Building Boundaries While Bolstering Bridges: Mental Health Professionals’ Expressions of Compassion for Those Who Use Opioids

Most scholarly work on the concept of compassion in mental health has focused on its use as a therapeutic strategy to assist those patients or clients who struggle with addiction (Carlyle et al., 2019), or on how those working in addictions and mental health might develop self-compassion to keep themselves mentally healthy and prevent compassion fatigue (c.f., Sinclair et al., 2017). Less is known about the development of a quality of compassion as it relates to how mental health practitioners understand this quality in interactions with their patients or clients. There is less research on how providers’ own experiences and expressions of compassion contribute to more effective service delivery and reduction in their compassion fatigue (Dowdell et al., 2022; Urmanche, 2020).

Many studies describe the phenomenon of compassion fatigue as a significant threat to health care workers working with addictions. For example, Dowdell et al. (2022) highlighted how emergency nurses caring for patients with opioid use disorder (OUD) experience deep frustration, emotional exhaustion, and job dissatisfaction due to recurring exposure to trauma, lack of patient progress, and stigma associated with opioid addiction. Similarly, Mamdani et al. (2023) found that peer overdose response workers, despite reporting generally high compassion satisfaction, often face emotional depletion due to their frequent encounters with overdose and death. Anderson et al. (2022) and Urmanche (2020) reported that unanticipated client deaths often led to disenfranchised grief and feelings of helplessness among providers, which in turn compromised their emotional and professional capacities.

Mindfulness, defined as nonjudgmental awareness of the present moment (Kabat-Zinn, 1994), is well established as a therapeutic tool for clients in health care settings, but is less explored as a means of assisting health professionals themselves. While mindfulness training has been shown to enhance empathy and patient care (Lamothe et al., 2014), its influence on the development and expression of compassion in providers remains underexamined. Some emerging evidence is encouraging. Abernathy and Martin (2019) found that mindfulness training for pediatric intensive care nurses increased compassion satisfaction and reduced burnout and secondary traumatic stress. Similarly, Callender et al. (2021) and Ruiz-Fernández et al. (2020) reported improvements in emotional regulation, self-compassion, and resilience among substance counsellors and nurses in high-stress care settings. Conversano et al. (2020) further observed that mindfulness-based interventions can help providers sustain empathy even when repeatedly exposed to distressing events.

The study used a qualitative approach to understand the process of compassion development and expression for mental health professionals who work with those who use and abuse opioids. While we recognize that there are many approaches to “qualitative research”, and that it can be hard to decide what should guide the typologies (see Braun and Clarke, 2025), we align most closely with an interpretive lens guiding our epistemology and ontology in qualitative work (Lincoln et al., 2018). We saw a qualitative approach with an interpretive bent as appropriate for the overall design because it offered the flexibility and depth required to explore the complex emotional and relational dimensions of compassion and empathy among healthcare providers responding to the opioid crisis. It also allowed us to acknowledge the nature of knowledge generated as co-interpreted or co-constructed (Lincoln et al., 2018).

We generally employed a snowball sampling method. After receiving institutional ethics approval, the authors sent emails with recruitment materials to organizations where MHPs support people who use opioids. We also obtained permission to hang recruitment posters at various places at our post-secondary institution which provides training for nurses, addictions counsellors, and psychologists, as well as local clinics and agencies providing relevant services. Information provided to potential participants at this point included the contact details of the first author, the overall procedure and inclusion criteria, participant incentive information, and details about ethics approval. Interested participants were asked to email or phone the first author to learn more and/or to sign up to participate.

For inclusion eligibility, participants had to be over 18, employed as a mental health professional, and currently working with those using opioids or having worked with same within the past six months as part of their professional role. All participants who expressed interest in the study followed through with participation, and none sought to withdraw from the study post-interview. Three participants agreed to follow-up interviews for respondent validation. Table 1 lists the current occupation of each participant (at time of interview). However, participants also spoke retrospectively of other relevant occupations they had previously been in. Participants were based throughout the southern part of the province of Alberta. Specific locations of each participant have been withheld for the purpose of anonymity as our community is small.

We desired a method of data collection that would capture the nuanced and often contradictory experiences embedded in healthcare practice, with a goal of the results to help inform training and policy (Rana et al., 2023). We chose semi-structured interviews as this method is well-supported as a means to gather information about these nuanced experiences (see Kvale, 2007).

Data were generated from 10 in-depth semi-structured interviews that occurred between February 2020 and August 2020. Two interviews occurred in person, and eight took place online via Zoom due to the onset of the COVID-19 pandemic. To maintain anonymity, the second author oversaw transcription of the interviews while ensuring to remove any information that would be considered identifiable. Three follow up respondent validation interviews were conducted by the first author and were recorded but not transcribed. These occurred in late 2021. The first author facilitated these conversations, made notes on these interviews, and subsequently deleted the recordings.

After establishing rapport and learning of the interviewee’s professional context, interviews followed a list of six open-ended questions about the development of compassion and its expression. The interviewers (first and second authors), who are experienced qualitative researchers, utilized active listening skills to encourage participants to both clarify their ideas and to expand on various statements.

After exploration of open-ended questions focused on compassion, the interviews shifted into exploration of mindfulness strategies and how these are implicated in participants’ personal and professional roles, as well as outlining perceived connections to compassion. There were four open-ended questions which guided this part of the interview. Interviewers continued to use active listening skills and prompts to gain clarity and expansion of participant responses. After each interview, the interviewers made brief field notes to inform the iterative data analysis process (Braun & Clarke, 2021).

We chose reflexive thematic analysis (RTA, Braun & Clarke, 2021) as our method for data analysis. The method’s emphasis on researcher reflexivity and positionality was particularly important for this topic, as it allowed us to acknowledge the influence of our (as researchers) values, assumptions, and emotional responses on the analytic process (Braun & Clarke, 2019). Moreover, RTA’s theoretical flexibility allows it to be applied within diverse epistemological frameworks without constraining our analytic lens (Braun & Clarke, 2021). This adaptability made it well suited to this study, where we took a more interpretive ontological stance to examine the meaning of providing compassionate care to those affected by opioids. RTA has gained widespread acceptance in applied health research, where it has been effectively used to translate qualitative insights into practice and policy recommendations (Campbell et al., 2021). Its extensive use across nursing, palliative, and addiction care research with emphases on service provider perspectives further supports its credibility and methodological fit for analyzing the lived experiences and tensions inherent in compassionate healthcare delivery (Dorey et al., 2022; Silverman & Levy, 2025). As our study participants included nurses, addictions counsellors, and psychologists, we saw this as an apt way to analyze their interviews.

We followed the six stages outlined by Braun and Clarke (2019; 2021) for engaging with the interview transcripts. The six stages are: (i) becoming familiar with the data, (ii) generating codes, (iii) identifying potential themes, (iv) reviewing initial themes, (v) refining and defining themes, and (vi) compiling the findings.

Each researcher reviewed the anonymized transcripts separately, with the first author and second authors subsequently developing codes which were noted on the transcripts. After the initial coding, both authors engaged in ongoing discussions about the codes and began developing initial potential themes. This process involved reorganizing codes from individual transcripts into more cohesive patterns which we developed into themes across the entire dataset. We consulted three participants about the appropriateness of the theme development in our follow up conversations. We also invited the third author, who was not involved in data collection, to offer perspectives on theme development. As part of the iterative analysis process, the research team had conversations and continued to develop and refine themes and the language used to describe them. Once we agreed on the essences of the themes, we compiled them into visual and narrative structures. Throughout the research process, we engaged in reflexive processes (Braun & Clarke, 2021).

Reflexivity is a critical element in qualitative research, particularly with those engaged in counselling or health services (Smith & Luke, 2021). Radical reflexivity encourages researchers to critically examine their own beliefs, assumptions, and emotional responses, throughout the research process, and to recognize how these internal factors may shape research topics, data collection, analysis, and interpretation. Reflexivity also invites researchers to remain open to non-traditional approaches to understanding human experiences, including the integration of spiritual and Indigenous perspectives (Smith & Luke, 2021). In studies involving sensitive and complex topics like opioid use, reflexivity helps researchers who are also MHPs to maintain ethical integrity to enhance the trustworthiness of findings in the research. Researchers must remain critically aware of how their own positionality influences the interpretation and representation of the narratives shared by research participants. The authors of this article bring diverse backgrounds to the research process, and we sought to be reflexive about how these backgrounds influenced our approach to the study and analyses.

Author One carries extensive experience across multiple roles, including the practical and research-focus of the health professions, with particular emphasis on compassion and empathy. Author One utilizes the work of Kristen Neff (2021) in their professional work with clients and for self-development.

Author Two is a counselling clinician specializing in addictions, with direct experience working with individuals impacted by substance use, including opioid use and addiction. This author also has prior experience contributing to projects utilizing a interpretive and phenomenological approach, and graduate training about holistic and spiritual dimensions of care in the field of addictions. Author Two also utilizes self-compassion in her professional work.

Author Three is a graduate student in counselling psychology with prior experience in qualitative research. This author has a background in supporting vulnerable families navigating complex needs, including mental health.

Authors One and Two were actively involved in conducting the interviews for this process. Following each session, they met and engaged in collaborative debriefings to reflect on the interview process, to discuss preliminary impressions, and to identify potential themes within the data. Author Two led the initial coding by exploring the transcripts and making notes by hand and uploaded the annotations onto a digital copy of the interview. Author Three revisited the interview data in early 2024 to provide further analysis and insight, while speaking with Author One about the quotes and themes.

Throughout the research process, the authors engaged in ongoing self-reflection and maintained a stance of critical curiosity. By doing so, they aimed to honour the authenticity of each MHPs' experiences, while actively recognizing how their own interpretations may enrich or detract from the research process, and strove to maintain an openness to each other’s and the participants’ perspectives (Smith & Luke, 2021).

The nature of our participants’ roles as health care professionals required them to balance their capacity for compassion with their clients/patients who use opioids with their own needs and circumstances. Participants generally spoke about compassion as a tool to connect them with the experiences and worlds of their clients and patients. When they spoke about honoring their own needs and circumstances, they framed it as a mechanism that served to separate themselves from the experiences and worlds of their clients. They also indicated that engaging in some type of separation was as an essential process for staying well within their profession. As Marilyn, a nurse working with vulnerable people, explained:

I listen to trauma all day, it’s pretty intense… but I am pretty okay when I go home… for the most part, not take it on or bring it home with me on a deeper and personal level. I step into my nurse role and this is separate from my home person. That little bit of separation allows me to show compassion and to listen and to give someone what they need and show them the empathy that they need without draining myself…This is crucial to my own well-being.

The researchers (authors 1 and 2) are heavily influenced by the work of Neff (2021) in our own clinical approach to working with those using opioids. Thus, the three elements of self-compassion (common humanity, self-kindness, and mindfulness; Neff, 2021) as they were experienced in response to seeing patients’ and clients’ suffering seemed useful in guiding the findings as a theoretical tool (Braun & Clarke, 2021). For each of the elements typically associated with self-compassion, participants outlined that their experiences as HCPs involved a non-linear process of finding a balance in relating to or finding connection with their patients who use opioids while also having a sense of separation or differentiation from their clients’ or patients’ experiences. Separation meant various things to the participants but essentially was about participants’ need to find a way to see themselves and their patients more objectively and clearly, and to not get mired down in their patients’ dysregulated states or needs that were not theirs to take on. The balance between this separation and connection was about healthcare professionals navigating the tension between deeply empathizing with patients while maintaining enough emotional separation to sustain their well-being and effectiveness, and each of the participants in the study touched on this in some way.

Participants highlighted the deep connection between compassion and the human experience, emphasizing that recognizing human suffering is inherent to patient care, and is a way to build bridges and connect with patients. Participants emphasized that they did not necessarily have to have gone through addiction to connect with clients, rather they highlighted remaining open to the shared human experience of suffering. As an example, Lisa, a nurse, explained that she is not immune from struggling with life and its challenges, and she recognized she could just as easily be in a similar situation as her patients: And that helps me to maintain that compassion and to say you know what, where for the grace of God go I, because we all have struggles and it's simply sometimes just a matter of how have I…been able to cope, what strategies do I use, what support systems do I have.

Often, this recognition of shared humanity (Neff, 2021) came from having an internal experience of relating in some way to the experiences of clients and their struggles. Berri spoke of listening to stories about active addiction in a harm reduction setting, and having empathy for her patients and a recognition of their resilience:

Yeah, I think the first is listening, and empathic listening….and I think finding appreciation for the fact that when you are trying to survive on a daily basis with an active addiction, sometimes homeless, or sometimes having to care for dependents, takes an incredible amount of resilience.

Others, such as Bright One, indicated that they could relate to parts of their patients’ addictions having gone through similar experiences, and that this allowed them to build empathy and compassion, and to relate by “sitting in the dark with them”.

Participants further described that recognizing the shared nature of human suffering helped them maintain compassion for both their patients and themselves. In line with Kristin Neff’s idea of common humanity (Neff, 2021), participants acknowledged that suffering is a universal experience and extends to their experiences as human MHPs as well. By seeing patients' struggles as part of a broader human condition, providers like Marilyn and Berri were able to connect to their patients, with an understanding that both they and their patients are navigating the same fundamental vulnerabilities of being human. Marilyn, a nurse, indicated.

I think there’s a little bit of humanity that is lost in addiction. They don’t get treated like humans, they go to the ER or wherever they are at on the street, people treat them less than human. I think showing humanity in general goes a long way.

Berri also talked about the humanity of her patients when serving them at a mobile clinic. “Maybe it’s just treating them as another human being, and I think it’s innate in us to want to establish that connection.”

Participants emphasized that they did not necessarily have to have gone through addiction to connect to the humanity of their clients, rather they highlighted remaining open to the shared human experience of suffering. Yoda, an addictions counsellor, described how he related to one of his clients with compassion even though he didn’t have the same lived experience:

And I still to this day have a lot of compassion for her and really like and value her as a person, because it was almost as if, you know, in spite of the difficulties and the many things that she shared about her story, she was a real human being in my eyes and I could really connect with her that way.

Other participants, such as Bright One, a psychologist, spoke about how shared experiences with trauma and addiction allowed them to connect to the humanity of their clients. They acknowledged in their training to become a mental health provider, “I decided that I had to be truthful with myself because as you know when you become a psychologist you need to really deal with your stuff.” Bright One noted that they share parts of their own history carefully and only when appropriate, seeing it as helpful to build bridges of connection by acknowledging, from personal experience, how addiction can function as a response to trauma.

They survived and so when people look at it and like I look – when someone has an addiction and I'm like well, that is a result of something that has gone on through their life and this is the only way they know how to cope.

Self-kindness, one of the three core elements of self-compassion (Neff, 2021), involves extending warmth, patience, and understanding toward oneself during times of difficulty, rather than responding with harsh self-criticism. It is the practice of treating oneself with the same care and empathy one would offer a close friend in moments of struggle.

Participants’ professional roles encompassed the need to be kind to themselves while navigating the demands of working with clients experiencing addictions and trauma within the constraints of healthcare and non-profit systems. Compassion in these contexts was not a simple matter of giving endlessly to others. Rather, participants described an ongoing process of balancing connection with patients and separation from their suffering and indicated that it was a dynamic that required continual attention to self-kindness.

Self-kindness, as participants described it, often involved extending care, understanding, and patience toward themselves in moments of struggle, self-doubt, or fatigue. It also meant recognizing their own humanity alongside that of their clients and acknowledging when limits needed to be set to maintain a good working relationship. Participants spoke of how showing compassion and setting boundaries were not opposites, but interrelated actions that supported each other. For some, self-kindness meant deliberately creating emotional or physical distance to preserve energy and clarity; for others, it meant leaning into connection with authenticity and presence once they felt resourced enough to do so.

Bodie, a counsellor, spoke of self-kindness as an internal process that directly influenced their external relationships with clients. “I’ve learned to love myself. And by learning to love myself and have compassion for myself, I’m able to put that over to my clients, and my clients are able to see that I have that for them.” For Bodie, self-kindness and compassion toward clients were part of the same continuum. In essence, caring kindly for herself became the foundation for offering care to others.

Candis, a psychologist, described how self-kindness meant taking time in nature and engaging in intentional separation from her clients’ emotional burdens and this enabled her to return to her work with more energy and attentiveness. “I think it makes me a better practitioner. Like I’m not as burned out, I don’t feel that ‘oh, I have to go to work today,’ or that feeling where you’re just tired and not as on as you would be.” For her, stepping back was not a withdrawal of compassion but an act that allowed for more genuine connection when she was with clients.

Participants often reflected on how building boundaries was not a form of detachment or numbing out, but an act of care for both self and others. Bright One expressed this succinctly, stating, “compassion still requires boundaries,” while Lisa emphasized that compassion “doesn’t mean that one does not challenge” clients. Two nurses also described this interplay between care and firmness as part of “person-centred care,” where compassion involved “pushing the patient and knowing that you are pushing” (Laura). These instances illustrated that connection did not always mean comfort; sometimes, self-kindness involved maintaining enough distance to challenge clients in ways that served their growth and safety.

At times, participants described how establishing these boundaries initially felt like failures of compassion. Marilyn recounted a moment in a methadone clinic when she felt she had pushed a client too far: “Some people respond to gentleness, kindness and compassion, others respond better to being pushed a little bit. I made the judgment call, and I made the absolutely wrong judgment call by pushing him… I said, ‘you need to do this, it’s part of the program,’ and I pushed him, and he reacted.” For her, self-kindness involved reflecting on this misstep without self-blame; recognizing that care for clients sometimes requires risk, and that maintaining compassion for herself after difficult moments was part of continuing to show up in her work.

Other participants, like Kerri, described how long-term exposure to the suffering of others reshaped their sense of compassion and patience: “In some ways, I’ve become more hardened and, in some ways, I’ve become more perceptive. I have less patience to be with the struggles over and over…but I’m more direct and to the point.” What might appear as emotional hardening was, for her, a way to stay connected to clients while protecting her own capacity to keep engaging over time.

Across accounts, participants’ reflections demonstrated the intricate balance between building connection with clients and bolstering boundaries through acts of self-care and self-kindness. Separation and connection were not fixed states but fluid movements within the same relational space. Acts of self-kindness—whether resting, taking space, setting limits, or forgiving oneself—helped participants stay grounded and emotionally available as MHPs. Thus, it seems for the participants that boundaries were not necessarily barriers but an essential way to ensure they could build sustainable and authentic relationships with themselves and their clients.

Participants consistently described mindfulness (the third element of Neff’s (2021) model) as a grounding practice that supported both self-compassion and compassion for others. While the form it took varied across participants; from structured visualization to taking mindful pauses before speaking, it was often characterized as a way of maintaining awareness and presence in emotionally charged interactions. Mindfulness allowed participants to notice their own internal states without being overwhelmed by them, and to create enough space to respond intentionally rather than reactively in their work with clients. Participants’ descriptions of mindfulness and its utility seem to be consistent with current understandings whereby mindfulness allows for some objectivity and separation from emotional reaction to events (Kabat-Zinn 1994; Kinsella et al., 2025; Neff, 2021).

Lisa spoke about using mindfulness to connect with patients during clinical encounters: “That’s my mindful practice, being relational and making sure that what is the next thing that is going to come out of my mouth. I can take an extra five seconds to edit that before it comes out and think about how that person is going to respond.” She later described this as creating a calm exterior despite inner turbulence:

Think of a duck paddling—on top it looks calm, but underneath it’s going a mile a minute. That’s all because of mindfulness, to be able to take those five extra seconds and make sure what’s coming out is in alignment with how I want to show up.

This kind of mindful “self-monitoring” was echoed by several participants who described how taking even brief pauses helped them regulate their emotions, maintain empathy and compassion, and sustain an objective focus on the client’s needs. Laura reflected on the importance of mental clarity between sessions, saying, “If I can’t kind of close that door between patients metaphorically, I can’t walk through that door with a clean mind that’s not busy, that is then focused on them and what their suffering is.” For her, this mindful transition between encounters allowed her to “hear that suffering and not compare it,” keeping each interaction separate and further allowed her to discern how to be responsive to the unique needs of each patient.

Several participants also described mindfulness as a practice that connected rather than distanced them from clients. By cultivating awareness of their own reactions, they could remain open and attuned to the client’s experience. Bright One shared how being willing to be vulnerable with clients deepened the therapeutic relationship: “When you are willing to be vulnerable with them, I think it just opens up the relationship deeply.” At the same time, participants acknowledged that mindfulness sometimes required them to recognize when feeling calm or passive was becoming counterproductive. Lisa reflected on this tension: “The zone of being mindful doesn’t mean that you don’t challenge. So, I think in some ways being too mindful in the way that I’m mindful might not be to their best interest.” For her, mindfulness involved balancing calm awareness with assertive engagement, a dynamic that required ongoing balancing the needs of self and other.

Across accounts, participants described mindfulness as both a personally stabilizing and relational force. It enabled participants to stay anchored amid distress when interacting or thinking about their clients, to recognize their limits, and to approach their work with clarity and purpose. Whether through brief visualization, self-check-ins, or quiet reflection, mindfulness generally seemed to support practitioner presence, preserve their emotional balance, and ultimately made sustained compassion possible. This was summarized by Kerri, a psychologist.

I try to be aware of everything that's going on in the therapeutic encounter. And it also extends like outside of the therapeutic encounter as well. You know, if I'm having a stressful day, if I haven't had much to eat, if I'm thirsty, if I haven't gone to the bathroom and I'm rushing into a session I know that all of those things can really impact how my presence, you know, my attunement, how I show up in relationship. And when it comes to mindfulness, I think that it's absolutely critical in the work that I do in order to cultivate that sense of safety in the here and now in the present moment.

The participants experienced a tension between connecting to their clients and separating from them through intentional strategies that allowed them to express compassion without generally taking on the distress of their clients. In this way, they shared experiencing moments of utilizing various mindfulness strategies which allowed for intentional boundary-setting. These practices emerged as a form of relational wisdom, enabling them to preserve empathy without giving into exhaustion or over-identification with clients’ needs or addictive struggles. In this way, self-kindness and mindfulness were not only self-protective but also essential ingredients in sustaining authentic, compassionate connection in their work.

Themes were aligned with various ideas associated with Kristin Neff and self-compassion (Neff, 2021). Participants indicated how self-kindness or treating oneself with the same level of care and empathy that one would treat a close friend, played out in their relationships with their patients. Participants’ narratives revealed that self-kindness is enacted through both connection and separation. The analysis underscored how caring for the self becomes the basis for authentic connection with others. These findings align with research indicating that self-compassion correlates with better well-being and reduced burnout among helpers (Conversano et al., 2020; Lyon & Galbraith, 2023; Prudenzi et al., 2022). What this study adds is a nuanced view of how in relational healthcare roles, self-kindness may mean stepping back (separation) to stay fully present (connection). The dual idea of separation and connection is thus not a contradiction, but a dynamic relational process that sustains the professional’s capacity to connect.

Moreover, participants described boundary-setting not as withdrawal of compassion, which is a common notion where relational practices are devalued as “soft skills” (Darley et al., 2024; Ferguson et al., 2022), but as an act of kindness toward both self and other. Bright One’s remark, “compassion still requires boundaries,” and Lisa’s reflection that compassion “doesn’t mean that one does not challenge” clients, highlighted how the “kind” side of self-kindness can also involve firm relational limits. These insights resonate with literature on compassion fatigue and provider self-regulation, showing that maintaining objectivity, some healthy distance and boundaries are part of sustaining caring relationships between MHPs and their patients (Du et al., 2024; Mitsea et al., 2023).

In sum, balancing separation and connection in clinical relational work is not simply self-indulgence but can show care to both self and other; and paradoxically can allow for better client care. This is congruent with what much of the current literature indicates generally about MHPs and their patients. This finding adds more nuance for understanding the unique demands of showing compassion for oneself and one’s clients due to the nature of opioid use and addiction, as well as how these aspects can be understood through a self-compassion lens (Neff, 2021).

Another finding that emphasized the balance between separation and connection from clients/patients was during the discussion of mindfulness. Participants described mindfulness as a practical tool for regulating emotional states and relational responses. Lisa’s description of holding back before speaking when in a stressful conversation (that’s my mindful practice; I can take an extra five seconds to edit that before it comes out) exemplified how mindfulness enabled her moment-to-moment responsiveness rather than more automatic reactive patterns. Laura’s reflection that she must “close … the door between patients metaphorically” before engaging the next person emphasized how mindfulness could facilitate transitions with patients.

The mindfulness practices described above reflect emerging literature that speaks to how mindfulness implementation among healthcare professionals predicts lower burnout, greater compassion competence, and safer practice environments (Brun et al., 2023; Prudenzi et al, 2022; Watson et al., 2022). Further, several recent studies found that mindfulness explained significant variance in psychological distress and cognitive weariness among healthcare staff (see Charvin et al., 2025; Rushforth et al., 2023).