and to assess its psychometric properties.
Methods
Population
Participants were caregivers of relatives with
dementia living in the community. All caregivers
were recruited through social and health care
centers in Madrid (Spain) between September 2005
and May 2009. Once located, an initial interview
was carried out by telephone in order to confirm
that volunteers were the primary caregivers of family
members with dementia. In order to participate
in the study, caregivers were required to identify
themselves as the primary source of help for their
relatives, and to report devoting more than one
hour per day to caregiving duties for more than
three months during the assessment period. Two-
hundred-and-ninety caregivers were called for the
assessment interview. Two of them quitted the
interview referring to lack of time due to caregiving
duties. The sample characteristics of the final
sample (288 caregivers) are shown in Table 1.
Caregivers gave their consent to participate in the
study, and approval for the research was obtained
from both the Spanish Ministry of Education and
the Ethics Committee at the Rey Juan Carlos
University (Madrid).
Measures
Face-to-face interviews were carried out by trained
psychologists with each of the caregivers at
the participating social and health centers. The
interviews lasted approximately 90 minutes, and
included the following variables (means, standard
deviations and range for the assessed variables are
shown in Table 2):
Sociodemographic information. This comprised the
caregiver’s and care recipient’s age, gender and
652 A. Losada et al.

Table 1. Sample characteristics

N % M SD RANGE
...........................................................................................................................................................................................................................................................................................................

Caregiver age (years) 288 59.63 12.60 29–87

Caregiver sex
Female 228 79.2
Male 60 20.8
Daily hours caring 10.91 7.84 1–24
Time caring (in months) 53.15 46.10 3–312
Co-residence
Yes 225 78.1
No 63 21.9
Care recipient
Spouse 107 37.2
Parent 166 57.6
Other relative (father-in-law, 15 5.2
mother-in-law,
aunt, etc.)
Care recipient age 78.97 8.35 48–97
Relative’s illness
Alzheimer’s disease 167 58.4
Other dementia 121 41.6

Table 2. Means, standard deviations and range for Burden. The Zarit Burden Interview (Zarit et al.,
the assessed variables 1980) was used, and the ZBI guilt factor obtained by
Ankri et al. (2005) was used to analyze convergent
M SD RANGE
........................................................................................................................................................
validity. Because the burden scale was included in
Burden 30.50 15.90 1–69 the latter stages of the study, data for this instrument
Frequency of behavioral 34.90 14.68 0–83 are only available for 166 caregivers. The internal
problems consistency found in this study for this scale was
Appraisal of problem 17.81 14.62 0–64 0.90 (Cronbach’s α).
behaviors Frequency and appraisal of behavioral problems.
Care recipient functional 66.34 31.01 0–100 The Revised Memory and Behavior Problems
status Checklist (Teri et al., 1992) was used to assess these
Frequency of leisure 8.21 4.41 0–23 variables. It includes 24 items which, through two
activities subscales, assess both the frequency of behavioral
Satisfaction with leisure 6.57 3.56 0–19
problems and the appraisal of these behaviors as
activities
being irritating or upsetting for the caregivers. In
Social support 10.63 3.84 1–18
Anxiety 16.14 8.91 0–36 this study, the internal consistency found for the
Depression 18.00 11.73 0–55 frequency scale was 0.82, and for the appraisal scale
(45.49∗ ) was 0.88 (Cronbach’s α).
∗ Percentage
Functional status. The care recipient’s functional
of caregivers above clinical cut-off for depression. status was assessed with the Barthel Index
(Mahoney and Barthel, 1965). Higher scores on this
kinship, time spent caring (in months), and number measure are indicative of better physical functioning
of hours per day devoted to care. of the relative. Internal consistency of this scale was
Guilt. Following a review of the literature, and 0.92. (Cronbach’s α).
based on the clinical experience of the authors and Frequency of and satisfaction with leisure.
three other experts consulted for this purpose, we Satisfaction with leisure time was rated using the
developed an initial pool of 34 items measuring Stevens et al. (2004) Leisure Time satisfaction
guilt. All the items were originally created for the measure. This instrument consists of six items
development of the Caregiver Guilt Questionnaire measuring the level of satisfaction felt by caregivers
and no initial domains or factors were hypothesized, with regard to the amount of time spent on leisure
given the limited literature in this area. Response activities over the past month (quiet time for
options range from 0 (“never”) to 4 (“always or yourself, engaging in hobbies, etc.). It was measured
almost always”) (see Appendix). on a three-point Likert-type scale (0 = “not at

all”; 2 = “a lot”). Frequency of leisure activities
was measured using an adaptation of the Leisure
Time satisfaction measure. Caregivers were asked
to report the extent to which they had participated
in the assessed activities over the previous month.
This was measured on a five-point Likert-type scale
(0 = “not at all”; 4 = “a lot”). Internal consistency
indices in the present study were 0.83 for the
satisfaction scale and 0.73 for the frequency scale
(Cronbach’s α).
Social support. The Psychosocial Support
Questionnaire (PSQ; Reig et al., 1991) was used.
This scale has six items (e.g. “My friends and/or
relatives pay me visits at home”) that were used to
assess caregivers’ perceptions of the frequency of
support they receive. Response options range from
0 (“never”) to 3 (“very often”). In the present study
we found an internal consistency index for this scale
of 0.78 (Cronbach’s α).
Anxiety. The Tension-Anxiety subscale from the
Profile of Mood States (POMS; McNair et al.,
1971) was used. It consists of nine items (e.g.
“tense”), and caregivers are asked to rate on a
Likert-type scale (0 = “not at all”; 4 = “extremely”)
how they felt during the previous week. Internal
consistency for this scale in this study was 0.85
(Cronbach’s α).
Depression. Depression was assessed by means of
the Center for Epidemiological Studies-Depression
Scale (CES-D; Radloff, 1977), a 20-item measure
that assesses depressive symptomatology (e.g. “I felt
sad”), with response options ranging from 0 (“rarely
or none of the time [less than one day per week]”)
to 3 (“most or all of the time [5–7 days perweek]”).
Scores of 16 or higher may be indicative of clinical
depression (Radloff and Teri, 1986). Cronbach’s α
coefficient for this scale was 0.90.
Results
Factorial validity of the Caregiver Guilt
Questionnaire
Following the usual procedures for the development
of assessment instruments, a principal components
analysis of the 34 initial items of the scale was
carried out using varimax rotation, in order to
maximize the orthogonality of the factors. Five
factors were obtained with eigenvalues higher than
1.0. The ten items showing the lowest factor
loadings (<0.45) on the corresponding factor
were removed. In subsequent analysis, five factors
explained 56.58% of the variance. Next, another
two items with the lowest factor loadings on
the corresponding factor (<0.45) were deleted.
The resulting 22 items loaded on five factors
Caregiver Guilt Questionnaire 653
(eigenvalues from 4.08 for the first factor to 1.77 for
the fifth factor) explained 59.25% of the variance.
Factor loadings are shown in Table 3.
The first factor includes seven items referring to
caregivers’ feelings of guilt associated with negative
feelings, emotions or acts towards their relative
(e.g. “I have felt bad about getting angry with the
person I’m caring for”). This factor, of which all
items are positively scored, was labeled guilt about
doing wrong by the care recipient. The six items of
the second factor mainly reflect caregivers’ feeling
that, in general, they could be doing a better job
as a caregiver (e.g. “I have thought that perhaps
I’m not caring well for my relative”). This factor
was labeled guilt about failing to meet the challenges
of caregiving. All items are positively scored except
item number 6, which is inversely scored. The third
factor contains four items regarding caregivers’
negative feelings about looking after themselves
and taking part in activities other than caring for
their relative (e.g. “I have felt bad for leaving my
relative in the care of someone else while I had
fun”). This factor was labeled guilt about self-care,
and all its items are positively scored. The fourth
factor is made up of two items reflecting caregivers’
negative feelings associated with the fact of not
being able to devote as much time as they would
wish to their other relatives (e.g. “I have felt bad
for not looking after my other relatives [husband,
wife, children, etc.] as I should”). This factor was
labeled guilt about neglecting other relatives, and all its
items are positively scored. The fifth and final factor
includes three items about caregivers’ negative
feelings related to having had negative emotions or
feelings towards other people who do not devote
time and effort to caregiving duties as they should,
or who do not have such responsibilities. This
factor was labeled guilt about having negative feelings
towards other people, and all its items are positively
scored.
Scores for the resulting guilt subscales are
determined by computing the sum of the scores
of the items belonging to the corresponding scale,
with item number 6 being first reversed. The total
score on the Caregiver Guilt Questionnaire (CGQ)
consists of the sum of the scores of all the subscales.
A higher score reflects greater guilt.
Reliability
Acceptable to good reliability indices were obtained
for the CGQ factors and the full scale. Specifically,
a Cronbach’s α of 0.88 was obtained for the total
scale, 0.89 for the guilt about doing wrong by the
care recipient factor; 0.76 for the guilt about failing
to meet the challenges of caregiving factor; 0.69 for
the guilt about self-care factor; 0.86 for the guilt
654 A. Losada et al.

Table 3. Factor loadings of the CGQ items

FAC TO R S

CGQ ITEMS 1 2 3 4 5
...........................................................................................................................................................................................................................................................................................................................

11. I have felt bad about telling off the person I’m caring for, for some 0.849
reason
10. I have felt bad about getting angry with the person I’m caring for 0.832
14. I have felt bad about not having more patience with the person I’m 0.754 0.375
caring for
2. I have felt guilty about the way I’ve sometimes behaved with my 0.753
relative
12. I’ve got angry with myself for having negative feelings toward the 0.693
person I’m caring for
8. I have felt bad about things I may have done wrong with the person 0.602 0.340
I’m caring for
20. I have felt guilty about having so many negative emotions in relation to 0.513 0.341
caring
22. I have felt guilty thinking that my lack of information and 0.771
preparedness might mean that I’m not handling the care of my relative
in the best way possible
9. I have thought that perhaps I’m not caring well for my relative 0.317 0.711
21. I have thought that the way I care for my relative may not be 0.636
appropriate and may make his/her problem get worse
13. I’ve found myself thinking that I’m not up to the job 0.588
5. I have thought that I’m not doing things right with the person I’m 0.545
caring for
6. I have thought that, given the circumstances, I’m doing a good job as a −0.510 −0.330
caregiver
16. I have felt bad for leaving my relative in the care of someone else while 0.774
I had fun
15. I have felt bad about leaving my relative in the care of someone else 0.706
while I do my own things (e.g. work, shopping, going to the doctor)
7. When I’ve gone out to do some pleasant activity (e.g. eating out in a 0.684
restaurant), I’ve felt guilty and unable to stop thinking that I should be
caring for my relative
1. I have felt bad about having made some plan or done some activity 0.661
without taking my relative into account
3. I have felt bad for not looking after my other relatives (husband, wife, 0.873
children . . .) as I should, due to my caregiving
4. I have felt bad about not being able to devote more time to my family 0.844
(husband, wife, children . . .), due to my caregiving
18. I have felt like a bad person for hating and/or envying other relatives 0.833
who could have taken responsibility for some caring and do not do so
19. I have felt bad for having negative feelings (e.g. hate, anger or 0.766
resentment) toward some relatives
17. I have felt guilty about having wished that others “could have this 0.590
burden” or suffer as I do
Note: Numbers in bold in each column represent items clustered to the corresponding factor. Items <0.30 are not shown.

about neglecting other relatives factor; and 0.61 for were analyzed through t tests. The results of these
the guilt about having negative feelings towards other analyses are shown in Table 4. Female caregivers
people factor. scored significantly higher than male caregivers on
the factors guilt about neglecting other relatives (t =
−2.94; p < 0.01) and guilt about having negative
Associations with demographic variables thoughts towards other people (t = −2.15; p < 0.05).
Mean differences in the CGQ factors and total Female caregivers also obtained higher CGQ total
score across sex and kinship (spouses and children) scores (t = −2.16; p < 0.05). Significant differences
 Caregiver Guilt Questionnaire 655

Table 4 Guilt mean scores (and standard deviations) across sex and kinship
G U I LT
G U I LT ABOUT
G U I LT ABOUT H AV I N G
ABOUT FA I L I N G TO N E G AT I V E
DOING MEET THE G U I LT A B O U T FEELINGS
WRONG BY CHALLENGES G U I LT NEGLECTING T OWA R D S
THE CARE OF ABOUT OTHER OTHER C G Q T O TA L
RECIPIENT CAREGIVING SELF-CARE R E L AT I V E S PEOPLE SCORE
.............................................................................................................................................................................................................................................................................................................................

Sex
Female 8.83 (6.45) 5.14 (4.66) 1.98 (2.74) 1.06 (1.87) 1.64 (2.23) 18.69 (12.83)
Male 7. 51 (6.11) 4.55 (4.62) 1.24 (2.39) 0.50 (1.13) 1.10 (1.57) 14.86 (11.81)
Care recipient
Spouse 7.33 (6.27) 4.03 (4.07) 1.34 (2.50) 0.61 (1.27) 0.89 (1.46) 13.71 (10.95)
Parent 9.70 (6.38) 5.65 (5.01) 2.13 (2.79) 1.17 (2.02) 1.99 (2.42) 20.85 (10.08)
Other relative 7.56 (6.20) 4.96 (4.35) 1.81 (2.63) 0.89 (1.62) 1.35 (1.92) 14.40 (11.38)

Table 5. Correlations and intercorrelations between guilt and other variables

G U I LT G U I LT
G U I LT ABOUT ABOUT
ABOUT FA I L I N G G U I LT H AV I N G
DOING TO MEET ABOUT N E G AT I V E
WRONG THE CHAL- N E G L E C T- FEELINGS
BY THE L E N G E S O F G U I LT ING T OWA R D S CGQ G U I LT
CARE RE- C A R E G I V- ABOUT OTHER OTHER T O TA L (ZBI
CIPIENT ING SELF-CARE R E L AT I V E S PEOPLE SCORE FAC TO R )
.........................................................................................................................................................................................................................................................................................................................

Guilt (ZBI factor) 0.401∗∗ 0.352∗∗ 0.182∗ 0.136 0.177∗ 0.455∗∗ –

Frequency of 0.334∗∗ 0.331∗∗ 0.324∗∗ 0.102 0.230∗∗ 0.418∗∗ 0.338∗∗
behavioral problems
Appraisal of behavioral 0.456∗∗ 0.457∗∗ 0.228∗∗ 0.232∗∗ 0.158∗ 0.509∗∗ 0.337∗∗
problems
Functional status 0.091 0.149∗ −0.055 −0.090 −0.031 0.057 −0.070
Frequency of leisure −0.145∗ −0.113 −0.171∗∗ −0.075 −0.096 −0.192∗∗ −0.195∗
Satisfaction with −0.248∗∗ −0.165∗∗ −0.151∗ −0.097 −0.140∗ −0.286∗∗ −0.271∗∗
leisure
Social support −0.168∗∗ −0.157∗ −0.034 −0.073 −0.061 −0.188∗∗ −0.305∗∗
Depression 0.388∗∗ 0.364∗∗ 0.248∗∗ 0.212∗∗ 0.120∗ 0.462∗∗ 0.308∗∗
Anxiety 0.440∗∗ 0.368∗∗ 0.173∗∗ 0.177∗∗ 0.198∗∗ 0.462∗∗ 0.346∗∗
Guilt about doing – 0.559∗∗ 0.352∗∗ 0.218∗∗ 0.339∗∗ 0.854∗∗ 0.401∗∗
wrong by the care
recipient
Guilt about not rising – 0.364∗∗ 0.159∗∗ 0.255∗∗ 0.765∗∗ 0.352∗∗
to the occasion as
caregivers
Guilt about self-care – 0.210∗∗ 0.283∗∗ 0.585∗∗ 0.182∗
Guilt about neglecting – 0.142∗ 0.383∗∗ 0.136
other relatives
Guilt about having – 0.507∗∗ 0.177∗
negative feelings
towards other people
p < 0.05; ∗∗ p < 0.01

in CGQ score and all the factors were also found on about failing to meet the challenges of caregiving (F =
considering kinship. Spouses obtained lower CGQ 5.51; p < 0.01), guilt about self-care (F = 5.84; p <
total scores than those caring for a parent, and 0.01), guilt about neglecting other relatives (F = 3.02;
scored lower in all CGQ factors: guilt about doing p < 0.05) and guilt about having negative thoughts
wrong by the care recipient (F = 5.44; p < 0.01), guilt towards other people (F = 12.43; p < 0.01).
656 A. Losada et al.
Convergent and criterion validity
Correlations between CGQ factors and total score
are shown in Table 5. Convergent validity was
assessed through the correlation between CGQ
factors and total score, and guilt as measured by
the ZBI guilt factor (Ankri et al., 2005). As it can be
seen, significant correlations were found between
the ZBI guilt factor and CGQ factors and total
score, except in the case of the factor Guilt about
neglecting other relatives. No significant differences
were found in guilt scores between those caregivers
who completed the ZBI and those who did not
except for the factor Guilt about neglecting other
relatives. Caregivers who completed the ZBI had
higher scores (M = 1.15; SD = 1.01) in this factor
than those who did not (M = 0.71; SD = 1.38)
(t = −2.21; p < 0.05).
Significant associations between CGQ factors
and total score and appraisal of problem behaviors,
depression and anxiety were also found. Caregivers
with higher CGQ scores also scored higher on
appraisals, depression and anxiety. Similar findings
were obtained for frequency of behavioral problems,
except that the association between this variable and
the CGQ factor guilt about neglecting other relatives
was not significant. Functional status was found
to be significantly associated only with guilt about
failing to meet the challenges of caregiving factor:
caregivers who report higher functional status of
their care recipients also score higher scores on
this CGQ factor. Caregivers who are less satisfied
with their leisure time score higher on the CGQ
and all its factors, except for the factor guilt about
neglecting other relatives. Similar findings were found
on analyzing frequency of leisure activities: those
caregivers who report taking part in more leisure
activities score lower on guilt about doing wrong
by the care recipient, guilt about self-care and CGQ
total score. Caregivers with higher scores on social
support present lower scores on guilt about doing
wrong by the care recipient, guilt about failing to meet
the challenges of caregiving and CGQ total score.
Similar associations to those found with the CGQ
were found between the ZBI guilt factor and all
the other variables assessed: all associations were
significant, except that with functional status.
Discussion
The main aim of this study was to examine
the psychometric properties of a new scale
for measuring guilt among dementia caregivers,
namely, the Caregiver Guilt Questionnaire (CGQ).
Through principal component analysis, 22 items
were found to be represented by a five-factor
structure. The factors were labeled guilt about doing
wrong by the care recipient, guilt about failing to meet
the challenges of caregiving, guilt about self-care, guilt
about neglecting other relatives and guilt about having
negative feelings towards other people. A significant
proportion of variance of the guilt construct is
explained by these factors, and reasonable internal
consistency indices were found for all the factors
and for the total questionnaire.
The convergent validity of the CGQ was
supported by the substantial correlations found
between the CGQ (total score and some of its
factors) and the ZBI guilt factor (Ankri et al., 2005),
especially with the first two factors, guilt about doing
wrong by the care recipient and guilt about failing to
meet the challenges of caregiving. This result is not
surprising if we consider that the content of the
items included in these two factors is similar to that
of the items included in the ZBI guilt factor: guilt
associated with a general sense of not being a good
caregiver. The low, though significant, correlations
between the ZBI guilt factor and the CGQ factors
guilt about self-care and guilt about having negative
feelings towards other people, on the one hand, and
the non-significant association with the factor guilt
about neglecting other relatives, on the other, suggest
that the CGQ measures dimensions of guilt which
are not tapped by the ZBI guilt factor. Furthermore,
the low to moderate intercorrelations between the
CGQ factors, together with the different patterns
of associations found between the CGQ factors
and the other variables analyzed in the study,
reveal that guilt may be better conceived as a
multidimensional and domain-specific experience.
However, this should not necessarily be taken
as an argument against the usefulness of a total
CGQ score, which is supported by the interesting
correlations found between this global score and the
variables included in the study.
In this regard, similar results to those found by
Ankri et al. (2005) with the ZBI guilt factor were
obtained. Caregivers looking after their parents had
higher guilt scores than spouses in CGQ total score
and all its factors. This result could be explained by
the fact that adult children giving care, especially
daughters, may have more sources of guilt, as they
are more likely to experience conflict between their
multiple roles (caregiver, mother or father, worker,
etc.) and to perceive interference of their caregiving
role with work and family (Yee and Schulz, 2000).
In this regard, adult children caregivers have been
found in some studies to admit potentially harmful
behaviors (e.g. verbal aggression, ignoring) towards
their care recipients to a greater extent than spouse
caregivers (Sasaki et al., 2007). Such behaviors are
likely to generate guilt in caregivers.

In this study, guilt has also been found to be
significantly associated with behavioral problems in
the care recipient. As Pagel et al. (1985) argue,
caregivers facing more behavioral problems may
make stronger attempts to control their relative’s
behaviors. Given the difficulty of controlling such
behaviors, their attempts may be frustrating and/or
unsuccessful, thus generating feelings of guilt.
In a similar way to what has been found for other
distress-related variables in caregiving research (e.g.
Pinquart and Sörensen, 2003), female caregivers
scored significantly higher than male caregivers,
specifically in the factors guilt about neglecting other
relatives and guilt about having negative feelings
towards other people. Caring for others is a more
central element in their identity than it is for men,
and female caregivers are usually more involved
than male caregivers in the roles of assisting and
nurturing all family members, besides the care
recipient. Given that women usually perceive more
responsibility for caring for all family members, they
are likely to be more vulnerable to guilt associated
with the perception that they are neglecting other
relatives due to caregiving. In fact, female caregivers
have been found to report more role conflict, more
caregiving costs and more interference with family
and leisure time than do men (Ingersoll-Dayton
and Raschick, 2004). The finding that female
caregivers report more guilt than men about having
negative feelings towards other people could be
explained by the fact that female caregivers report
greater role strain than male caregivers (Ingersoll-
Dayton et al., 1996) and receive less formal and
informal support (Yee and Schulz, 2000). These
differences between male and female caregivers
may be related to different coping styles, but
also to different internalized norms about caring
and nurturing responsibilities, with women more
liable to assume caregiving as a moral (filial)
responsibility they have to bear, that is, as “the
normal way” they should behave according to
social and family expectations (Ingersoll-Dayton
and Raschick, 2004). As suggested by Gonyea
et al., (2008), role theory can provide interesting
insights for understanding the emergence of guilt
feelings among adult children caregivers, especially
women. These gender differences may explain why
female caregivers have been systematically found
in the caregiving literature to report more burden,
anxiety, depression and health problems than male
caregivers (Pinquart and Sörensen, 2003; Yee and
Schulz, 2000). These negative emotional outcomes
may facilitate the generation of negative thoughts or
feelings towards other people, such as irritability or
resentment.
The results of this study are consistent with
those of previous studies suggesting the relevance
Caregiver Guilt Questionnaire 657
of guilt in caregiving outcomes. Strong associations
were found between guilt and important outcome
variables such as depression or anxiety, suggesting
a significant relationship between guilt feelings and
caregiver distress. Similarly, Gallagher et al. (2008)
found guilt, as measured with the ZBI guilt factor,
to be associated with greater anxiety in caregivers
of children with intellectual disabilities. It is our
hypothesis that caregiver guilt contributes to the
generation and exacerbation of depression and
burden. However, the cross-sectional nature of this
study precludes us from drawing any conclusions
about causal links between guilt and other negative
emotional outcomes in caregiving.
Another relevant finding of this study that
endorses the need to take guilt feelings into account
on analyzing caregiver distress are the significant
associations between guilt and other variables
pertaining to key dimensions in theoretical models
such as the stress and coping model (e.g. Knight
et al., 2000). For example, caregivers who report
having guilt feelings about doing wrong by their care
recipient or failing to meet the challenges of care-
giving report low scores on leisure (frequency and,
to a greater extent, satisfaction with leisure) and so-
cial support. Once again, the cross-sectional design
of the study does not permit us to make causal
inferences in this regard, but it would be really
interesting for future studies to analyze whether
guilt feelings have any influence on the reduction of
time devoted to leisure or of social support levels.
Some other limitations of this study should
be acknowledged. With regard to random error,
although internal consistency of the scale (and
its factors) has been found to be reasonable, no
test-retest assessment of guilt has been made, so
data on the stability over time of CGQ scores are
not available. With regard to potential sources of
systematic error, some of these can be addressed.
For example, regarding content validity, other
domains or experiences that may be sources of guilt
for caregivers (e.g. thoughts about placing the care
recipient in a nursing home) are not tapped by the
CGQ, even though they may influence caregiver
distress. Furthermore, as several empirical studies
have shown in recent years, there are substantial
differences in caregivers’ experience of distress
across cultures (e.g. Knight et al., 2000), and guilt
is considered to be a culturally sensitive emotion,
strongly influenced by cultural perspectives and
social norms (Bierbrauer, 1992). In order to test the
cross-cultural content validity of the CGQ, it seems
necessary to apply this instrument in other cultures
so as to confirm the findings of the present work.
Finally, the convenience-based nature of the sample
limits its representativeness and, in consequence,
the generalizability of the results.
658 A. Losada et al.
As has been already noted, the construct of
guilt has not yet been adequately integrated into
empirically based models of personality and/or
emotion (Kugler and Jones, 1992). Currently, solid
theoretical accounts of this emotional experience
are still lacking, especially in caregiving research,
where this variable has started to be analyzed only
very recently. Hence, there is a clear need for
empirical studies, such as that presented here, which
may contribute to improve our understanding of the
psychological and behavioral implications of guilt,
and the dynamic of its relationships with caregivers
distress and coping behaviors. These studies may
eventually help us to develop more comprehensive
caregiving models which include this variable and
thus describe more accurately caregivers’ subjective
experiences. The main contributions of the present
study to the literature on guilt may be summarized
as follows: it provides evidence on (a) the multi-
dimensional and domain-specific nature of guilt;
(b) the association between guilt and caregivers’
distress; and (c) potential behavioral implications
of guilt (frequency of and satisfaction with leisure),
which may mediate its relationship with distress.
It is clear that there are many questions regarding
guilt which deserve further attention, such as the
relationship between guilt and caregivers’ values
(e.g. familism), moral or religious beliefs, or
dysfunctional thoughts about caregiving. These
questions could be explored in future studies which
would provide important insights into the nature of
guilt and its role in the caregiving stress process.
The practical implications of our findings are
evident: they indicate the importance of addressing
guilt feelings in interventions and helping caregivers
to acknowledge and manage them, as a way of
reducing their distress and of promoting more
adaptive ways of coping with caregiving. In this
regard, helping caregivers to review and adjust
their expectations and standards in relation to their
obligations and capacities, to accept their limitations
and weaknesses, and to acknowledge their needs,
might facilitate a reduction in their guilt feelings
which, in turn, could lead to the development of
more adaptive behaviours, such as increasing their
leisure activities or seeking social and instrumental
support, which constitute important targets in
cognitive-behavioral interventions (e.g. Coon et al.,
2003). Even when this study has focused on
the measurement of guilt in dementia caregivers,
this emotional phenomenon is considered to be
a key experience in many different caregiving
experiences, and it has been found to be associated
with psychosocial maladjustment in caregivers (e.g.
Spillers et al., 2008). In this sense, it might be
interesting to explore the usefulness of the CGQ to
assess guilt in caregivers of people suffering from
other chronic conditions (e.g. terminal illnesses
such as cancer).
In conclusion, the CGQ presents acceptable
psychometric properties, and may contribute to
the development of sensitive and conceptually valid
outcome measures for psychosocial intervention
research (Moniz-Cook et al., 2008). It is our hope
that future studies using this instrument in our
context and in other countries will permit further
analysis of its utility for getting closer to our shared
objective of improving our ability to help caregivers.
Conflict of interest
None.
Description of authors’ roles
Andrés Losada and Marı́a Márquez-González both
worked on the design of the study and its imple-
mentation, the development of the CGQ items, the
data analysis and the writing of the paper. Cecilia
Peñacoba collaborated on the development of the
CGQ items. Rosa Romero-Moreno worked on the
study implementation and the writing of the paper.
Acknowledgments
The authors would like to thank Nancy Pachana,
Ph.D., from the University of Queensland, for her
help with the CGQ back-translation. This study
was partially funded by grants from the Spanish
Ministry of Education (SEJ2006–02489/PSIC)
and from the Spanish Ministry of Science and
Innovation (PSI2009-08132/PSIC).
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Appendix: Caregiver Guilt Questionnaire (CGQ)
Below is a list of some feelings and thoughts.
Please tell us how often you have had these feelings
and thoughts during the past few weeks using the
following options:
0 = never; 1 = rarely; 2 = sometimes; 3 = several
times; 4 = always or almost always
1. I have felt bad about having made some plan or
done some activity without taking my relative into
account [Me he sentido mal por haber hecho algún
plan o actividad sin contar con mi familiar].
2. I have felt guilty about the way I’ve sometimes
behaved with my relative [Me he sentido culpable
por la forma en que me he comportado en ocasiones
con mi familiar].
3. I have felt bad for not looking after my other relatives
(husband, wife, children . . .) as I should, due to my
caregiving [Me he sentido mal por no atender a
mis otros familiares (marido, mujer, hijos. . .) como
deberı́a, debido al cuidado].
4. I have felt bad about not being able to devote more
time to my family (husband, wife, children. . .), due
to my caregiving [Me he sentido mal por no poder
dedicar más tiempo a mi familia (marido, mujer,
hijos . . .) como deberı́a, debido al cuidado].
5. I have thought that I’m not doing things right with
the person I’m caring for [He pensado que no estoy
haciendo las cosas bien con la persona a la que estoy
cuidando].
6. I have thought that, given the circumstances, I’m
doing a good job as a caregiver [He pensado
660 A. Losada et al.
que, teniendo en cuenta las circunstancias, estoy
haciendo bien mi tarea como cuidador/a].
7. When I’ve gone out to do some pleasant activity (e.g.
eating out in a restaurant), I’ve felt guilty and unable
to stop thinking that I should be caring for my
relative [Cuando he salido a hacer alguna actividad
agradable (p.ej., ir a cenar a un restaurante), me
he sentido culpable y no he dejado de pensar
que deberı́a estar cuidando o atendiendo a mi
familiar].
8. I have felt bad about things I may have done wrong
with the person I’m caring for [Me he sentido mal
por cosas que quizá habı́a hecho mal con la persona
a la que estoy cuidando].
9. I have thought that perhaps I’m not caring well
for my relative [He pensado que quizá no estoy
cuidando bien].
10. I have felt bad about getting angry with the person
I’m caring for [Me he sentido mal por haberme
enfadado con la persona a la que estoy cuidando].
11. I have felt bad about telling off the person I’m caring
for, for some reason [Me he sentido mal por haber
regañado por alguna razón a la persona a la que
estoy cuidando].
12. I’ve got angry with myself for having negative
feelings toward the person I’m caring for [Me he
enfadado conmigo mismo/a por tener sentimientos
negativos hacia la persona a la que cuido].
13. I’ve found myself thinking that I’m not up to the
job [Me he encontrado pensando que no estoy a la
altura de las circunstancias].
14. I have felt bad about not having more patience with
the person I’m caring for [Me he sentido mal por
no tener más paciencia con la persona a la que estoy
cuidando].
15. I have felt bad about leaving my relative in the care
of someone else while I do my own things (e.g. work,
shopping, going to the doctor) [Me he sentido mal
por dejar a mi familiar al cuidado de otra persona
mientras yo hacı́a mis tareas (p.ej., trabajo, compra,
ir al médico, etc.)].
16. I have felt bad for leaving my relative in the care of
someone else while I had fun [Me he sentido mal
por dejar a mi familiar al cuidado de otra persona
mientras yo me divertı́a].
17. I have felt guilty about having wished that others
“could have this burden” or suffer as I do [Me he
sentido culpable por desear que a otros “les toque
esta cruz” o sufran lo mismo que yo].
18. I have felt like a bad person for hating and/or
envying other relatives who could have taken
responsibility for some caring and do not do so [Me
he sentido mala persona por odiar y/o envidiar a
otros familiares que podrı́an hacerse responsables
parcialmente del cuidado y no lo hacen].
19. I have felt bad for having negative feelings (e.g., hate,
anger or resentment) toward some relatives [Me he
sentido mal por tener sentimientos negativos (p.ej.,
odio, enfado o rencor) hacia algunos familiares].
20. I have felt guilty about having so many negative
emotions in relation to caring [Me he sentido
culpable por el hecho de tener tantas emociones
negativas en relación al cuidado].
21. I have thought that the way I care for my relative may
not be appropriate and may make his/her problem
get worse [He pensado que la forma en la que cuido
de mi familiar podrı́a no ser adecuada y contribuir
a que su problema vaya a peor].
22. I have felt guilty thinking that my lack of information
and preparedness might mean that I’m not handling
the care of my relative in the best way possible
[Me he sentido culpable al pensar que mi falta
de información y preparación podrı́a hacer que no
estuviera manejando el cuidado de mi familiar de la
mejor forma possible].
Note: The Spanish items are shown in square
brackets.