Caring in Crisis: The Impact of Systemic Failures and Patient Loss on Behavioral Health Clinicians

The opioid epidemic remains one of the most significant public health challenges of our time, exacting a devastating toll on individuals, families and communities worldwide. Individuals with opioid use disorder (OUD) are at an increased risk of overdose death compared to the general population [1], and the rates of opioid overdose death continue to occur at alarming rates, particularly with the rising prevalence of synthetic opioids such as fentanyl [2]. In 2022 alone, the United States witnessed a record-breaking 109,680 deaths attributed to drug-related causes, as reported by preliminary data from the Center for Disease Control (CDC). Against this backdrop, there is growing concern regarding the capacity of the behavioral health workforce to effectively address the needs of individuals grappling with OUD. 

The opioid crisis, along with legislative efforts to improve access to substance use treatment services, has expanded help for those in need. However, a significant gap remains between the number of individuals diagnosed with Substance Use Disorder (SUD) and those who actually receive treatment. The 2022 National Survey of Drug Use and Health revealed that only about one in four people (24.0% or 13.1 million individuals) aged 12 or older who needed substance use treatment received it that year. Alarmingly, among the 1.8 million adolescents aged 12 to 17 diagnosed with SUD and not receiving treatment, 97.5% (approximately 1.7 million) neither sought treatment nor acknowledged the need for it (Substance Abuse and Mental Health Services Administration [SAMHSA]). 

The demand to increase service delivery prompted many treatment providers to rapidly expand their service provisions. Despite these efforts, the behavioral health workforce faces numerous challenges that hinder its ability to meet the growing need for substance use treatment. Various factors contribute to the gap between those needing and those receiving treatment for SUDs, most notably the state of the field, workforce issues, access to services, funding limitations and the pervasive experience of stigma [3-6]. There have been long standing concerns regarding the preparation, recruitment, and retention of a qualified workforce, particularly in substance abuse treatment [6,7]. Nationwide, this sector grapples with staffing shortages, retention difficulties, and deficiencies in training that significantly hinder service provision [4,7-9]. Recruiting qualified applicants and managing staff turnover remain critical issues, contributing to decreased organizational efficiency, lowered performance quality, and increased stress in the work environment [8,10]. 

The pressure to meet the increased volume of patients needing services has heightened demands on organizational staffing, leading to increased caseloads and necessitating shifts in agency procedures. Some agencies have adopted task shifting in overdose response programs—shifting responsibilities to less specialized workers—to increase effectiveness and involve persons with lived experience of substance use and recovery [11,12]. Due to their social position as individuals who have used substances, this population often experiences heightened feelings of being devalued, has limited employment opportunities, further exacerbating workforce issues and leading to increased experiences of burnout [12,13]. While this approach aims to address the workforce shortages, it has been found to increase these issues [12,14], further highlighting the ongoing need for comprehensive strategies to support employees and enhance job satisfaction, ultimately improving treatment outcomes for clients. 

This workforce crisis is further exacerbated by several persistent issues, including the lack of preparation in higher education that incorporates up-to-date evidence-based research and practices [15]. Education and training programs have not kept pace with dramatic changes in healthcare delivery, not only in behavioral health but across all health professions. Training provided to direct care staff without graduate degrees has been minimal. Additionally, challenges in recruitment and retention, combined with a lack of emerging leaders to replace the aging leadership, have contributed to the ongoing crisis in the behavioral health workforce [15]. 

Staffing shortages and high turnover rates are particularly concerning in the substance use treatment field due to their impact on the ability of organizations to provide consistent, effective, and quality services [8,10,16]. Turnover rates in the field of substance use treatment tend to be relatively high compared to other healthcare sectors, with research identifying rates between 19% and 50% [9,17]. Voluntary turnover rates among counselors have been found to range from 25% to 35% [7,17], with SAMHSA estimating the annual turnover rate to be approximately 33% [6]. These high turnover rates pose major barriers to effectively addressing treatment needs and ensuring the consistent delivery of high quality services [8,7,10,17]. 

The reasons for high turnover rates among counselors are multifaceted and complex. Factors such as low wages, limited opportunities for career advancement, and the demanding nature of the work have been found to contribute to job dissatisfaction and increased turnover intentions [16,18]. Additionally, counselors are more likely to witness an overdose, observe the extensive damage drugs cause in individuals' lives, and experience the death of patients to overdose than their mental health counterparts, which intensifies the emotional strain and exacerbates burnout. Although detailed data on the prevalence of this experience is limited, a study by Walley et al., [19] found that 38% of staff in medication management treatment programs and 45% of detox staff reported witnessing an overdose. This highlights the frequency and severity of potentially distressing events that substance use counselors are exposed to, further contributing to the high levels of stress and burnout in this field. Moreover, there is a significant lack of organizational responses that support clinicians who have had these difficult experiences, which further increases their emotional burden. These stressors have been found to play a role in counselor turnover and contribute to the experience of emotional exhaustion and burnout [10,16]. High turnover rates interfere with creating supportive environments that could buffer against these stressors [8]. Research indicates that individuals experiencing burnout are less engaged with their clients [10], underscoring the need for better support systems within the workforce. 

Additionally, the quality of coworker relationships, supervision, and social support play significant roles in the level of job satisfaction achieved by individuals [10,18,20]. Poor levels of staff support have been directly associated with increased burnout, while access to quality clinical supervision has been found to act as a protective factor [10,21]. In fact, organizational cultures that are innovative and open to change experience less burnout and higher employee engagement [10]. 

As a result of these challenges, many substance use counselors are leaving acute care settings for private practice. The move to private practice is often driven by the desire for better work-life balance, increased autonomy over which clients they see, and the potential for higher income. In private practice, counselors can set their own schedules, limit their caseloads, and focus on providing quality care without the pressure to meet productivity targets. This shift highlights the need for systemic changes in acute care settings to retain skilled counselors and ensure they receive the support necessary to manage the demands of their work effectively. 

This study seeks to fill a gap in the literature regarding counselor experiences in the substance use field by highlighting the specific challenges they face, their emotional responses to patient overdose deaths, and the support systems currently in place. Counselors working with high-risk populations often encounter immense challenges, including managing high patient acuity, dealing with high recidivism rates, and navigating pervasive stigma. These issues are further compounded by systemic problems within organizations, such as high turnover rates, inadequate training, and insufficient support systems. By amplifying the voices of counselors and addressing the unique challenges they face in the wake of opioid-related deaths, this study aims to contribute to efforts that support counselor well-being, enhance patient care, and address systemic barriers to effective opioid addiction treatment. Understanding these dynamics is crucial for developing comprehensive strategies that not only improve the well-being of clinicians but also the overall effectiveness of substance use treatment.

This study utilized in-depth semi-structured interviews to explore clinicians' experiences with the opioid overdose death of a client in their care. A qualitative approach was chosen to delve into the subjective experiences of the participants, the meanings they ascribe to these events, and how these experiences have transformed their perspectives [22,23]. Participants were selected through criterion sampling to identify independently licensed clinicians who were actively providing care to a client at the time of their overdose death. To ensure a sufficient number of participants and reach saturation, snowball referral sampling was also employed. This study received approval from the Assumption University Institutional Review Board. 

• Participants 

Participants were 12 independently licensed clinicians who were actively providing services in the field and who had lost a patient in their care to opioid overdose death. They consisted of four males and eight females with ages ranging from 27-62. All of the participants were employed full-time at the time of interview. All of the participants reported the loss of a client to opioid overdose death and 11 of the 12 had also lost at least one patient to other causes throughout their career. Additionally, while they all began their careers in acute treatment settings, seven of the participants were now in private practice, one had transitioned from acute care to outpatient, and two had entered into roles that involved less direct care. 

• Procedure 

Recruitment was conducted via the Psychology Today LISTSERV and social media platforms such as Facebook, Instagram, and LinkedIn. Snowball referral sampling was utilized to address the stigmatization associated with grief among providers and overdose deaths, which might deter participants from responding to direct advertisements [24]. This method helped overcome recruitment barriers and ensured an adequate number of participants for the study. Interested participants completed a basic demographic questionnaire and provided informed consent via the Survey Monkey platform. Once eligibility was confirmed, participants were invited to participate in an interview either in person, via Zoom, or via telephone. The interview process included a brief study overview and review of informed consent, followed by a 60-minute in-depth semi-structured interview, and concluded with a debriefing that covered how the data would be stored and used in the research study. 

A semi-structured interview guide was used to explore the clinicians' experiences in their work and the impact of losing a patient to opioid overdose. Participants received a $50.00 Amazon gift card as a token of appreciation for their participation. Additionally, all participants were provided with a summary of their interview transcript for review as part of the member-checking process. Feedback was elicited regarding the accuracy, clarifications, and additional information for inclusion. Interviews were audio recorded and stored, along with field notes, on a password-protected laptop. 

• Data Analysis 

This qualitative study employed thematic analysis to identify themes across the experiences of clinicians. A six-phase thematic analysis process, as recommended by Clarke and Braun [25], was utilized for its reflexive and recursive approach, allowing the meanings that clinicians ascribed to their experiences to be captured effectively [25,26]. The audio-recorded interviews were transcribed verbatim, and the analysis began with familiarizing the data, involving a thorough review of each transcript while listening to the audio recordings [27]. This process facilitated immersion in the data and ensured transcript accuracy. 

The second phase involved generating initial codes by examining each transcript to identify patterns and establish preliminary categories pertinent to the study. Initial codes were created manuall, and the transcripts were then uploaded into MAXQDA for further analysis. A subsequent round of manual coding using MAXQDA ensured consistency between paper codes and software-generated codes. Coding was conducted inductively, allowing themes to emerge organically from the data. The third phase involved clustering similar codes into meaningful themes. These themes were reviewed, named, and defined to ensure they accurately represented the clinicians' experiences and were distinct from one another. This comprehensive analysis provided a deep understanding of the systemic challenges and personal impacts faced by clinicians dealing with opioid overdose deaths.

The findings from the participant interviews revealed several key themes that encapsulate the experiences and challenges faced by clinicians working with individuals with SUD. These themes are: A Field in Crisis: Perspectives on the Current State, Organizational Responses to Overdose Death, Support System Shortcomings and Exodus to Private Practice. These themes provide a comprehensive understanding of the systemic issues and personal impacts the participants encountered in their work. The first theme, A Field in Crisis: Perspectives on the Current State, highlights their perceptions of the dire state of the behavioral health field, marked by high patient acuity, recidivism rates, and challenges in meeting client needs. The second theme, Organizational Responses to Overdose Death, explores how organizations handled the tragic events of patient overdose deaths, revealing a lack of adequate support and debriefing processes for clinicians. The third theme, Support System Shortcomings, delves into the participant’s experiences of insufficient peer support, inadequate supervision, and lack of resources that exacerbated feelings of isolation and burnout. Finally, the fourth theme, Exodus to Private Practice, explored the trend of clinicians moving from formal and acute treatment settings for private practice, driven by the desire for greater autonomy, better work-life balance, and a more manageable caseload with less acuity. These themes collectively explore the multifaceted challenges of the participants, providing a comprehensive understanding of the complexities they navigate in their professional roles. 

A field in crisis: perspectives on the current state 

The participants in the current study highlighted a range of significant challenges they faced when working with individuals with SUD, including managing high patient acuity, dealing with high recidivism rates, and navigating pervasive systematic stigma, all within the constraints of demanding organizational cultures. P5 emphasized the difficulty of the role, stating, “I believe that working with substance use is probably one of the hardest populations that you can work with.” The participants also highlighted the serious implications of their work, expressing the critical responsibility they felt in their interventions, which could often mean the difference between life and death. “You are literally functioning in that space of life and death” (P11). P1 recounted his initial shock upon entering the substance use treatment field: 

• The severity of the disease was much bigger than I had ever seen yet in my career…just to see how easily people just died. Like they’re there one day and gone the next…it was really like, “oh jeez, yeah this is serious, this really is life or death.” 

This acknowledgement reflects a deep internalization of the unique stressors and pressures that come with providing care to individuals who are at heightened risk of overdose death. 

However, the participants did not view these difficulties as the primary obstacles in their work. Instead, they saw them as part of the trade-off for the rewards of helping those "who everyone else has given up on” (P1), “those who oftentimes don’t get represented” (P8). They found deep fulfillment in their ability to positively impact the lives of individuals often marginalized by society. P8 expressed, “One’s heart just gets so drawn in wanting to help them.” This sense of purpose and the successes they witnessed motivated them to persist despite the significant hardships they encountered. Reflecting on the balance of challenges and rewards in their work, P5 noted, "Being able to show them that despite their fears about it, there’s so much good that comes from it too.” P1 summarized the experience well when pondering his decision to be clinician and work with individuals who use substances, “It’s a hard balance to decide, but if I had to choose, I’d probably still go back to being a clinician." 

Although the participants entered the field for various reasons, such as personal or family experiences with substance use and a strong desire to help others, many reported feeling unprepared for the realities they would face and lacking a full understanding of the field's challenging nature. 

• I think that’s something that really took me by surprise was the difference between mental health counseling and addiction counseling. To really differentiate between the two at all levels of training is critical. The worst days in addiction counseling can be pretty tough, just to be prepared for it to take its toll on you and also to really take care of it. (P1) 

P1 further elaborated, "I found it necessary to really take care of myself. You deal with a lot more stress throughout the day, I think. You know, constantly confronting defense mechanisms, battling with resistance and complacency, a threat of overdose, it’s a bit of a ballgame." The intense emotional labor required in SUD treatment highlights the need for robust support systems and effective coping strategies. 

In addition to the challenges they faced working within substance use treatment, clinicians also had to navigate the pervasive stigma surrounding substance use. This added layer of difficulty came from both the community and within the field itself. P8 expressed feeling pressure to counteract these negative perceptions through her own actions, stating, "I feel an extra responsibility to show up in a genuine, warm, empathic, and non-judgmental way.” Similarly, P5 shared his frustration with societal attitudes towards substance users, noting how these negative perceptions further complicated their roles as clinicians. 

• It’s never really validated, just how horrifying it is, because the world gives you the message that if you’re a substance user, usually you deserve it, it’s your own fault that you go through that because you use drugs. If you didn’t use drugs, you wouldn’t go through that and that’s the answer. You know what I mean? 

He also described how he witnessed this stigma infiltrating professional attitudes, leading to desensitization and inadequate care. 

• I don’t think we care for them the way we should. Like if someone around you had a heart attack in front of you, that’s like traumatic right? And I think people often feel because it’s something substance related, it’s not worth our time or attention and clinical care. 

Further emphasizing how community and provider stigma created additional challenges for these participants, P5 recounted his experiences with the negative attitudes of emergency responders, highlighting the need for cross-disciplinary collaboration. 

• The EMTs and the police come and they have all these questions and they’re really not supportive and they’re angry that they are there for somebody that is using drugs and they treat you as if you were part of the show. I mean it really was a horrendous experience. 

He believed these attitudes arose from desensitization and a lack of understanding of the trauma faced by substance users, which fostered what he described as “blame mentality” and negatively impacted service delivery and organizational culture. He emphasized, 

• I don’t think anything related to substance use is like, well you deserve it. This is your own fault. That is a lousy mentality. We should be moving away from blaming people who are struggling. I’m not saying, certainly people choose to use drugs, but the consequences that come along with that shouldn’t be thrown in their face every time they have an issue. I don’t think that’s helpful. To me, it wouldn’t help me. (P5) 

In addition to these challenges, participants criticized the prevalent “one-size-fits-all” approach in many treatment settings, arguing that it created significant barriers to providing individualized care. They noted that this standardized approach often failed to accommodate the unique needs and circumstances of each patient, thereby reducing the effectiveness of treatment. Participants expressed frustration with rigid protocols that prioritized uniformity over flexibility, which often resulted in inadequate support for those who did not fit the typical patient profile (P5, P6, P10, P11, P12). P11 explained, 

• Especially with residential treatment, everything’s abstinence-based and 12-step-based, and those are not things that lots of people connect with and so I think it’s also that can provide a barrier for folks. If they feel like they have to completely give up everything in order to have a roof over their head. In some of these places, they need to sign on to the 12-step approach, which just isn’t for everybody, for many reasons. So I think that’s tricky. 

The lack of tailored treatment options was identified as a major obstacle to successful recovery, because it overlooked the complexities and variations inherent in SUDs. By highlighting these issues, the participants emphasized the urgent need for more personalized and adaptable treatment strategies within the field. This rigid approach can alienate individuals who do not resonate with these methods, limiting their access to effective treatment. 

Additionally, some participants recognized that the high acuity of the patients they were seeing might indicate a need for a higher level of care, making it challenging to provide adequate services. P6 noted, "I also think that many at the outpatient day program were severely mentally ill, and I think their ability to comprehend some of the things that were going on in the group was limited." This recognition highlights the need for customized approaches that take into account the specific needs and abilities of each patient. 

The participants' experiences underscore the immense challenges and pressures faced by clinicians working with individuals with SUDs. Despite deriving deep satisfaction from their work and actively striving to combat stigma, the participants often found themselves handling high-stakes situations with insufficient support. Their narratives emphasize the importance of fostering cross-disciplinary understanding to reduce negative interactions between providers from different service sectors. The lack of support extends beyond emotional and supervisory guidance to include the availability of essential resources needed for effective care. The scarcity of resources in the field, from inadequate funding to limited access to necessary tools and services, further intensifies the difficulties clinicians face. The following section examines this critical issue, exploring how resource scarcity affects clinicians' ability to provide quality care and meet their clients' needs. 

Resource scarcity and the challenge to find personalized treatment options 

The clinicians in the current study consistently described the immense challenges of providing care to high-risk patients within a system that lacks the necessary resources to respond to such significant needs. P6 highlighted the financial constraints faced by clinicians working in outpatient programs: "So at (outpatient provider), the outpatient day program is about finances, limited resources, not being able to afford resources, because it was Medicaid primarily." This lack of financial support severely restricts the availability and quality of care, making the jobs of clinicians even more difficult. 

P11 further elaborated on the resource scarcity:

• There’s no resources. There’s not enough resources. There’s not enough good resources. The treatment isn’t long enough; insurance won’t pay for treatment that we know is effective. We know long-term treatment works. There are very few options, very long wait lists. 

This resource shortage creates a cycle of acute care where patients frequently enter and exit the system without receiving the sustained support needed for long-term recovery. P8 emphasized that this is particularly felt in the scarcity of specialized treatment options, particularly for women and children, further complicating efforts to achieve successful outcomes. 

The issue becomes even more complex when addressing medically complicated substance-using populations. As P11 noted, 

• That’s another lacking service area, treatment programs that can work with really medically complicated substances using populations. We’ve got like two in this state that are able to handle these clients; that’s really challenging when you have a client who wants help but also happens to have these medical concerns and you will be lucky if you find a bed. 

The shortage of specialized beds means that even when clients are ready and willing to seek help, their chances of receiving timely and appropriate care are slim. Clinicians described the profound difficulties they face in trying to provide adequate care within an under-resourced system. This shortage often leaves them feeling powerless against the systemic barriers that obstruct effective treatment and long-term recovery for high-risk patients. The perspectives shared by participants underscore the immense challenges of working in a field where the demand for care far exceeds the available resources and feeling powerless to prevent patient overdose death. 

P5 explained his experience with the regulations and procedures required for entry into SUD treatment, noting how difficult it was to respond swiftly enough to mitigate the significant risks involved. "There are regulations you have to meet...no matter which way you shook it, it was never really quick enough, I guess," he reflected, recalling the loss of a patient before he could even begin methadone maintenance. This sentiment was echoed by P9, who shared the experience of losing a patient to overdose who had sought care. "To be perfectly honest, the only thing that kept him from getting what he needed in terms of treatment were insurance issues." She described the frustration with the limited treatment options available to patients without private insurance, stating "he didn’t like the solutions that were put in place and he did go out and overdose." Further emphasizing the systemic issues that she experienced, this participant explained that the policies and attitudes around readmissions frequently disadvantage individuals seeking treatment. "Readmissions tend to not get reimbursed…they wouldn’t place him in a private hospital that I was working for. So we brought him to a public hospital nearby. It was a city hospital. He went there and left" (P9). This participant found herself experiencing patient loss while questioning if it was the direct result of a systematic failure. 

Culture of productivity: high caseloads, low wages and workforce shortages 

The clinicians in the current study often described a culture of productivity within their organizations that was experienced as creating a significant barrier to providing quality care (P2, P4, P5, P10 and P11). They shared that this culture emphasized the quantity of services delivered over their quality, creating substantial pressure to meet productivity targets. Participants reported that the constant push to meet these targets left them feeling overwhelmed and ineffective (P2, P5 and P11). The drive to maximize service numbers often results in high caseloads, leaving clinicians with insufficient time to adequately address each patient's needs. Additionally, low wages and a shortage of available providers exacerbate these challenges, contributing to high levels of stress and burnout among the clinicians themselves, and observed in their peers. This environment not only impacted the well-being of the clinicians but also the effectiveness of the treatment they can provide, ultimately compromising patient care. 

P2 highlighted that she experienced the caseload expectations as overwhelming and occurring in a manner that did not prioritize patient or provider needs. "It’s like just take what you got and figure it out. Like when somebody leaves it’s just who you got, they just divvy out their clients and all that stuff." This redistribution of clients without considering the existing workload placed additional strain on the clinicians and compromised the quality of care. P5 similarly expressed his frustration with what he perceived as the unrealistic expectations placed on clinicians: "It’s amazing to me the expectations that people have. I still can’t get over it. You know what I mean? That’s kind of par for the course (in this field) though.” The emphasis is regularly on the services that are being provided rather than on the providers themselves, leading to burnout, frustration, and unmet emotional and mental health needs in our workforce..

The participants in the current study believed that the high caseloads they encountered were a direct consequence of the shortage of available providers and broader systemic issues within the field. They described a constant struggle to balance their desire to help more patients with the need to protect their own mental health. 

• Clinicians are getting burnt out because there are not enough providers and there are too many people that need help. One of the hardest things to do is say no...nobody has space. You think, should I take on one more person? It is a constant balance between wanting to help people, but I also have to protect my own mental health. I know that is a very delicate balance. I know what my symptoms are when I am working too much. I am irritable and I cannot sleep at night. (P4) 

This reveals the constant tension between clinicians' professional duties, coupled with the knowledge that many people are in need of services, and the necessity to protect their own mental health amidst a shortage of providers.

The participants in this study expressed significant frustration with the issue of low wages. They noted a considerable gap between compensation for substance abuse roles compared to mental health treatment positions. This disparity added financial strain to their already demanding roles, exacerbating the challenges they faced and contributing to the high turnover rates within the field. P5 reflected on his experiences, stating, 

• Pay was a big issue in places I’ve worked at. I made almost no money, and I work with substance use not exclusively. In order to make money I’ve had to broaden my horizons. It’s the same everywhere; substance abuse professionals get paid far less than just about every other subfield within human services and I think that keeps really qualified good people from sticking around. 

The disparity in pay was described as demotivating for current clinicians and a deterrent for highly qualified professionals considering entering or staying in the field. P5 further emphasized the issue, noting, 

• I mean you think there would be more money since the death rates keep increasing…Nobody really advocates for equitable pay and I think it’s easy to get burnt out when you make very crappy money and you deal with other challenges, right? There’s so many structural things that are not about the clients that contribute to people moving on to other fields of practice that they really shouldn’t be surprised. 

P3 highlighted another aspect of the problem that may be the direct result of the stressors discussed thus far, pointing out that often the least experienced and trained staff were placed in the most acute settings without adequate support or preparation. “This contributes to our high turnover rates and burnout.” He observed that this practice made it even harder for clinicians to manage their workload and emotional well-being. This concept was reinforced by other participants who recounted their experiences of being unprepared and unsupported as they entered the field. P7 shared her experience working in a hospital environment as her first experience with SUD. 

• They just threw me in there, I had no one to hold my hand. I definitely tried, I didn’t know what I was doing. I was in awe. I never saw this life, hearing the anguish and then seeing how sick people were, how mentally tortured they were too. It was like a bad dream 

This sentiment of being unprepared was also shared by P8 who felt that this was a missing piece for her starting out in the field. “To be able to educate people up front, so they are prepared to deal with things like this would be a great and important goal. Because I didn’t really feel like I got that, my experience was how I learned.” 

The experiences shared by the participants paint a picture of a field in crisis, where clinicians are constantly navigating high-stakes situations with limited resources and support. They spoke of the intense emotional labor involved, the pervasive lack of necessary resources and systemic issues that hinder effective care. Despite these challenges, the participants expressed a deep commitment to helping marginalized individuals and found fulfillment in their successes. They underscored a pressing need for more effective and compassionate interventions, along with systemic changes that provide better training, support and resources for those working in the field of SUD treatment. Participants stressed the importance of ensuring fair compensation and providing comprehensive support systems. They believed that without addressing these foundational issues, the field would continue to experience high turnover rates and a decline in care quality, ultimately worsening the situation for those struggling with substance use disorders. 

Organizational responses to patient overdose deaths 

In addition to dealing with high caseloads and insufficient resources, the participants emphasized the critical issue of how their organizations respond to patient overdose deaths. The emotional toll of losing a patient to overdose, compounded by inadequate organizational support, significantly affected their mental health and job satisfaction. Participants noted that the immediate focus on quality assurance and legal implications often overshadowed attention to their experiences and needs. They reported an expectation to swiftly return to business as usual, with little regard for the emotional impact of such a loss. They described losing a client to overdose as profoundly distressing, and when met with a lack of proper support, it exacerbated feelings of helplessness and burnout. Unhealthy practices, such as informal death notifications, further intensified their distress. This theme explores how the clinicians perceived and were affected by their organizations' responses to patient overdose deaths. 

The clinicians in this study shared their experiences with how their organizations responded to patient overdose deaths. P5 stated “It doesn’t feel like there were any real considerations beyond the agency’s well-being and that was really what brought it up into something.” Many participants described an overarching focus on quality assurance and liability that overshadowed the support they needed during such a distressing event (P2, P5, P6, P7, P10, P11 and P12). This emphasis on business and documentation often intensified their emotional burden, leaving them feeling unsupported and undervalued. They identified the pervasive question of responsibility that arises as the first priority immediately after a patient’s overdose death, with P8 succinctly pointing out, “I think there is always the question of responsibility.” The anxiety surrounding potential investigations and liability was a common experience among the participants (P2, P4, P5, P6, P8, P10 and P12). P8 shared her concerns, “Knowing it was still an open case, was there going to be any kind of investigation of his treatment, or anything like that?” 

P2 shared how she experienced the focus on quality assurance and the increase in distress it created for her. 

• And it didn’t help that (organization) was not supportive at all. Their quality and assurance people called me literally the day I found out and was like why is your chart looking like this? Like there was no support and the issues with the chart came from the clinician before me and had nothing to do with me. So I had not only to grieve the loss of a client I had seen twice a week…like we were literally very close. So not once did they say how do you feel? And how are you doing like I’m so sorry. They were all business. 

This lack of support was a key factor in P2's decision to leave her organization. She expressed that for her to continue providing effective care, she needed to feel supported, especially during times of loss. 

• Such a lack of support is one of the reasons that I left (organization). I understand it is a business and you have to run your business effectively, but for you to do that you have to have clinicians that can be effective in the field and you can’t be effective if you're not supported when you lose a client. (P2) 

Not only did the participants leave their current organizations, but some also shared feelings of disillusionment that left them considering leaving the field entirely due to the overwhelming focus on liability. 

• You need to go through every note I ever wrote…to make sure that I’m not somehow going to get sued. Like, if that’s the way it works, I don’t even want to work in this field anymore...it just made no sense to me. (P5) 

This feeling of being let down by the field was evident when the participant described how organizational responses often prioritize liability over compassion. P5 expressed a deep emotional response to the way his records were scrutinized after a patient’s death: 

• People almost immediately went through my records and said, we just want to make sure there’s no way you can be held accountable for doing something wrong. And I remember thinking, what would I have done wrong? Like did I shoot the man? You know, apparently (insurance company) reviews every record when somebody passes away, as if there is something to uncover….So people immediately focus on that part and nothing else. And I think that’s maybe where people come in with like the idea that maybe you did something wrong. Maybe you could have done something to save this person and that gets communicated the wrong way. 

While he understood the necessity of quality assurance, the emotional toll of feeling scrutinized and blamed overshadowed the intended purpose of these reviews. 

• I’m not against people reviewing records but when that’s the first thing people focus on without saying, my God, how are you? You just lost a client that’s really difficult. And that was universal everywhere I worked that people immediately jumped to that. And that’s just, to me, not a very healthy way of looking at it. (P5) 

This reflects the clinicians' understanding of the need for liability checks, yet stresses the absence of vital emotional support and compassion. While many clinicians in the study felt an overwhelming emphasis on quality assurance that overlooked their human aspects, they acknowledged the importance of being prepared for liability and risk management. P6 described an incident where insufficient documentation had serious consequences: “The person denied it and then attempted suicide, but it wasn’t documented well. That was something we talked about, like if these conversations are happening, how do you make sure you are getting them in your chart?” The participants' experiences emphasize the need for a balance between liability preparation and emotional support within organizational practices. 

P10 expressed a lack of confidence in his organization's ability to implement quality assurance programs that were non-punitive and had meaningful outcome measures. “A lot of stuff is just really disingenuous, it’s checking boxes, it’s covering everybody, we told them, we did this, you know? When somebody dies you know it’s a witch hunt every time.” This focus on potential mistakes rather than on support created an environment where participants felt blamed and isolated, making it less likely they will seek help or discuss their experiences openly in the future. P10 referred to this as a “cover your ass” mentality, noting that it instilled a sense of fear and significantly influenced his approach to the job. 

• You definitely want to make sure that you take all the necessary steps, so that when something goes wrong, and often it does, you’ve documented that you’ve done everything you could possibly do, so they can’t turn the tables on you. A lot of bad things have happened. 

He emphasized that the organization's approach fostered fear, leading to the belief that “the top brass is going to come down to you and their going to roll on you and if you didn’t cover yourself, you’re gone” (P10). P5 echoed this sentiment stating: “People almost always think about how we’re gonna get in trouble for this, not like the poor client, or the clinician who worked with somebody.” This highlighted the absence of meaningful recognition of the life lost and the subsequent emotional strain on those providing care. P10 shared his belief that this type of organizational culture was a major factor in the experience of low morale by staff. “The morale in any type of job like this is always going to be low. And it’s going to ebb and flow.” 

The participants emphasized that just as much preparation and energy should go into supporting their emotional well-being as is devoted to quality assurance. P5 pointed out, "Some people think you should be prepared for liability all the time, and it should always be focused on. That’s not gonna help people." He concluded that the priority often becomes about avoiding trouble rather than addressing the needs of the clinician and the loss of the client. These experiences highlight the critical need for organizations to balance quality assurance with compassionate support for clinicians. Without this balance, the participants believed that the mental health of clinicians and the quality of care they could provide will continue to suffer, exacerbating the already significant challenges faced in the substance use disorder field.

Business as usual 

A pervasive theme among the participants was the expectation to resume work immediately following the death of a patient (P2, P5, P6, P7, P8, P10 and P11). The clinicians described feeling pressured to carry on with their work as if nothing had happened, with minimal time allocated for processing their grief or receiving emotional support. This swift return to normalcy not only heightened their distress but also highlighted a significant gap in organizational support practices. 

P2 expressed frustration with the lack of support and the expectation to carry on with her duties without acknowledgment of her loss. "They expect you to just go see your next client like okay well you know, thanks for letting me know…it was such a lack of support." This sentiment was echoed by P7, who recounted a particularly distressing experience: 

• It’s like, next patient…I mean, I remember that day, it bothers me, because that day I had a patient coming in and the medical assistant just kind of told me, I was really taken aback, but it’s like wow. And I have to take this next patient. I can’t even process this right now, that she died. 

Even when clinicians were not directly told to resume their duties, the lack of structured support left them with an internalized expectation to carry on with their work as usual. P4 described these feelings 

• You try to buck up and keep going and run my group. I started my group and we all checked in and it was my turn to do the psycho-ed piece and I was like you know what? I can’t run group tonight. I found out one of my client’s died. I can’t do it. The clients were so shocked and they were so surprised I was upset about it. I really think they looked at me differently after that. They were so surprised I cared. 

This expectation to maintain an appearance of normalcy fosters a work environment where emotional responses are minimized and professional responsibilities are prioritized, often to the detriment of the clinician's mental health. P11 emphasized that the organizational culture subtly demands clinicians quickly resume their responsibilities without letting a patient's death impact their work. 

• I remember hearing the news. I was between sessions. It was very chaotic. I worked in a very fast paced environment…my supervisor knew that this is someone that I had worked with for a decent amount of time and immediately pulled me in to check on me and see how I was doing and at the same time, there was not a tremendous amount of time for me to like really process because I had a client in the waiting room. 

Having to continue working without adequate time to grieve or process the loss resulted in an emotionally numbing effect, with clinicians internalizing that they had to suppress their emotions to meet their job demands. This can lead to long-term emotional exhaustion, burnout, and a sense of isolation. 

Despite the challenges, some participants found that diving back into work provided a temporary distraction. P1 and P11 noted that focusing on their work allowed them to get through the day until they had the space to process their emotions. P1 shared, "Diving back into work, becoming a workaholic again, that’s a good way to kill some time and distract and help the next one." While this approach may offer short-term relief, it is not a sustainable or healthy coping mechanism. The expectation to continue working without adequate support or time to process the loss reveals significant gaps in organizational practices. These gaps not only affected the clinicians' emotional well-being but also highlighted the need for more compassionate and structured support systems within healthcare organizations. 

Informal death notifications 

Participants also expressed concern over the way in which their organizations informed them of a client’s death. They were particularly concerned with the common practice of informal death notifications. The manner in which they were informed significantly impacted their ability to process the loss and continue their work. They shared that these notifications were often delivered insensitively, compounding their emotional strain. They reported that the news was frequently conveyed abruptly, casually, or via voicemail, which the participants found lacking in compassion. 

P2 described a particularly jarring experience: "So how I found out about him passing away was from a counselor...she came to me and she said, ‘I just want to let you know that he overdosed and passed away and my client found him.’" The abrupt and casual delivery of the news failed to provide the necessary emotional support and left P2 feeling distressed. In a second incident P2 shared that she received a notification by voicemail: "The clinical director left it on my voicemail. I’m at work and then I see that I have a voicemail, so I checked it and I literally just started crying. I said to myself you know, you have to really realize the failure to work in it, and you get used to it kind of…you’ll never really get used to it." Receiving such significant news through a voicemail without any immediate support amplified the emotional impact of this loss for this participant. This type of notification, delivered without prior consideration of the clinician's emotional state, underscores the need for more thoughtful communication strategies. 

P5 recounted several instances of being informed about a client's death in ways that felt inappropriate to him. "I remember being in a meeting with a group of people and somebody came into the meeting and said, ‘one of your clients is dead,’ and I’m like ‘what?’ and she goes, ‘I know it was suicide, sorry.’ And everybody’s looking at me like, what are you going to do? It was so uncomfortable. I just thought, what a difficult way of telling somebody anything." This abrupt and insensitive method of delivering such news left P5 feeling deeply unsettled, highlighting the lack of empathy in these notifications and the added emotional burden they created for him. 

In another instance, P5 recounted a particularly stark moment when he was informed of a client's death abruptly and without compassion: "I got a notification that she didn’t get to her job. So, I said to the nurse, why wasn’t she there? She was like, ‘she’s dead.’ I mean, it was just like people were so numb and desensitized that anytime they delivered it, it was like nothing. It’s got to have a little bit more care to it, you know what I mean?" The impersonal and abrupt nature of this notification highlighted to P5 a troubling desensitization toward the death of individuals with SUD, making an already difficult situation even more challenging to process. 

P7’s also recounted the informal manner in which the news of a client’s death was delivered to her in passing. "Did you hear what happened to Joe? You know, that sort of thing. Did you hear what happened to Jim? They found him dead this morning." These casual notifications were particularly difficult for P7, highlighting the need for more structured support. She shared feeling as if it was common in her organizational culture to share this type of information in passing. “You see people and they are like ‘did you hear about Jen?’ I might have worked with her several years ago, and someone is randomly like ‘yea they found her last month she had overdosed.’” The casual delivery of such significant news was challenging for P7, making her feel that the gravity of the event was minimized and leaving her without the support she needed in those difficult moments. 

P8 shared an experience where the news of a client's death came indirectly: "My colleague at the clinic heard it from one of his clients who knew her and then my colleague looked it up I think, I don’t know." This secondhand delivery left P8 feeling caught off guard and lacking the necessary support to process the loss, highlighting the emotional strain and sense of isolation that can result from inadequate communication. The reliance on secondhand information highlights a gap in formal communication channels within organizations, which can lead to confusion and additional stress for clinicians. 

However, it is important to note that not all of the clinicians had negative experiences with death notifications. P3 described a more compassionate and structured approach within his organization: 

• We had a clear understanding around how each clinician wanted to be informed of an overdose loss. You know, some wanted to be told at the end of the day. Some people wanted to be told right away. Some people, if it was their day off, wanted to be told on their day off or if they were away from the clinic. Yet other people wanted to wait until they were on site. 

This tailored approach made P3 feel respected and supported, illustrating how thoughtful handling of such notifications can significantly improve the support provided to clinicians and help them manage their emotional responses more effectively. These varied experiences highlight the importance of developing formal, compassionate protocols for informing clinicians about a client’s death. Tailoring the approach to individual preferences, providing immediate emotional support, and ensuring sensitive delivery can help mitigate the emotional toll on clinicians and promote a healthier work environment. 

The clinicians in this study highlighted several key issues in organizational responses to patient overdose deaths. First, the focus on quality assurance often overshadowed the emotional support needed by clinicians. This emphasis on liability and documentation review left clinicians feeling scrutinized rather than supported during a stressful time. Second, the expectation to quickly return to business as usual after a patient’s death left clinicians with insufficient time to grieve and process their emotions. This practice prioritized professional responsibilities over the mental health of the clinicians, leading to further emotional strain. Lastly, the way death notifications were handled often lacked sensitivity and care. Informal and abrupt notifications added to the emotional burden on clinicians and highlighted the need for more compassionate communication practices. Together, these subthemes emphasize the need for healthcare organizations to develop balanced protocols that address both quality assurance and the emotional well-being of their staff. By doing so, organizations can foster a more supportive environment that enhances both clinician well-being and patient care. 

Support system shortcomings 

The participants described how the challenges they faced after a patient’s overdose death were compounded by systemic issues within their organizations. They emphasized a lack of robust support systems, citing inadequate peer support, insufficient supervision, and a general scarcity of resources as significant contributors to their ongoing stress and burnout. Additionally, participants noted unrealistic expectations about client outcomes and attitudes that placed blame on them for their clients' actions, further exacerbating these difficulties. Their experiences highlight the importance of understanding these systemic shortcomings to develop strategies that better support their well-being and enhance their ability to provide high-quality care. 

Lack of an organizational culture and approach to supporting clinicians 

Many of the participants highlighted the absence of a supportive organizational culture in which they could process and address the stressors that they experienced in their roles (P2, P4, P5, P6, P7, P8, P10, P11 and P12). Each organization appeared to address client overdose differently and the participants recounted that they were often unaware of how these situations would be addressed, if at all. The lack of a clear, supportive protocol for dealing with client overdoses left many clinicians feeling abandoned and struggling to cope with their emotional burden on their own. 

P5 vividly recounted a distressing incident where a client overdosed within the facility, saying, "It was weeks before I stopped seeing that when I went to sleep, and we talked about it a little amongst ourselves, but nobody from the agency came to see how we were doing.” He shared that the lack of follow-up from the agency left him to cope on his own, without any feeling of support. P5 further reflected on the lack of systematic efforts to debrief and support the staff in his organization after this traumatic event, expressing dismay. "It was almost like we never processed it to this day. The thing that I can’t understand about overdose in general is clinicians who don't process it among themselves, it’s a traumatic event because when a client killed himself there would be some sort of review right? Internal review, there would be supervision." P2 shared a similar experience of feeling a complete lack of support and unfilled promises of help from administrators in the organization in which she worked. 

• It’s crazy that I had that experience at (organization) where nobody really supported me, when I spoke with a coworker, she was like “it happens all the time.” And nobody said anything it’s just like “you know so and so passed away, if you guys need us, we’re here.” And then they never checked back in or anything…I know that it impacted me, I remember the impact it had on me at the time. 

Similarly, P11 observed that her organization lacked a formal plan to provide support to staff after an incident, and the limited assistance available came only from immediate supervisors. 

• Internally, we didn’t have much support outside of my immediate supervisors. There were no peer support groups or similar resources. It was a smaller organization, and they just didn’t have that in place. I do wish there had been more opportunities for group or peer supervision; it just wasn’t offered. I believe it would have been helpful not only for this type of situation but for many others as well. 

For this participant, she believed that this support should extend beyond the death of a client to supporting clinicians in the challenging aspects of their role.               

• When you’re working in the field, even if client’s don’t pass away, they will disappear for months sometimes right? Or years, you won’t hear from them. I think that also comes with its own set of feelings and emotions of just not knowing and the are they dead? Are they not dead? Are they okay? There’s that risk with any client, but I think that was something that was honestly tough though. A lot of times working in substance use treatment when clients terminate the relationship you don’t typically get an answer as to why. 

She shared that having an outlet and a form of support to process these experiences would have been useful for her. P8 shared similar beliefs of the importance of connection in the wake of significant events. “I think the most important thing for someone is connection, human support. Peer support or therapy, or some kind of a support group.” 

Echoing this sentiment, P5 found it puzzling and disheartening that providers, who frequently assist clients in managing stressful situations and major life events, did not seem committed to supporting one another in the same way. "System providers really don’t do well and kind of debriefing and dealing with the traumatic stress of that. In the majority of times that I’ve dealt with client loss, it’s almost been not there. There’s been no real discussion, a little bit, but not like a positive kind of debriefing and to this day I can’t imagine how we could be working with people to help them deal with situations and not really do that for ourselves." 

P5 also noted that his experiences were not isolated to one agency but were consistent across multiple settings that he had worked. 

• There was never a systematic effort to kind of process things and I can’t figure out why that is. And it's been across multiple agencies. It’s almost like providers can’t face it so they don’t. And they just move on, which doesn’t feel healthy to me. 

He further shared his belief that “mandatory supervision” should be an expectation after a distressing workplace event. He shared that in his experience supervision “is almost always the last priority.” 

In the current study there was a marked difference between the experiences of participants who experienced support and those who were impacted by its absence. While the majority of participants found their organizational culture to be lacking in these ways, some of the participants experienced effective systems of support. P3 highlighted the benefits of having support systems in place when he described working in an acute setting. 

• I was lucky to have it happen at a clinic where I was very close with my colleagues. I knew that there were people that I was working with that had experienced it before…Once everyone had been informed, there was a meeting to discuss the classic responses…having a plan for how we are going to help our clients who also knew the individual. And then just having a group of people to discuss our surprise our sadness and to be able to talk about it amongst colleagues was really helpful. It was a very non-judgemental group of clinicians. So there was no sort of expectation of what was appropriate or not, everyone had their own process… that process was really a team approach. 

While this participant acknowledged that he is not sure if the model he experienced was intentionally integrated by the organization or a result of being “lucky” to have great colleagues, he was clear that he found it to be beneficial in the aftermath of patient death. P1 echoed the benefits of organizational culture that provided support and acknowledged distressing incidents. 

• It can bring us closer together, grieving as a unit, we would often go to funerals and wakes, mostly the wakes. Going to the wakes together and being as a group. Active leadership was so important, it helps it become more real and it helps build more closure. Setting the tone for how to grieve together and how to come closer after a tragedy like that. 

P9 also experienced a sense of closeness as she worked through the experience of loss interpersonally with her peers within her organization. “Just listening to some of the staff, the ways they opened up and talked about the loss of the client and what it meant to them.” Yet for this participant she also experienced that this sense of connection stopped when it came to exploring the clinical aspects of the work.” It was clear at the clinical level, that people just didn’t give each other the room necessarily. It was really clear that people grieved independently and I don’t think that the organization necessarily felt that grieving should be shown there.” 

For participants whose organizational culture, supervisors, and peers acknowledged and validated the pain of loss, the environment became more conducive to healing. These participants found that such support allowed them not only to grieve but also to integrate the loss effectively into their ongoing work. 

Peer support 

The participants highlighted the lack of robust peer support as a crucial systemic challenge in SUD treatment (P2, P4, P5 and P11). They shared that it impacted their professional performance and contributed significantly to their stress and burnout. The dynamics within peer relationships often led to unhealthy environments where they felt judged, blamed, and unsupported. 

P5 shared his experiences with the negative impact of peer interactions, highlighting a pervasive blame culture: 

• There were even coworkers who almost looked at me like somehow it was my fault. I wasn’t a good enough social worker in some way. One person was like, ‘well, if you had been doing what you were supposed to be doing maybe he would still be alive.’ I mean it was just really insane actually, as if I had any control over whether somebody was using drugs or not. You know what I mean? So, there were certainly times when I remember feeling like ‘wow that’s lousy of you.’ 

This sense of being unfairly blamed for clients' behaviors left P5 feeling unsupported and demoralized, illustrating the toxic work environment that can result from such interactions. 

Further illustrating this issue, P5 described the tendency among some coworkers to attribute client outcomes directly to the clinician's competence. "One coworker stands out…If a client did something that was undesirable, it was almost always the therapist’s fault. I have another coworker who said ‘unless your clients are staying clean, they are making you look bad.’" Such attitudes fostered a blame culture and perpetuated unrealistic expectations about the control clinicians have over their clients' behaviors. P5 felt that this environment of judgment and blame led to a "codependent" relationship between clinicians and their clients, where the clinician felt excessively responsible for the client's outcomes. This unhealthy dynamic placed additional emotional burdens on P5, making him feel personally accountable for his clients' actions, which he found neither realistic nor fair. 

Even when there was no outright blame, the fear of being judged by peers persisted. P8 explained, "One of the things that we often feel anxious about, when we share this kind of material with other clinicians, is that somebody’s judging our work. We’re aware of the work in a way that a lay person isn’t and so in some ways the stakes can feel higher when we’re talking about this with another clinician." This constant fear of judgment can lead to isolation and reluctance to seek support or share experiences, further exacerbating the stress and emotional burden on clinicians. 

Yet some of the participants in the study felt that their peers were the only place where they felt support in their organizations around the loss of a client. P10, having described what he perceived as a punitive workforce culture, one that was “reactive not proactive,” highlighted the importance of utilizing peers to buffer organizational stressors and provide support to one another. When describing his interactions with his coworkers he shared “We used to go to (hospital) and we’d sit at the tables and have a coffee and just shoot the bull about stupid stuff. Or we’d go for a walk and relax.” P8 echoed the importance of having peer support when she was struggling with the death of a client. “I found my colleague was really there to support me and that was really helpful.” P3 shared that he found “peer supervision within the clinic was probably the biggest help…having colleagues who I knew would support me was helpful to me.” For these participants, the peer support was a major factor in how they processed client death as well as managed the stressors of their roles. 

These experiences highlight the participants' perspectives on the urgent need for improved peer support systems in SUD treatment. Many emphasized the importance of creating an environment where clinicians can discuss their challenges without fear of judgment or blame. They stressed the need for fostering a culture of empathy, setting realistic expectations, and promoting mutual support among peers. Addressing these issues could help reduce the stress and burnout clinicians face, ultimately enhancing their well-being and the quality of care they provide. As P5 noted, “Limitations right? Like people, I think, if a client is struggling, that’s why they’re here. But people often assume it’s because our work isn’t good enough. I don’t like to equate those because then it feels hopeless.” This sentiment underscores the importance of acknowledging the limitations inherent in the work and the necessity of supportive supervision. 

Supervisory support 

Participants emphasized the crucial role of supervisory support in mitigating the challenges they faced. Effective supervision helps clinicians navigate the complexities of their work, providing much-needed guidance, validation, and emotional support, especially after an overdose death. They stressed that supportive supervisors are essential for fostering a healthy work environment and addressing the unique challenges they encounter, ensuring their well-being and professional growth. However, many participants noted significant shortcomings in their supervisory relationships, which they felt exacerbated their stress and emotional burden. 

Poor supervisory support was a common theme among the clinicians interviewed (P2, P3, P4, P5, P7 and P10). P2 described her relationship with her supervisor as completely unsupportive. "My relationship with my supervisor, like I had no love for her. Literally in supervision, I was not receptive to anything, I was a wall. The way they handled everything just shut me down from the program altogether." This lack of empathy and support led her to disengage from the supervisory process, which made it even harder for her to manage the demands of her role. 

P4 shared a particularly disheartening experience with her supervisor following the death of a client: 

• The first time one of my clients died, I was heartbroken, crying. My supervisor’s response was, 'I am really surprised you are so upset by this. As a seasoned clinician I would expect for you to be able to manage this better.' My response was, 'When I stop caring, it is time for me to leave the field.' I was sort of offended. I thought this is a human being, this is a person that just died. I have to feel that, I want to feel that. I can’t have it cripple me and not let me be able to do my work. However, I still have to feel it. 

This participant’s experience underscores the importance of supervisors recognizing and validating the emotional responses of their staff, rather than dismissing or minimizing them. She felt that instead of being dismissed or minimized, her feelings should have been recognized, highlighting the necessity for a supervisory relationship that respects the clinician's humanity and the emotional challenges of their work. 

P5 also highlighted the problematic approach of some supervisors, who often placed undue responsibility on clinicians for their clients' actions. 

• They almost always presented in a way that makes me feel like I’m responsible, and I said, how could I be right? I mean, you do the best you can and you document what you do. The client has the ability to make their own decisions, even if they have a guardian. You can’t stop them from walking out the door and buying drugs and using; what can you do? You’re not going to tackle them to the ground, so yeah. 

This perspective highlights the participant's belief that supervisors should reinforce the boundaries of clinicians' responsibilities and emphasize realistic expectations about their control over client behaviors. 

The participants in the current study emphasized the timing of support and supervision as another crucial component of an effective and supportive organizational culture. P6 shared 

• I don’t always love having supervision right after something like that because I don’t always feel like I’ve had enough time to wrap my head around it. I appreciate the support and the intention, but I think sometimes you need some space to reflect on what happened. I think you need some space to kind of reflect and I think some of the best processing is when you’re not forcing the process. 

In addition to the timing of supervisory interventions, P10 expressed that the type of support and supervision needed can vary throughout a clinician's career and should be tailored to the individual rather than following a one-size-fits-all approach. “My supervisor is great, but he’s very laissez-faire…but I wouldn’t recommend him for someone new. I got him right out of the gate, but I wasn’t new to the game. But somebody needing support, they need somebody that’s going to check in with them, provide them with that supervision.” 

The participants in this study emphasized the significant benefits of quality supervision for their success in the field (P1, P2, P4, P6, P8 and P10). Many shared that they had not always experienced what they considered to be effective supervision (P2, P4, P5 and P10). P10 shared his belief that promoting individuals based on convenience rather than leadership skills contributes to the presence of ineffective supervisors. 

• So I really think it comes down to making sure that you have quality supervisors. But that doesn’t happen, there’s always a lot of people that move up or get promoted, and they’re not necessarily the right people. They just happen to know the right people. (P10) 

The experience of having unsupportive supervisors motivated some participants to strive to become the kind of supervisor they needed or would have benefitted from (P2, P4 and P5). P5 shared that he works to counteract these harmful perspectives in his own supervisory relationships. 

• And I think that’s helped me as a supervisor, when I provide clinical supervision. Because a lot of young clinicians feel like every time there’s an outcome that’s not desirable that they’re going to get in trouble or people are going to think they’re not good enough. And that is something that I focus on right away because I believe that’s a great way to burn somebody out by holding them accountable for things that they have no control over. (P5) 

P3 shared these sentiments as he described trying to help new clinicians understand the nature of their role and the boundaries of responsibility. 

• One of the things that I’ve talked about in supervision with younger clinicians is my understanding of what my role is. I know that I have a responsibility to assess for safety pretty much at every session, I know that I have a responsibility to ask difficult questions and have difficult conversations. I know that it’s my responsibility to offer not only support but skills and suggestions for where people can receive additional support. It shaped me in a sense that if I know I am doing every one of those things, then I’m able to sleep at night. 

While he acknowledged that he would always worry about his clients, he explained that this is different from worrying about his role in their well-being. He further elaborated: “It happens and we cannot prevent every death, because we’re not responsible for how our clients live their lives.” For this participant, it was crucial to help new clinicians understand that they have a specific role to play in their clients' lives, with clear boundaries regarding what that role is responsible for and can achieve for someone else. 

P4 pointed out that the quality of supervision often varied depending on who held the supervisory role, which influenced her decision to seek out ways to become an effective supervisor. 

• I always had supervision. My first supervisor was very good. My second supervisor was very good. Then I went through a series of not good supervisors, which then provoked me to take three different trainings on how to be a supervisor. I felt like I knew what bad supervision felt like and I did not want to provide that to people. 

P2 described her efforts to cultivate an organizational culture that provided the support she found lacking in her previous workplaces. 

• It has been my mission as a program director to help people, clients, and my staff get to a place where they do not have the experiences that I did at (organization). Where my employees will not walk away to go to another place and say ‘oh when I worked for that place, they were never supportive and it was awful. I make sure, because I know what I experienced and how detrimental that could have been to this field, if I had left because of what (organization) did. 

P4 also aimed to shift organizational culture by developing organizational support for clinicians dealing with stressors related to client death, fostering a culture where supervision was both utilized and valued. 

• When I worked at (organization), we developed training for clinicians around secondary trauma and vicarious trauma. We explained how hard it was to lose somebody that you are working with as a clinician, and encouraged people to bring it to supervision. I was part of the team that provided that, so I wasn’t really on the receiving end of it. 

While this participant was able to develop a support strategy for others, it did not help to fill the gap that she personally experienced in support. 

Yet some of the participants such as P11, while wishing that her organization had a greater culture of support, noted the benefit of having a supervisor who had personally experienced similar challenges.When discussing her experience with her supervisor, this participant emphasized the power of shared experiences and the importance of normalizing the grief process after a loss. 

• I think just hearing her experiences and knowing that like they had also gone through it and they had also had a tough time with it, you know? Just hearing them share about that, I felt less alone in the experience and I don’t want to say less crazy but you know, I just didn’t feel like I was overreacting or underreacting it was just sort of like a normalizing of what I was going through which was really helpful. (P11) 

The participants' experiences underscored the vital importance of having effective and empathetic supervisory support. They expressed a desire for supervisors to create an environment where they felt heard, validated, and supported in their emotional responses to their work. Recognizing the emotional toll of patient losses, offering appropriate emotional support, and clarifying the limits of clinician responsibility were all seen as essential aspects of this support. The narratives shared by the participants highlighted the profound impact that inadequate support systems had on their professional and personal lives. They emphasized the need for more structured and compassionate approaches within their organizations to help them cope with the demanding nature of their work. 

Exodus to private practice 

The participants in this study highlighted a growing trend among clinicians to transition from formal and acute treatment settings to private practice, with nine of the participants leaving acute settings for private practice or outpatient settings. This shift was driven by several factors, including the desire for greater autonomy, a better work-life balance, and more manageable caseloads. Many participants expressed frustration with the high demands and limited support within organizational settings, which often led to burnout and a sense of helplessness. In contrast, private practice offered them the ability to set their own schedules, choose their clients, and create a more personalized approach to care. Additionally, it allowed them to determine the level of risk they were willing to take in terms of client acuity. 

This constant pressure to manage overwhelming caseloads, coupled with unrealistic expectations and high demands, has driven many of the clinicians in the current study to seek alternative work environments where they can regain a sense of control over their workload and better protect their well-being. P4 shared that these types of expectations, coupled with a lack of feeling supported, led her to the decision to leave an acute care setting and start her own private practice. She explained, 

• Part of why I started my own practice five years ago is because not a whole lot of people are making sure that clinicians feel taken care of in the field. It is about the money. A proper caseload is maybe 50 clients. If somebody is asking somebody to carry 70-80 clients and run 5 groups a week but nobody is caring about how they are dealing with grief or if they are burnt out. That is the expectation nowadays. It is not right, it is wrong, and that is why there are all these articles you see coming out that the next wave of the pandemic is going to be the mental health crisis. (P4) 

Additionally, P4 shared that she found the organizational shift from counseling to case management models, implemented to handle the growing demand for care, detracted from what she believed was essential for helping clients recover. This change significantly contributed to her decision to move into private practice. 

• This is one of the reasons that I ended up leaving. I was there for 9 years and they were switching to a case management model. Basically, clients would be seen once a month rather than once a week for counseling. If you are seeing somebody once a month, that’s not counseling. I was strong in my opinion. It is not fair. I couldn’t sign off on that. Not only is it not fair on the clinician working there, you’re setting up an environment for secondary trauma and burnout. 

Reflecting on her decision to transition to private practice, she described it as both relieving and empowering: "I realized I still care deeply and want to help people with this condition, but the current system isn't the right way. I didn't feel properly equipped to do that" (P4) 

The participants in the current study conveyed that the challenges they encountered in the field, the experience of client overdose deaths, and the responses they received in the aftermath significantly influenced their decision to move into private practice. These experiences also shaped their decisions about their clients and the care they provided. Many participants realized that continuing to work with individuals in active addiction or early recovery posed too high an emotional burden for them to bear, not out of fear of getting in trouble, but because they recognized their emotional limits (P3, P5, P6, P8 and P12). The reasons they shared for transitioning to private practice or outpatient settings and the decisions they made about which clients to serve were closely tied to their perception of "risk." 

P6 shared the need to create space from working with those in crisis. “Private practice has been different, I feel like it’s the one place where I haven’t dealt with any crisis.” She continued by describing needing to step away from treating individuals with acute SUD, at least for a period of time. 

• I think I can help people that aren’t… like alcohol seems to be fine for me. I seem to do well with that. Food as an addiction, I seem to do well with, but opioids and heroin use, I think it’s just like too much and maybe one day when it’s a little further out, I can bring it back into my work. 

P8 explained how losing a young client to an overdose led her to reevaluate the level of responsibility she wanted in her work. 

• After the experience with that young man, I decided I’m not gonna see that kind of client in my private practice anymore…I’m not gonna work with anyone whose actively using unless they have a really long history of recovery, or who’s opioid addicted. I just feel like it’s too much responsibility to have someone, even if they’re on methadone or suboxone. 

Even P3, who reported having a supportive organizational culture and strong peer support, shared that he made a conscious choice to "do things differently" in his private practice. He had long since internalized that "in order for me to stay in the field and not feel burned out, I had to just accept a high level of uncertainty." Despite this acceptance, he still opted for a private practice where his clients' acuity and risk levels were lower. 

• My caseload is much less acute in my private practice. I’m dealing with hardly any pre-contemplative individuals who are I think the ones that are typically most at risk.. the people I see in my private practice typically are appropriate for an outpatient level of care at the time of the evaluation I do with them. I do limit the risk in terms of my selection process. 

P3 also shared that he had witnessed many of his colleagues experience burnout and choose not to work with individuals with SUD any longer or to leave the field altogether. 

• I’ve had two of my close colleagues who have burnt out of this field. Both are clinicians who I highly respect. One is still in practice as a therapist but does not work with SUD cases any longer. And the other left the field essentially left clinical practice and now helps other clinicians build private practices. I think to some extent it had to do with personality and risk tolerance. 

P5 also managed his risk level by leveraging the autonomy that private practice offers, allowing him to choose which patients to provide services to and who to include in his support network. He shared that this agency reduced his fear of being blamed and minimized exposure to the negative quality assurance processes he had experienced before. 

• I don’t feel like I have an agency that’s wondering if I’m going to get them in trouble if I didn’t do X, Y, or Z or something trivial. I have a little more choice over my kind of associations with coworkers or colleagues, which when you work for an agency, you don’t have that. So in some ways, some of the negative influences I’ve been able to kind of weave out because I’m my own kind of practitioner. It gave me a lot of agency over that. And I have the ability to say to a client, I don’t think I have capacity to really help you and like a client with an eating disorder, I don’t treat eating disorders and I feel like you need more of a referral than somebody who can see you every two weeks. So it gives me a little bit more agency over whether or private practice is the right setting for some people who really have multiple stressors in there life. 

He further explained that while private practice doesn't eliminate all risk, it significantly reduces it. 

• It’s not that people with commercial insurance can’t have substance use disorders because you know they do. But generally the people that I see in private practice aren’t at as great of risk for overdose as the people I used to see in other agencies….I have not had one person with an opiate disorder even ask for therapy which is a little concerning right? (P5) 

P11 shared the same sentiment about working in an outpatient clinic. “The clients I have now are pretty stable, they are in outpatient, so there’s less of a huge risk there.” 

The theme of "Exodus to Private Practice" highlights how the participants' experiences with organizational challenges, the emotional toll of client overdose deaths, and insufficient support systems led many to transition to private practice. They shared that private practice offered greater autonomy, a more manageable caseload, and the ability to set personal boundaries, which collectively helped mitigate the emotional burden of working with high-risk populations. This shift not only allowed them to maintain their commitment to helping individuals with SUD but also to protect their own well-being. The participants' narratives underscore the importance of addressing systemic issues within organizations to retain skilled clinicians and enhance the overall quality of care in the substance use disorder field.

This study aimed to explore the experiences of clinicians working in the SUD treatment field, focusing on the challenges they face, their emotional responses to client overdose deaths, and the support systems currently in place. Through in-depth interviews, several key themes emerged, offering a comprehensive understanding of the systemic issues and personal impacts encountered by these clinicians. 

The findings of this study revealed while there are many rewards and benefits to clinicians working in the field of substance use treatment, that there are also many challenges including managing high patient acuity, high recidivism rates and pervasive stigma. These results align with previous research that highlights the severe state of the behavioral health field, marked by high patient acuity and systemic issues [8,10,16]. The participants' experiences also reflect the literature's emphasis on the emotional labor involved in SUD treatment and the frequent inadequacy of resources [6,15]. Despite these hardships, many clinicians expressed a deep commitment to helping marginalized individuals and found fulfillment in their successes. They emphasized the urgent need for more effective and compassionate interventions, along with systemic changes that provide better training, support, and resources. 

A significant finding was the perceived connection between supervisory relationships, feelings of being supported, and clinician well-being. Many participants reported poor supervisory support, which hindered their ability to cope with the challenges they faced, particularly the overdose death of a client. They stressed the need for supervisors to provide empathetic and effective support, recognizing the emotional toll of the job and reinforcing realistic expectations about clinician responsibilities. The presence of supportive supervisors who acknowledged and validated their emotional responses was noted as a critical factor in their ability to manage stress and avoid burnout. This aligns with previous literature emphasizing the importance of effective supervision in mitigating burnout and promoting clinician well-being [10,21] as well as the influence of leadership behaviors on satisfaction [20]. In an attempt to find purpose in their experiences some of the clinicians sought out supervisory roles where they could engage in the type of support that they felt they had needed during their own challenging times. 

Consistent with the previous research, the participants also highlighted the importance of peer support in creating a healthy work environment and buffering against the negative challenges of the job [7,21]. Many described how positive peer relationships contributed to a sense of camaraderie and shared purpose, helping them cope with the emotional demands of their work. Conversely, the lack of peer support often led to feelings of isolation, decreased feelings of effectiveness, and increased stress. The participants emphasized that having peers who understood their experiences and provided emotional support was crucial in managing the pressures of their roles. 

The way organizations responded to client overdose deaths emerged as a critical issue affecting the well-being of the clinicians' in the current study, adding to the existing literature on workforce issues. Participants described the emotional toll of losing a patient to overdose, often compounded by a lack of adequate organizational support. Many felt that the immediate focus on quality assurance and legal implications overshadowed their need for emotional support and debriefing. P5 shared his frustration: "It doesn’t feel like there were any real considerations beyond the agency’s well-being." This lack of empathy and support left clinicians feeling undervalued, isolated, and at times blamed for their client’s actions. The emotional burden was further intensified by the insensitivity of death notifications, which were often delivered abruptly and without compassion. P8 described a particularly distressing experience: "Did you hear what happened to Joe? They found him dead this morning." Such experiences highlight the need for more structured and compassionate communication practices within organizations. This includes a clear organizational and systemic model for how client overdose deaths will be handled that goes beyond quality assurance and prioritizes the well-being of the staff and clients. 

Another key theme was the trend of clinicians moving into private practice. Participants cited the autonomy to choose clients and set boundaries about caseloads as major factors in their decision to leave acute treatment settings. They expressed that the emotional burden of working with high-risk populations in organizational settings was unsustainable, leading them to seek environments where they had more control over their work and client interactions. This shift to private practice allowed them to manage their emotional well-being more effectively and continue their work in a less stressful context. For many, the decision was also influenced by the high-risk nature of the patients they worked with, which they felt they could no longer manage. The emotional impact of client overdose deaths was a critical factor in this decision for many of the participants, coupled with the lack of effective support systems to help manage these experiences. These experiences highlight the need for a supportive organizational culture that acknowledges the emotional toll on clinicians and provides robust support systems. 

This shift to private practice also underscores the broader impact on the field of substance use treatment emphasized in the previous literature [8,9,21]. As clinicians leave formal treatment settings for private practice, the capacity to meet the growing demand for services diminishes, exacerbating the gaps between those needing services and those receiving them. Long waitlists and insufficient treatment options continue to pose significant barriers to care, further highlighting the need presented in the previous literature for systemic reforms to retain skilled clinicians within the field. 

The study underscores the urgent need for systemic changes within SUD treatment organizations. Participants called for more comprehensive support systems, including robust peer support, adequate supervision, and realistic workload expectations. They highlighted the necessity of balancing quality assurance with compassionate support to mitigate burnout and enhance the quality of care provided to clients. By capturing the voices of clinicians directly involved in SUD treatment, this study provides valuable insights into the multifaceted nature of their work. Addressing the identified deficiencies and implementing supportive organizational practices are crucial steps toward improving clinician well-being and the effectiveness of SUD treatment. 

Future studies should delve deeper into the impact of supervisory relationships and peer support on clinician well-being. Investigating the effectiveness of different support systems and identifying best practices for creating a supportive organizational culture could provide valuable insights. Additionally, research should explore the long-term outcomes of clinicians who move into private practice and how this shift affects their professional satisfaction and client outcomes. Examining the role of policy changes and funding structures in addressing systemic issues within the field is also crucial. By continuing to build on these findings, future research can help develop comprehensive strategies to support clinicians and improve the overall effectiveness of SUD treatment.

While this study provides significant insights into the experiences of clinicians in the SUD treatment field, it has several limitations. The sample size was relatively small and may not be representative of all clinicians working in this field. Additionally, the qualitative nature of the study means that the findings are based on self-reported data, which can be subject to bias. Future research could benefit from larger, more diverse samples and the inclusion of quantitative measures to validate the findings.

This study aimed to fill a gap in the literature by exploring the experiences of clinicians working in the SUD treatment field, shedding light on the specific challenges they face, their emotional responses to patient overdose deaths, and the support systems currently in place. The findings highlight the immense challenges and pressures faced by these clinicians, including high patient acuity, systemic stigma, and inadequate resources. Despite these hardships, many clinicians expressed a deep commitment to their work and found fulfillment in their successes. However, the lack of robust support systems, poor supervisory relationships, and the emotional burden of working with high-risk populations often led to burnout and a shift towards private practice. Addressing these systemic issues and implementing supportive organizational practices are crucial steps toward improving clinician well-being and the effectiveness of SUD treatment. By prioritizing the well-being of clinicians and providing comprehensive support, healthcare organizations can enhance the quality of care provided to individuals with substance use disorders and ultimately improve treatment outcomes.

This study was conducted in accordance with the ethical standards of the Assumption University Institutional Review Board (IRB). Approval was obtained prior to the commencement of the research. All participants engaged in the informed consent process and provided their consent prior to participation in the study. The authors declare that they have no competing interests. 

This research was funded by a Faculty Development Grant from Assumption University.

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