Affective Ambivalence in Informal Caregivers in the Face of Loss and Grief Processes

Population aging is a global phenomenon with profound implications for healthcare systems and social dynamics. In Puerto Rico, adults over 60 represent an increasing proportion of the population, placing a growing burden on informal caregivers—primarily women—who often provide long-term care without adequate training, institutional support, or emotional resources [1]. These caregivers frequently face intense emotional and physical demands that place them at heightened risk for anxiety, depression, and somatic symptoms [2,3].

One of the most underexplored psychological phenomena in this population is affective ambivalence, defined as the simultaneous experience of opposing emotions toward a care recipient, such as affection and resentment, or commitment and exhaustion [4,5]. This emotional dissonance is often triggered by ambiguous losses and anticipatory grief—forms of loss that lack clear social validation or closure [6]. If unresolved, affective ambivalence can disrupt emotional functioning, impair caregiving quality and contribute to long-term psychological distress [7,8].

Despite the increasing literature on caregiver burden, the subjective emotional experience of caregiving, particularly the coexistence of contradictory feelings, has received limited empirical attention [9,10]. This oversight hinders the development of clinically sensitive interventions that address both the cognitive and affective complexities of caregiving.

This study applies a psychoanalytic and phenomenological framework [11,12] to explore how affective ambivalence manifests in informal caregivers of older adults navigating experiences of loss and grief. By centering the caregiver’s voice, this research contributes to a more nuanced understanding of emotional vulnerability in caregiving and proposes implications for mental health interventions that reduce psychopathological risks while enhancing caregivers' emotional resilience.

Research design

This qualitative study was conducted using descriptive and interpretative empirical phenomenological design, grounded in the work of Clark Moustakas (1994) [12]. This approach allowed for an in-depth exploration of informal caregivers of older adult’s experience and to interpret affective ambivalence during processes of loss and grief. Moustakas’ methodology, which synthesizes the Van Kaam method (1966) [13] and the Stevick–Colaizzi–Keen method (1973), is particularly useful for identifying the essence of lived experience by focusing on intentionality, temporality, and intersubjectivity [14].

According to Fuster (2019) [15], phenomenology is appropriate when the objective is to analyze human experiences that transcend quantification and instead require interpretive depth. The qualitative nature of this design made it suitable for describing the internal contradictions, emotional coexistence, and subjective meaning-making processes reported by the participants.

Participants and sampling

Participants were selected through purposive, homogeneous sampling, as recommended by Creswell and Poth (2017) [16], to ensure that all participants shared key experiential characteristics related to the caregiving role. The study included five female informal caregivers residing in Puerto Rico who met the following inclusion criteria:

• Age 21 or older
• Literate in Spanish
• Resident of Puerto Rico
• Access to internet and digital devices
• Provided unpaid care to someone aged 60 or older
• If the older adult was deceased, at least one year must have passed

Exclusion criteria included being a paid caregiver, lacking technological access, or being emotionally unable to participate in the reflective interview process.

This selection process was guided by ethical and methodological principles for working with bereaved populations, including a sensitivity window of at least 12 months post-death, based on prior research [17,18].

Recruitment and ethical approval

Recruitment was conducted via social media platforms (Facebook, Instagram, WhatsApp), with prospective participants completing a Google Form. The study was approved by the Institutional Review Board (IRB) of the Pontifical Catholic University of Puerto Rico, under protocol IRB-F01. All participants received and electronically signed:

• Informed Consent Form
• Consent for Audio/Video Recording

Participants were informed of the voluntary and confidential nature of the study and were not offered monetary incentives.

Instruments and data collection

Two instruments were developed:

1. Sociodemographic Data Sheet: Collected detailed data on caregiver age, gender, marital status, education, income, caregiving experience, support networks, and the health status of the older adult.
2. Semi-Structured Interview Guide: Comprised of 35 open-ended questions across four domains—caregiving experience, affective ambivalence, types of losses, and grief manifestations. These dimensions allowed for rich, contextual exploration of emotional contradictions and meaning-making processes.

Interviews were conducted via Zoom, lasted approximately 45 to 75 minutes, and were digitally recorded. Participants were encouraged to choose quiet, private environments. Each interview was conducted in conversational Spanish, allowing for flexibility and depth [19].

Crisis management protocol

Given the sensitive nature of the study, a Crisis Identification and Intervention Protocol was implemented. This included:

• Pre-coordination with the Interdisciplinary Community Services Clinic for emergency referrals.
• Real-time emotional monitoring during interviews.
• Participant safety measures such as obtaining emergency contact information and physical location.
• Immediate cessation of interviews in the event of emotional distress.
• Follow-up and documentation submitted to the IRB within 72 hours of any adverse event.

This protocol complied with ethical standards established by the Puerto Rico Board of Psychology and the Puerto Rico Psychological Association.

Transcription and data management

Interviews were transcribed verbatim using Sonix.ai software and reviewed manually for accuracy. Transcripts incorporated verbal and non-verbal elements (e.g., pauses, sighs, intonation) to ensure contextual fidelity [14]. All documents were securely stored in encrypted digital and physical formats. After five years, they will be destroyed per IRB protocols.

Data Analysis

Analysis followed Moustakas’ Multiangulation Model (1994) [12], executed in several stages:

1. Epoche: The researcher practiced bracketing to suspend personal assumptions.
2. Initial Reading: Interviews were read in full to identify significant experiential moments.
3. Horizontalization: Equal weighting was assigned to all relevant statements.
4. Meaning Units and Categories: Statements were grouped into meaning units and clustered into themes.
5. Textural Description: Described “what” participants experienced, using their own words.
6. Structural Description: Analyzed “how” the experiences occurred, within their existential contexts.
7. Essence Synthesis: A final integrative narrative captured the essential structure of affective ambivalence.

This analysis incorporated both textual and structural elements, resulting in an integrated description of the phenomenon. Coding and theme development were performed using Microsoft Excel. Analytical rigor was maintained through:

• Credibility: Member checking and triangulation.
• Dependability: Audit trails of decisions and procedures.
• Confirmability: Reflective journaling and peer debriefing.
• Transferability: Use of thick, contextual descriptions of caregiving realities [21].

Participant and care recipient profiles

This study explored the lived experiences of five female informal caregivers between the ages of 25 and 45, all residing in Puerto Rico. Despite differing family dynamics and caregiving contexts, all participants reported common emotional, social, and psychological burdens. Below is a summary of the caregiving experiences and the conditions of the older adults under their care:

Participant 1: A 25-year-old woman assumed the role of informal caregiver for both of her grandparents, who were elderly and had since passed away. She cared for her grandfather for three years and later for her 93-year-old grandmother for one year. While pursuing her university studies, she experienced significant overload, managing hygiene, feeding, medication administration, mobility, and companionship. Initially, she received support from her mother, and later from her sister and a hired assistant. Her experience was marked by emotional exhaustion, academic disruption and family conflict. Despite having no formal training, she learned through experience and developed a complex emotional bond characterized by ambivalent feelings.

Participant 2: At age 26, this caregiver provided care for her 62-year-old mother, who was experiencing physical and cognitive decline. They lived together, and she managed daily tasks such as hygiene, feeding, companionship, and supervision of medical treatment. Direct support was minimal, with only financial assistance from a sister living abroad. Though she felt unprepared, she tried to meet her mother’s needs “doing what she could,” with no formal training. Her narrative reflects a sense of responsibility combined with emotional exhaustion and a degree of affective distance.

Participant 3: A 29-year-old woman was the primary caregiver for her father until his death, a role she held for approximately two years. During this time, she handled all caregiving responsibilities, including personal hygiene, meals, medications, household tasks, transportation to medical appointments, and companionship. Although she received occasional help from uncles and neighbors, the majority of the burden was hers. Her account reveals complicated grief marked by guilt, affective ambivalence, and an enduring emotional bond. The absence of formal training and the intensity of her caregiving experience heightened her emotional vulnerability.

Participant 4: At 38 years old, this woman cared for her 81-year-old grandmother for five years until her passing. The relationship between them was emotionally distant, and caregiving was assumed out of family obligation rather than personal choice. She managed all daily tasks—cleaning, feeding, mobility, and medical appointments—without assistance from any other family members. The lack of support led to frustration, resentment, and emotional ambivalence. Although she had no prior training, she took on the role entirely on her own, carrying a heavy emotional and physical burden.

Participant 5: This 45-year-old woman faced the complex task of simultaneously caring for two elderly family members: her 65-year-old mother and 83-year-old grandmother, both of whom are still alive and fully dependent. She has held this caregiving role for six years, assuming responsibility for hygiene, feeding, mobility, medication management, medical appointments, and household tasks. Initially supported by her mother, she became solely responsible after her mother’s cancer diagnosis. Her narrative reveals extreme exhaustion, identity erosion, and feelings of isolation, all exacerbated by the total absence of training. She expressed a profound emotional toll, visible in both her verbal account and body language.

All five women were the sole or primary caregivers, with caregiving periods ranging from two to six years. Educational backgrounds varied (from high school diplomas to master’s degrees), as did employment status (full-time work, underemployment, or public assistance). None had received formal training. They assumed the caregiving role primarily due to family expectation, not personal agency. Core responsibilities included hygiene assistance, mobility, medication management, supervision, and emotional support.

Older adults' cared profile

Older adult cared for by Participant 1: This participant provided comprehensive care for her maternal grandparents, both of whom were elderly and deceased at the time of the interview—her grandfather was 81 and her grandmother 93. Both had high levels of physical dependency, requiring full assistance with hygiene, mobility, feeding, medication management, medical appointments, and constant supervision. They lived with the caregiver, who initially assumed full responsibility in the absence of formal or familial support. The intensity of these caregiving demands created substantial emotional and logistical strain, particularly as she was trying to complete her university education simultaneously.

Older adult cared for by Participant 2: This participant cared for her mother, a 62-year-old woman who remains alive and exhibits significant functional deterioration. The mother requires help with hygiene, eating, mobility, and medication management, and shows no initiative to perform basic self-care tasks independently. In addition to caring for her mother, the participant is also responsible for her younger sister, intensifying her sense of overload. The mother is emotionally and physically dependent on the participant, who expressed feelings of moral obligation, emotional exhaustion, and affective distance in their relationship.

Older adult cared for by Participant 3: The participant cares for her father, a 73-year-old man who is still alive. He became bedridden following a hip fracture, which rendered him highly dependent for all basic daily activities. His condition is complicated by a history of alcoholism, cirrhosis, and refusal to seek medical or psychological treatment. He lives with the caregiver, who reported emotional distress and desperation due to the intensity of his needs and the emotionally complex father-daughter dynamic.

Older adult cared for by Participant 4: This participant provided care for her maternal grandmother, who passed away from cancer. The grandmother, aged 81, required sustained and intensive assistance during her terminal illness, including hygiene, mobility, medication management, and emotional support. The participant received no help from family members, leading to physical and emotional overload. Her experience was marked by anticipatory grief and affective ambivalence due to the complex intergenerational relationship and the isolation she felt throughout the caregiving process.

Older adults cared for by Participant 5: This caregiver was responsible for both her mother (65 years old) and her grandmother (83 years old), both of whom were alive at the time of the interview and fully dependent for all basic life functions. Her mother had been diagnosed with cancer, and her grandmother also exhibited severe functional decline. They lived with the participant, who managed their care simultaneously and without consistent support. The dual caregiving role caused significant physical, emotional, and existential burden, including a loss of personal identity and profound social isolation.

All caregivers reported limited support from family networks, viewing caregiving as an obligation rather than a voluntary commitment.

Thematic findings

Affective ambivalence 

Theme 1: Persistent emotional contradiction

Participants consistently described conflicting emotions—love and resentment, pride and guilt, relief and sadness—as chronic internal states rather than temporary moods. These shaped their identity as caregivers and human beings. 

Theme 2: Isolation and emotional silencing

Due to fear of criticism or cultural expectations, most participants felt unable to express ambivalence, leading to internalized emotional turmoil. 

Theme 3: Duty versus desire

Caregivers often wanted to fulfill their role but also longed for personal freedom, generating resentment masked by moral obligation. 

Illustrative quotes:

• “I felt my life had been hijacked. I was helping her, but I was also drowning” (P1)
• “My grief was mixed with anger and guilt” (P3)
• “I don’t know if I felt anything when she passed. Maybe numbness. Maybe peace” (P4)

These narratives align with [4] concept of ambivalence and with findings by Swales & Owens (2020) [22] and Van Harreveld et al. (2015) [5], who affirm that unresolved emotional contradictions carry significant psychological weight. Ambivalence here is not mere contradiction—it is an ongoing psychological tension emerging from unmet needs, blurred boundaries, and social invisibility.

Informal caregiving as a gendered role

Theme 1: Role imposition based on gender

 Participants assumed caregiving responsibilities due to cultural and familial norms that equate caregiving with female identity. 

Theme 2: Emotional labor made invisible

The psychological and emotional toll of caregiving was largely unrecognized, both by their families and broader society. 

Theme 3: Lack of shared responsibility

Support from family members was minimal, reinforcing the idea that caregiving is a solitary, gendered burden. 

• “They assumed I’d take care of her because I’m the daughter. It wasn’t even a conversation” (P2)
• “Since I don’t have children, it was automatically expected of me” (P5)

These experiences confirm the critiques posed by Vaquiro Rodríguez & Stiepovich Bertoni (2010) [23] and Torres-Avendaño et al. (2018) [24] on the feminization of care. The moral imperative attached to being a “good daughter” or “available woman” often obscured the lack of choice involved.

Experiences of loss

Theme 1: Symbolic and cumulative losses

Participants reported losing personal time, career opportunities, social connection, autonomy, and even aspects of their identity. 

Theme 2: Transformation of self

Being a caregiver eclipsed other facets of identity, reducing self-definition to that of the caregiving role. 

Theme 3: Ruptured relationships

Caregiving disrupted family dynamics, leading to isolation or estrangement. 

Quotes:

• “I lost touch with who I was” (P1)
• “She was there, but we were never close” (P2)
• “I stopped being me. I was just the caregiver” (P5)

These losses align with Boss’s (1999) [6] theory of ambiguous loss—experiences of loss without closure or resolution, deeply affecting caregivers’ emotional and psychological equilibrium.

Grief and Post-Loss dynamics

Theme 1: Delayed or blunted grieving

Some participants reported numbness or emotional suspension during end-of-life phases, with grief manifesting later. 

Theme 2: Relief and sorrow coexisting

Liberation from the caregiving role came with guilt and sadness, reflecting unresolved emotional ambivalence. 

Theme 3: Fragmented mourning

Without preparation or familial support, grief was prolonged or disjointed. 

• “I didn’t cry then, but months later I’d break down over anything elderly” (P1)
• “I cry now, but I also sleep better. There’s no guilt in resting” (P4)

These narratives reflect Edelman et al.’s (2007) [25] findings on complicated grief and point to the risks of suppressing emotional needs during caregiving.

This study positions affective ambivalence as a core emotional thread in the caregiving experience. The findings reveal that:

• Caregiving is rarely voluntary. Instead, it arises from social and gendered imperatives.
• Ambivalence is not a dysfunction. It is a legitimate emotional response to the duality of caregiving: devotion and deprivation, pride and paralysis.
• Symbolic losses deepen emotional burden. The erosion of identity, future prospects, and relationships leads to unacknowledged mourning.
• Grief is shaped by unresolved emotional tension. In many cases, the inability to grieve openly led to chronic sorrow, guilt, and emotional disorientation.

The emotional lexicon of caregivers—filled with metaphors of drowning, invisibility, and fragmentation—points to a need for narrative-based and therapeutic interventions. Caregivers must be supported not just clinically, but through validation, visibility, and justice.

Implications

The findings advocate for:

• Psychological care that validates ambivalence as a natural byproduct of caregiving.
• Policy reform to redistribute caregiving duties beyond gender norms.
• Healthcare integration of informal caregivers as essential partners in eldercare, not passive extensions of family duty.

This study reframes caregiving as a socially constructed, emotionally taxing, and ethically complex experience. Affective ambivalence emerges as both a symptom and signal of deeper structural inequities. It calls for a paradigm shift—from viewing caregiving as a silent moral obligation to understanding it as a psychosocial condition requiring recognition, support, and shared responsibility.

This phenomenological investigation reveals that affective ambivalence is not an isolated emotional state but a pervasive undercurrent throughout the caregiving journey. Caregiving in Puerto Rico, as narrated by the five women in this study is interwoven with systemic gender expectations, unacknowledged labor, and emotional paradoxes. The tension between obligation and affection, resentment and pride, loss and continuity, generates a multidimensional emotional reality.

The results confirm that caregiving, when unchosen and unsupported, can lead to significant psychological strain, identity erosion, and complicated grief. Yet, these same narratives also illuminate the depth of human resilience and emotional insight. Participants demonstrated a capacity for reflection, emotional honesty, and meaning-making that, if supported through therapeutic and community-based interventions, could serve as a foundation for emotional restoration.

Thus, caregiving should no longer be conceptualized as a private, familial task. It is a public health issue, a gender equity matter, and a human rights concern. Policies and practices must be realigned to ensure that caregivers receive the acknowledgment, support, and emotional care they require to remain healthy and whole—both during and after caregiving ends.

This study is limited by its small and homogeneous sample, composed exclusively of five female caregivers residing in Puerto Rico. While suitable for phenomenological inquiry, the findings may not be generalizable to broader caregiving populations, particularly male caregivers or individuals from other cultural, socioeconomic, or geographic contexts. Furthermore, the study relied on retrospective self-reporting, which may be influenced by memory bias, emotional distress, or selective disclosure.

An additional limitation lies in the absence of data triangulation with external sources such as observations or corroborating accounts from family members or healthcare professionals. Lastly, the use of virtual interviews, while necessary due to logistical considerations, may have constrained emotional expression or depth of disclosure for some participants.

Recommendations

1. Clinical practice: Mental health professionals should be trained to recognize and validate affective ambivalence in caregivers and integrate it into therapeutic processes. Tailored interventions, including psychoeducation, support groups, and grief counseling, should specifically address the emotional complexities associated with caregiving. 
2. Policy development: Health and social policy must formally recognize informal caregivers as essential actors within the healthcare system. This recognition should be accompanied by tangible support mechanisms such as respite services, financial stipends, and legal protections that mitigate the emotional and economic burden of caregiving. 
3. Community programs: Local organizations and public health agencies should implement culturally responsive initiatives—such as caregiver wellness programs, narrative therapy workshops, and mobile mental health services—to reach underserved and isolated caregiving populations. 
4. Education and awareness: Public awareness campaigns should seek to destigmatize emotional contradictions within caregiving and promote equitable caregiving responsibilities across genders and family structures. 
5. Future research: Further qualitative and mixed-methods studies are needed to explore the experiences of diverse caregiving groups, including LGBTQ+ caregivers, caregivers in rural versus urban settings, and those across different age brackets. Future research should also evaluate the effectiveness of therapeutic interventions aimed at reducing ambivalence, supporting grief processes, and facilitating identity reconstruction.

The findings of this study make significant contributions to existing theoretical frameworks on caregiving, grief, and affect regulation:

• First, they support expanding the concept of affective ambivalence beyond its psychoanalytic or psychiatric origins, reframing it as a contextually embedded and normative psychological experience within caregiving relationships. This aligns with Swales & Owens (2020) [23] and invites a culturally situated understanding of ambivalence.
• Second, the results affirm that caregiving roles are not only behavioral responses to familial need but also processes that shape, and sometimes erode, caregiver identity. These insights contribute to feminist ethics of care by underscoring the emotional toll of invisible labor and advocating for the integration of caregivers’ voices into broader sociocultural theory.
• Third, the study highlights a dynamic interdependence between caregiving, symbolic loss, and identity. This theoretical framework underscores recursive emotional processes and calls for integrative models that encompass ambivalence, ambiguous loss (Boss, 1999) [6], and narrative identity in understanding caregiver well-being.

The researcher expresses deep appreciation to the five courageous women who participated in this study and shared their deeply personal stories. Their voices illuminate the psychological realities of caregiving and provide invaluable insight into an often-silenced experience.

Gratitude is also extended to the Pontifical Catholic University of Puerto Rico for its ethical oversight and institutional support throughout the research process. Special thanks to the mentors, clinical supervisors, and mental health professionals who continue to advocate for the visibility, dignity, and healing of caregivers across the island.

Finally, this work is dedicated to all informal caregivers in Puerto Rico and beyond. Your labor matters. Your story matters. Your emotional well-being deserves to be seen, supported, and honored.

This phenomenological study reveals that affective ambivalence is not an isolated emotional anomaly but a fundamental undercurrent in caregiving experience. As described by the five women in this research, caregiving in Puerto Rico is deeply shaped by gendered expectations, invisible labor, and emotional paradoxes.

The emotional tensions—between duty and autonomy, affection and resentment, grief and relief—give rise to a complex, multidimensional psychological landscape. When caregiving is assumed involuntarily and without adequate support, it leads to emotional strain, identity erosion, and the risk of complicated grief. Yet, within these same narratives lies evidence of resilience, insight, and the transformative power of meaning-making.

The caregiving role, traditionally viewed as a private, familial obligation, must be redefined as a public health issue, a matter of gender justice, and a human rights concern. Systemic reforms in mental health care, public policy, and community services are urgently needed to ensure that caregivers are recognized, protected, and emotionally supported—both during and after their caregiving journeys.

In conclusion, this study calls for a profound reimagining of how society understands and responds to caregiving: not as a silent duty, but as a socially constructed, emotionally intensive, and ethically significant human experience.

1. Font MC (2023) Impacto de un diagnóstico de cáncer pediátrico en el sistema familiar: perspectiva del cuidador primario. University of Puerto Rico, Rio Piedras 39: 71–88.
2. Rogero-García J (2010) The feminization of care for dependent older adults. Spanish Journal of Sociological Research 132: 147-174.
3. Frías-Osuna A, Jiménez-Picón N, del-Pino-Casado R and Pérez-Cruz M (2019) Consequences of informal caregiving for family caregivers of dependent older adults. Primary Attention 51: 77-85.
4. Bleuler E (1911) Dementia praecox or the group of schizophrenias International Universities Press, J. Zinkin, Trans.
5. Van Harreveld F, Schneider IK, Nohlen H U and van der Pligt J (2015) The ambivalence construct: Structure and implications for attitudes and behavior. Current Opinion in Psychology 6: 81-85.
6. Boss P (1999) Ambiguous loss: Learning to live with unresolved grief, Harvard University Press.
7. Farias MS (2002) Affective ambivalence and mental health: A complex relationship. Chilean Journal of Neuro-Psychiatry 40: 120-127.
8. Pascual R and Santamaría J J (2009) Ambivalence in the caregiver–care recipient relationship: A review from the perspective of attachment theory. Gerokomos 20: 17-24.
9. Ross D (2013) The paradox of caregiving: Empathy, resentment, and the psychodynamics of dependency. Journal of Applied Psychoanalytic Studies 15: 212-225.
10. Cuevas M (2019) Caring without rest: Emotional burden and affective ambivalence. Psychology for Well-Being 11: 34–48.
11. Freud S (1957) Mourning and melancholia. The standard edition of the complete psychological works of Sigmund Freud. 14: 237-58.
12. Moustakas C (1994) Phenomenological research methods. Thousand Oaks.
13. Van Kaam A (1967) Existential foundations of psychology. Philosophy and Phenomenological Research 28.
14. Gordon R (2017) The purpose and rigor of qualitative research, Routledge.
15. Fuster G (2019) Phenomenological analysis applied to clinical psychology. Journal of Phenomenological Psychology 7: 123-137.
16. Creswell JW and Poth CN (2016) Qualitative inquiry and research design: Choosing among five approaches. Sage publications.
17. Addington-Hall J and McPherson C (2001) After-death interviews with surrogates/bereaved family members: some issues of validity. Journal of pain and symptom management 22: 784-790.
18. Beck A and Konnert C (2007) The bereavement experience of older adults in nursing homes following the death of a spouse. Omega: Journal of Death and Dying 55: 371-387.
19. Hernández-Sampieri R, Fernández c and Baptista P (2014) Metodología de la Investigación.
20. Sandelowski M (1995) Sample size in qualitative research. Research in nursing & health 18: 179-183.
21. Lincoln YS and Guba EG (1985) Naturalistic inquiry. Sage Publications.
22. Swales CA and Owens RG (2020) Affective ambivalence and its clinical implications. Psychodynamic Practice, 26: 269-283.
23. Vaquiro Rodríguez M and Stiepovich Bertoni S (2010) Informal care for older adults: A gender-based perspective. Gerontological Studies 16: 9-19.
24. Torres-Avendaño M, Rojas M and Zamora D (2018) The feminization of care: An analysis from a gender perspective. Latin American Journal of Family Studies 10: 23-39.
25. Edelman M, Kuhn D and Fulton B R (2007) Advance directives and the person with dementia: A review of the literature. Archives of Gerontology and Geriatrics 44: 1-14.