In today’s fast-paced, technology-focused, and cost-conscious healthcare environment, many clinical caregivers find themselves anxious, frustrated, and under pressure.

For people working in substance abuse treatment, those feelings can be magnified as they work with patients with chronic illnesses who often struggle to change their lives, frequently relapse, and sometimes never fully succeed in their recovery.

Unfortunately, there is often no structured outlet for clinicians to express their own feelings. Who can clinicians talk to about the physical and emotional exhaustion associated with treating high-risk patients who persist in self-damaging behaviors? And what about all the bad outcomes, both small and large, with the attendant grief, shame, and self-doubt?

Caring for Yourself While Caring for Patients

Caring for others starts with caring for yourself. Whether at an institutional level, or personally, we recommend that caregivers:

• Take heed of stress and other negative emotions. Although addiction treatment professionals commonly experience them, they should not be considered normal.


• Recognize the “second victim” phenomenon that often occurs following adverse events, which can lead to trouble coping. Reach out to colleagues if you are involved in a bad outcome. Offer them the same support when adverse events happen to them.


• Take part in regular clinical supervision, ideally on an individual basis. Openly discuss your feelings, emotions, and personal struggles, not just the specifics of various patients on your caseload.


• Introduce system-level initiatives such as Schwartz Center Rounds or peer support teams. Hard-wire caring for caregivers in your organization.

Here are more details on how to incorporate these recommendations into your work.

Caregivers as Second Victims

Bad outcomes can take their toll. Providers involved in adverse events can become second victims. For example, a survey in one healthcare system found that one-third of respondents had experienced negative emotions following an adverse event (Scott SD et al, Jt Comm J Qual Patient Saf 2010;36(5):233–240). These included depression and anxiety, as well as concerns about their job performance. Fully 15% had seriously considered leaving their chosen profession.

Second victims can also experience typical symptoms of depression, such as fatigue, sleep disturbance, and problems with concentration (Scott SD et al, Qual Saf Health Care 2009;18(5):325–330). Other issues can include flashbacks, intrusive thoughts and memories, and phobic avoidance of the patient care area where the adverse event occurred. Although these symptoms are distressing and disabling, the majority of providers try working through them on their own (Scott SD, 2010, op.cit).

One small study of 31 second victims found that recovery proceeded through six stages that sometimes occur simultaneously, starting with the chaos and response surrounding the event and ending with “moving on” (Scott SD, 2009, op.cit). The final stage had three possible trajectories. Some providers make a good recovery (“thriving”) from the adverse event. Others, however, continue to experience intrusive thoughts and persistent sadness (“surviving”) or more serious struggles (“dropping out”).

Caregivers and the Status Quo

What kind of support do providers working in substance abuse treatment generally experience? They likely participate in regular staff meetings and meet with a clinical supervisor. The former typically involve group discussions about funding, care progression, and the day-to-day behavior of the patient mix. The focus is squarely on patients. “How should we deal with her behavior?” “Should we expedite discharge for patient X because he is sabotaging the recovery of others?”

Clinical supervision has a long tradition in certain mental health professions such as psychology and psychiatry. Good supervision goes beyond troubleshooting and promotes provider well-being and ongoing professional development (Hawkins P & Shohet R, Supervision in the Helping Professions. 4th ed. New York: Open University Press; 2012:98). Unfortunately, time pressures often force this kind of supervision to the periphery or reduce it to a perfunctory exercise dealing with the mechanics of care delivery. This can leave providers feeling isolated, overwhelmed, and increasingly burned out.

Schwartz Center Rounds

When Ken Schwartz, a Boston healthcare attorney, was battling lung cancer, he found that what mattered to him most was the care and compassion he received from his caregivers. Before he died at the age of 40, Schwartz founded the Schwartz Center for Compassionate Healthcare in 1995 to ensure that all patients receive compassionate healthcare and to provide support for clinical caregivers—the people who Schwartz said “made the unbearable bearable” (http://bit.ly/1beDsEy).

Led by a facilitator trained by the Schwartz Center, Schwartz Center Rounds bring clinical caregivers and members of the healthcare team together, usually for one hour once a month, to discuss their experiences, perspectives, and feelings on a range of topics drawn from actual patient cases.

The meetings provide a safe forum so providers can talk about a wide range of topics that may rarely get discussed elsewhere. For instance, they might share stories of hope or despair, or talk about issues such as the impact of patient violence, the potential emotional toll on caregivers when a patient is unable to initiate or sustain behavior change or dies, and what happens when a provider makes a mistake.

Since its pilot at Massachusetts General Hospital in Boston in 1997, more than 350 hospitals and other healthcare institutions across the US have adopted the program, which reaches more than 100,000 caregivers a year. It’s not only used in hospitals, but in outpatient settings, nursing homes, and home health and hospice agencies.

A study demonstrated that caregivers who participate in multiple Schwartz Center Rounds say they have an increased readiness to respond to patient and family needs, better appreciate their colleagues, have decreased feelings of stress and isolation, and are more open to receiving and giving support (Lown BA & Manning CF, Acad Med 2010;85(6):1073–1081).

Other Options

The University of Missouri has a program known as the Scott Three-Tiered Interventional Model (http://bit.ly/1moIfIq). This program is used for general education about the second victim phenomenon and includes specific interventions for those involved in an adverse event.

Tier one involves immediate emotional first aid delivered by frontline managers and colleagues (http://1.usa.gov/1cR9GAO). Tier two consists of support from trained peers through a “forYOU” team that provides counseling, mentoring, and connecting the second victim with other institutional supports 24 hours per day. Tier three involves professional counseling through chaplains, social workers, clinical psychologists, and the University of Missouri’s employee assistance program.

Other healthcare systems have developed similar solutions. For example, Brigham and Women’s Hospital has been operating a peer support team since July 2006 (van Pelt F, Qual Saf Health Care 2008;17(4):249–252; http://bit.ly/MsQyD0), and Johns Hopkins University has established a Second Victims Work Group to address the problem (Edrees HH et al, Pol Arch Med Wewn 2011;121(4):101–108). These programs can help caregivers care for themselves and deal with the emotional impact of bad outcomes.