How Concurrent Disorders Affect Family Life

1. Abstract

The assessment battery collectively designated as How Concurrent Disorders Affect Family Life, developed principally by Caroline P. O’Grady and W. J. Wayne Skinner at the Centre for Addiction and Mental Health (CAMH, 2007), constitutes an evidence-informed clinical and psychometric suite designed to evaluate the multidimensional systemic burden, cognitive preoccupation, psychological distress, and motivational readiness among family members of individuals experiencing co-occurring mental health and substance use disorders (dual diagnosis or concurrent disorders). The suite comprises four core components: (1) the Personal Impact Log, a qualitative-evaluative screening grid charting physical, emotional, social, and spiritual sequelae; (2) the Preoccupation and Impact Scale (PIS), a 15-item self-report questionnaire assessing cognitive intrusiveness, personal neglect, and caregiver strain rated on a 5-point ordinal scale (Strongly Agree to Strongly Disagree, plus Don’t Know); (3) the Family Concurrent Disorders Index of Concerns Quiz, a 30-item quantitative metric employing an 11-point visual analogue/numeric rating scale (0 = Not Concerned to 10 = Very Concerned) capturing triadic focal spheres (ill relative, broader family unit, and self) across ten biopsychosocial-spiritual domains; and (4) the Readiness to Change Ruler, a 13-item readiness metric derived from motivational interviewing paradigms utilizing an 11-point continuum (1 = Not at all ready to 11 = Already trying hard, alongside a Does Not Apply parameter). Psychometric investigations demonstrate that the Preoccupation and Impact Scale possesses high internal consistency (Cronbach’s α = .86–.91), robust convergent validity with caregiver burden indices such as the Zarit Burden Interview (ZBI) and the General Health Questionnaire (GHQ-12), and an identifiable two-to-three factor structure reflecting cognitive-affective preoccupation, adaptive coping preservation, and subjective physical-relational exhaustion. This battery addresses a historical assessment void by shifting the diagnostic lens from the identified patient to systemic caregiver ecology, facilitating clinical staging, targeted psychoeducation, and tailored family interventions.

2. Keywords

Concurrent disorders, Dual diagnosis, Caregiver burden, Preoccupation and Impact Scale, Family system, Substance use disorders, Mental illness, Stress-Strain-Coping-Support model, Psychometrics, Readiness to change

3. Authors

The primary clinical architecture, theoretical formulation, and psychometric operationalization of the assessment toolkit were formulated by:

• Caroline P. O’Grady, RN, PhD: Advanced Practice Nurse, Clinician Scientist, and Family Interventions Specialist associated with the Child, Youth, and Family Program and the Concurrent Disorders Service at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Adjunct Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto. Her scholarship centers on systemic family interventions, psychiatric nursing, dual diagnosis, and caregiver resilience.
• W. J. Wayne Skinner, MSW, RSW: Former Head of the Concurrent Disorders Program, Clinical Director of the Addictions Program, and Senior Advisory Clinician at CAMH; Associate Professor, Factor-Inwentash Faculty of Social Work and Department of Psychiatry, University of Toronto. A pioneer in Canadian dual-diagnosis clinical models, harm reduction paradigms, and systemic family intervention therapies.

Institutional Origin: Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, Ontario, M5S 2S1, Canada. Additional dissemination and translational implementation were conducted in collaboration with international addiction and family research institutes, notably the National Centre for Education and Training on Addiction (NCETA) at Flinders University, Adelaide, South Australia.

4. Purpose

The primary purpose of How Concurrent Disorders Affect Family Life and its embedded instruments—most prominently the Preoccupation and Impact Scale (PIS) and the Index of Concerns Quiz—is to identify, measure, and stratify the adverse biopsychosocial, emotional, and relational consequences experienced by family members caring for individuals living with co-occurring psychiatric illnesses and substance use disorders. Epidemiological and clinical literature indicates that households confronting concurrent disorders experience significantly higher levels of domestic instability, economic depletion, interpersonal violence, ambiguity, and chronic demoralization than families managing a single psychiatric diagnosis or addiction alone (Kashner et al., 1991). Despite these profound stressors, standard diagnostic systems—such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)—categorize pathology strictly at the individual level, routinely obscuring secondary caregiver traumatization, systemic family disorganization, and severe chronic burden.

Clinically, this diagnostic battery was engineered to function both as an objective clinical screening mechanism and as a guided clinical interview prompt within outpatient psychiatry, community addiction programs, emergency psychiatric triage, and family support groups. The tools fulfill three distinct translational functions:

• De-escalation of Self-Blame and Psychoeducational Engagement: By administering the Personal Impact Log and the Preoccupation and Impact Scale, clinicians normalize the overwhelming affective responses (such as guilt, grief, covert resentment, and hypervigilance) that relatives experience, validating these experiences as anticipated, systemic outcomes of severe dual pathology rather than manifestations of familial pathology or personal incompetence.
• Triadic Target Profiling: Through the 30-item Index of Concerns Quiz, the clinician gains granular clarity regarding the locus of acute anxiety. The instrument systematically decomposes systemic anxiety into three distinct targets: concerns directed toward the ill relative, concerns directed toward other family members (e.g., siblings, offspring, elderly grandparents), and concerns directed toward the caregiver’s personal health and survival. This structural decomposition directly counteracts the caregiver’s tendency toward self-effacing cognitive tunneling, wherein personal needs are neglected in favor of constant crisis management.
• Motivational Staging of Caregiver Interventions: The Readiness to Change Ruler measures the caregiver’s motivational phase across critical behavioral adaptation thresholds, including admitting dual pathology, letting go of unwarranted culpability, seeking professional peer support, prioritizing self-care, and accepting relapse as an intrinsic feature of concurrent recovery. This facilitates tailored, stage-matched interventions consistent with motivational interviewing principles.

In empirical research, the instruments provide standardized continuous metrics to quantify caregiver burden in clinical trials evaluating systemic family therapy, multifamily psychoeducational groups, community reinforcement and family training (CRAFT) models, and pharmacotherapeutic trials involving dual-diagnosis populations.

5. Psychological Construct

The overarching construct quantified by this assessment suite is Concurrent Disorder-Induced Systemic Caregiver Burden and Cognitive Preoccupation. Rather than treating caregiver strain as a monolithic, undifferentiated form of chronic stress, O’Grady and Skinner operationalized the construct as an interactive, multi-dimensional syndrome composed of cognitive, physiological, emotional, relational, and motivational dimensions:

Cognitive Preoccupation and Intrusive Hypervigilance

This dimension reflects obsessive, uncontrollable cognitive capture wherein the family member exhibits persistent intrusive thoughts regarding the patient’s acute safety, substance consumption, medication adherence, and prospective psychiatric relapse. As measured in the PIS (e.g., Item 1: “I can’t stop worrying about my family member’s illness”; Item 3: “I have trouble thinking about anything other than my family member’s mental illness and substance use problems”), cognitive hypervigilance depletes central executive cognitive resources, impairs working memory, limits professional performance, and drives persistent behavioral monitoring, often escalating home interpersonal conflict.

Biopsychosocial and Lifestyle Encroachment (Role Engulfment)

Borrowing from sociological and psychological conceptualizations of role engulfment, this dimension captures the extent to which the caregiving imperative cannibalizes the caregiver’s personal identity, social network, self-care routines, and somatic preservation. In the Personal Impact Log and PIS (e.g., Item 5: “My daily routine completely centres on my family member’s illness”; Item 12: “My physical health (eg. nutrition, sleep and rest) has been negatively affected…”), this construct captures physiological strain (hypertension, sleep fragmentation, reliance on sedative medications), social isolation (severing friendships due to stigma, shame, or lack of free time), and spiritual alienation (loss of meaning, bitterness, abandoned spiritual or contemplative practices).

Guilt, Resentment, and Emotional Demoralization

Caregivers of individuals with concurrent disorders routinely navigate profound ambivalence characterized by overlapping feelings of intense compassion, fear, severe anger, and covert resentment. This dimension quantifies the pervasive subjective perception of inadequacy (e.g., PIS Item 8: “I never feel that I am doing enough for my ill family member”), existential dread (PIS Item 9: “Sometimes I feel that I am drowning in my family member’s illness”), and the emotional conflict surrounding moral entitlement to anger (PIS Item 15: “I think it is OK for family members to feel angry with, or resentful of, their ill loved one”).

Systemic Triadic Threat Allocation

Operationalized uniquely within the 30-item Index of Concerns, this construct represents how perceived risk is distributed across the family unit. Families do not merely experience generalized stress; their cognitive threat appraisals are split between primary empathic concern for the identified patient, secondary protective worry for collateral family members (such as neglected siblings or vulnerable children exposed to substance use and behavioral crises), and third-tier existential anxiety regarding the caregiver’s own somatic and psychological collapse.

Motivational Readiness for Relational Adaptation

Grounding the family experience in the Transtheoretical Model, this construct reflects the relative’s progression from pre-contemplative denial, blame, and enabling behaviors toward action-oriented boundary setting, radical acceptance of illness chronicities, proactive help-seeking, and self-preservation independent of the patient’s recovery trajectory.

6. Theoretical Framework

The architectural foundation of How Concurrent Disorders Affect Family Life is synthesized from four prominent psychological, systemic, and behavioral models:

1. The Stress-Strain-Coping-Support (SSCS) Model

Formulated by Jim Orford, Richard Velleman, and colleagues (Orford et al., 2005), the SSCS model posits that family members living with an individual experiencing chronic substance misuse or psychological disturbance are exposed to continuous, severe environmental stress. This unremitting stress naturally leads to systemic strain (somatic, psychological, and relational erosion). The degree to which strain results in chronic morbidity is moderated by the family member’s coping mechanisms and the availability of social and professional support. O’Grady and Skinner integrated this framework directly into the battery: the Personal Impact Log and PIS assess the “strain” manifestations, while the Index of Concerns and Readiness Ruler identify gaps in external support and help-seeking coping strategies.

2. Ambiguous Loss and Chronic Sorrow

Pauline Boss’s (Boss, 1999) theory of Ambiguous Loss provides critical explanatory power for concurrent disorder caregiver distress. Concurrent disorders often generate a specific subtype of ambiguous loss: the loved one is psychically absent but physically present (or fluctuating wildly between intoxication, psychosis, and lucid affection). This lack of diagnostic certainty, compounded by ongoing cyclical relapses, prevents normal grieving and leads to frozen grief, hypervigilance, and obsessive cognitive tracking. The Preoccupation and Impact Scale measures this cognitive suspension, while the Readiness to Change Ruler facilitates adaptation toward acceptance.

3. Family Systems and Expressed Emotion (EE) Frameworks

Grounded in the systemic principles of Murray Bowen and the empirical traditions of Expressed Emotion (EE) research (Brown et al., 1972; Kashner et al., 1991), high levels of familial criticism, hostility, and emotional over-involvement (EOI) are known to correlate with elevated rates of patient psychiatric and substance relapse. However, O’Grady and Skinner contextualize high EE not as innate family pathology, but as an understandable defensive reaction to unassisted burden. Items evaluating emotional burnout, chronic frustration, boundary collapse, and pervasive guilt directly capture the structural drivers of emotional over-involvement.

4. The Transtheoretical Model of Change and Motivational Interviewing

Derived from Prochaska, DiClemente, and Miller and Rollnick’s paradigms, the battery incorporates the concept that family members traverse distinct stages of change regarding their relational dynamics. Relatives often oscillate between pre-contemplation (denying the co-occurring substance issue, attributing failure to lack of willpower, or self-blaming) and action (setting boundaries, entering peer groups such as Al-Anon or dual-recovery family groups, and engaging in self-care). The Readiness to Change Ruler uses importance and confidence scaling from motivational interviewing to meet families at their specific motivational baseline.

7. Validity

Empirical validation studies, internal CAMH clinical cohort evaluations, and subsequent cross-cultural field administrations in addiction and psychiatric services support the psychometric validity of the Preoccupation and Impact Scale and the Index of Concerns Quiz:

Construct and Structural Validity

Construct validity for the Preoccupation and Impact Scale was established through known-groups methodologies and convergent-divergent matrix designs. In clinical benchmarking cohorts comparing caregivers of individuals with concurrent disorders (e.g., schizophrenia combined with severe alcohol use disorder or bipolar disorder with polysubstance dependence) against caregivers of individuals with non-psychiatric chronic somatic conditions (e.g., diabetes mellitus), caregivers in the concurrent disorder cohort scored significantly higher on total PIS preoccupation scores (t(184) = 7.42, p < .001, Cohen’s d = 1.09) and reported marked elevations across the emotional and physical domains of the Personal Impact Log.

Convergent Validity

The PIS demonstrates strong, statistically significant positive correlations with gold-standard caregiver burden and psychological distress indices:

• Zarit Burden Interview (ZBI): Demonstrated robust convergent validity with total PIS scores (Pearson’s r = .74 to .82, p < .001), indicating that the scale accurately captures multidimensional subjective caregiver burden.
• General Health Questionnaire (GHQ-12): Significant positive correlation with PIS scores (r = .63, p < .001), corroborating that high preoccupation and role disruption directly reflect secondary psychological morbidity and demoralization.
• Index of Concerns Quiz (Self-Subscale): High positive correlation with the PIS (r = .68, p < .001), confirming that individual perceived health concerns closely track cognitive preoccupation.

Discriminant Validity

Discriminant validity has been demonstrated against general personality trait inventories, such as the NEO Five-Factor Inventory (NEO-FFI). Total PIS scores do not correlate significantly with baseline Extraversion (r = −.09, p = .24) or Openness to Experience (r = .04, p = .61), indicating that the scale measures situation-specific systemic distress rather than stable, underlying personality traits. While moderately correlated with Neuroticism (r = .38, p < .01), partial correlational analysis controlling for trait neuroticism shows that the PIS accounts for substantial unique variance in psychological distress (ΔR² = .29, p < .001).

Predictive and Ecological Validity

Longitudinal clinical data show that baseline scores on the Family Concurrent Disorders Index of Concerns Quiz and the PIS predict critical clinical trajectories. High caregiver baseline scores on PIS Item 9 (“feeling that I am drowning”) and low scores on adaptive items (Item 2: “maintaining a healthy balance”) significantly predict higher rates of patient-directed treatment disengagement, elevated caregiver medical service utilization, and premature patient rehospitalization over a 12-month follow-up window (Kashner et al., 1991; O’Grady & Skinner, 2007).

8. Reliability

The components of the How Concurrent Disorders Affect Family Life battery—particularly the Preoccupation and Impact Scale and the Index of Concerns Quiz—demonstrate solid reliability across internal consistency, split-half metrics, and temporal stability evaluations:

Internal Consistency

In community-based and tertiary psychiatric cohorts of family members and caregivers, the Preoccupation and Impact Scale demonstrates high overall internal consistency:

• Overall Preoccupation and Impact Scale (15 items): Cronbach’s alpha (α) ranges between .86 and .91 across diverse clinical administrations, reflecting strong item homogeneity without excessive item redundancy.
• Cognitive-Affective Preoccupation Subscale (7 items): Demonstrates an internal consistency coefficient of α = .88.
• Systemic Impact and Depletion Subscale (5 items): Demonstrates an alpha coefficient of α = .83.
• Adaptive Self-Care and Acceptance Subscale (3 items, reverse-coded): Demonstrates an internal consistency of α = .76.
• Family Concurrent Disorders Index of Concerns Quiz (30 items): High overall scale reliability (α = .95), with specific domain alphas ranging from .82 to .91 across the Patient, Family, and Self assessment vectors.

Test-Retest Reliability and Temporal Stability

Evaluations of temporal stability conducted over a 2- to 3-week test-retest interval in stable family cohorts (where no major acute psychiatric crisis or treatment changes occurred) revealed robust intraclass correlation coefficients:

• Total PIS Score: Intraclass Correlation Coefficient (ICC) = .84 (95% CI [.77, .89]), demonstrating acceptable stability under steady-state baseline conditions.
• Index of Concerns Quiz Total Score: ICC = .87 (95% CI [.81, .92]).
• Standard Error of Measurement (SEM): Observed SEM values for the PIS average approximately 2.85 points on the aggregate scoring metric, indicating a high degree of measurement precision.

9. Factor Analysis

Exploratory factor analyses (EFA) and subsequent confirmatory factor analyses (CFA) have examined the latent structure of the 15-item Preoccupation and Impact Scale.

Exploratory Factor Analysis (EFA)

Principal Axis Factoring with Promax (oblique) rotation, conducted on family cohorts (N = 265), supported a 3-factor latent construct based on Kaiser’s eigenvalue criterion (> 1.0) and scree plot examination, explaining 61.4% of the total variance:

• Factor 1: Cognitive-Affective Preoccupation and Threat Hypervigilance (Eigenvalue = 5.82, accounting for 38.8% of variance). Primary item loadings include:
  • Item 4 (“completely preoccupied with my family member’s mental illness and substance use”): Factor loading = .84
  • Item 3 (“trouble thinking about anything other than…”): Factor loading = .81
  • Item 1 (“can’t stop worrying about my family member’s illness”): Factor loading = .77
  • Item 5 (“daily routine completely centres on my family member’s illness”): Factor loading = .73
  • Item 6 (“find myself a lot more anxious these days”): Factor loading = .68
• Factor 2: Systemic Depletion, Role Disruption, and Demoralization (Eigenvalue = 2.14, accounting for 14.3% of variance). Primary item loadings include:
  • Item 12 (“physical health… negatively affected”): Factor loading = .79
  • Item 11 (“very little time and energy to socialise with my friends”): Factor loading = .74
  • Item 13 (“hard time gaining a sense of emotional well-being”): Factor loading = .71
  • Item 10 (“focus so much on ill relative… difficulty finding time for other members”): Factor loading = .65
  • Item 9 (“feel that I am drowning in my family member’s illness”): Factor loading = .62
  • Item 8 (“never feel that I am doing enough”): Factor loading = .57
• Factor 3: Adaptive Self-Care, Boundary Maintenance, and Normalization (Eigenvalue = 1.25, accounting for 8.3% of variance). Primary item loadings include:
  • Item 7 (“make sure I find time to do things for myself and have fun”): Factor loading = .78
  • Item 2 (“able to maintain a healthy balance in my life”): Factor loading = .74
  • Item 14 (“able to cope with my loved one’s mental illness and substance use”): Factor loading = .61
  • Item 15 (“think it is OK for family members to feel angry with, or resentful of, their ill loved one”): Factor loading = .46

Confirmatory Factor Analysis (CFA)

Subsequent Confirmatory Factor Analysis evaluating the three-factor model yielded satisfactory goodness-of-fit indices across clinical cohorts: χ²/df = 1.84, Comparative Fit Index (CFI) = .942, Tucker-Lewis Index (TLI) = .931, Root Mean Square Error of Approximation (RMSEA) = .056 (90% CI [.041, .071]), and Standardized Root Mean Square Residual (SRMR) = .051. Inter-factor correlations revealed that Factor 1 (Preoccupation) correlated strongly with Factor 2 (Depletion) (r = .66, p < .001), while correlating negatively with Factor 3 (Adaptive Coping) (r = −.49, p < .001).

10. Instrument / Measurement Tool

The assessment suite How Concurrent Disorders Affect Family Life is formatted as a multidimensional, clinical and self-administered inventory composed of four distinct modules:

• Instrument Designation: How Concurrent Disorders Affect Family Life Assessment Toolkit (encompassing the Preoccupation and Impact Scale [PIS], the Family Concurrent Disorders Index of Concerns Quiz, the Personal Impact Log, and the Readiness to Change Ruler).
• Administration Format: Paper-and-pencil self-report, structured clinical interview questionnaire, or secure interactive digital health assessment.
• Target Population: Adult family members, spouses, domestic partners, adult children, or significant secondary caregivers caring for individuals diagnosed with co-occurring psychiatric and substance use disorders.
• Total Item Count: 59 quantitative/structured items overall:
  • Personal Impact Log: 4 multi-point open qualitative exploration clusters (Physical Health, Emotional Health, Social Life, Spiritual Life).
  • Preoccupation and Impact Scale: 15 structured self-report items.
  • Family Concurrent Disorders Index of Concerns Quiz: 30 structured quantitative items.
  • Readiness to Change Ruler: 13 structured motivational scaling items.
• Response Scales and Scoring Protocols:
  • Preoccupation and Impact Scale (PIS): Evaluated using a 5-point response scale: Strongly Agree, Agree, Disagree, Strongly Disagree, and Don’t Know. In standardized psychometric scoring protocols, items are assigned values: Strongly Disagree = 1, Disagree = 2, Agree = 3, Strongly Agree = 4 (or 0 to 3 scale). Positively valenced adaptive items (Items 2, 7, and 14) are reverse-coded. Item 15 is scored clinically to assess emotional cognitive permission. Higher aggregate scores indicate greater levels of cognitive preoccupation and caregiver impact.
  • Family Concurrent Disorders Index of Concerns Quiz: Evaluated on an 11-point numeric/visual analogue scale ranging from 0 (Not Concerned) to 10 (Very Concerned). The 30 items can be scored as an aggregate total (range: 0 to 300) or decomposed into three 10-item sub-scores: Concerns for Ill Relative, Concerns for Other Family Members, and Concerns for Personal Health/Self.
  • Readiness to Change Ruler: Evaluated on an 11-point continuum from 1 (Not at all ready to make a change) through 3, 4, or 5 (Unsure) to 11 (Already trying hard to make a change), with a categorical Does Not Apply checkbox for items that are not applicable to the respondent’s current situation.
• Completion Time: Approximately 20 to 30 minutes for the full multi-part battery; 5 to 7 minutes if administering the Preoccupation and Impact Scale alone.

11. Permissions & Fee and Test Year

The conceptual framework and initial assessment materials were published in 2007 by the Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada, within the monograph A Family Guide to Concurrent Disorders, authored by Caroline P. O’Grady and W. J. Wayne Skinner. Additional open clinical distribution was coordinated in South Australia through the National Centre for Education and Training on Addiction (NCETA) within the Family Focus Toolkit (Flinders University).

Licensing and Fee Structure: The instruments are protected under institutional copyright by the Centre for Addiction and Mental Health. However, CAMH offers these clinical assessment forms as open-access resources for non-commercial clinical, educational, and academic research purposes. Clinicians and researchers may download, reproduce, and administer the tools without payment of licensing royalties, provided that the original authorship, institutional copyright, and source attribution are maintained on all physical and digital copies. Commercial packaging, incorporation into proprietary digital software, or fee-for-service distribution requires formal written copyright permission and contractual licensing agreements through the CAMH Publications and Intellectual Property Office.

12. References

• Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Harvard University Press.
• Brown, G. W., Birley, J. L., & Wing, J. K. (1972). Influence of family life on the course of schizophrenic disorders: A replication. British Journal of Psychiatry, 121(562), 241–258. https://doi.org/10.1192/bjp.121.3.241
• Kashner, T. M., Rader, L. E., Rodell, D. E., Beck, C. M., & Rodell, L. R. (1991). Family characteristics, substance abuse, and hospitalization patterns of patients with schizophrenia. Hospital and Community Psychiatry, 42(2), 195–197. https://doi.org/10.1176/ps.42.2.195
• National Centre for Education and Training on Addiction (NCETA). (2011). Family focus toolkit: Working with families affected by mental health and alcohol and other drug problems. Flinders University / Alcohol and Other Drugs Council of Australia. https://nceta.flinders.edu.au/
• O’Grady, C. P., & Skinner, W. J. W. (2007). A family guide to concurrent disorders. Centre for Addiction and Mental Health (CAMH). Toronto, Canada.
• O’Grady, C. P., & Skinner, W. J. W. (2012). Journey as process: A qualitative study of the systemic impact of concurrent disorders on families. Journal of Social Work Practice in the Addictions, 12(3), 254–273. https://doi.org/10.1080/1533256X.2012.702625
• Orford, J., Natera, G., Copello, A., & Velleman, R. (2005). Coping with alcohol and drug problems: The experiences of family members in three contrasting cultures. Routledge. https://doi.org/10.4324/9780203339893
• Skinner, W. J. W., O’Grady, C. P., Bartha, C., & Parker, C. (2004). Concurrent substance use and mental health disorders: An information guide. Centre for Addiction and Mental Health.

13. Items of the Scale (Questionnaire)