"Space for pain in measured doses": How professionals navigate the hidden presence of grief in substance use treatment.

INTRODUCTION: Despite extensive documentation of loss experiences throughout the substance use (SU) trajectory and evidence that grief-focused interventions improve treatment adherence and long-term recovery, few SU treatment programs systematically integrate grief work. Additionally, prior research has centered on the clients' perspective, overlooking the viewpoint of the professionals responsible for implementing grief-oriented interventions. The study addressed these gaps by exploring whether and how professionals integrate grief into their clinical practice.

METHODS: This qualitative study employed reflexive thematic analysis within a constructivist framework, based on semi-structured interviews with 32 Israeli professionals specializing in SU treatment: social workers (n = 20), psychologists (n = 6), and psychiatrists (n = 6). The analytic approach was primarily inductive, with interviews initially structured to explore clinical approaches without explicitly mentioning loss or grief, allowing themes to emerge naturally before introducing direct prompts. Analysis proceeded through an interpretive orientation, capturing underlying meanings and theoretical constructs.

RESULTS: Three interrelated themes emerged. First, professionals demonstrated a comprehensive recognition of the diverse loss experiences across the SU trajectory. Second, they described emotionally attuned engagement with clients' grief, including adaptation of therapeutic language to clients' emotional capacities to create accessible pathways for processing painful losses. Third, despite their awareness, professionals identified that grief often remains hidden in clinical practice due to structural constraints and sociocultural influences - particularly the dominant trauma discourse.

CONCLUSIONS: A complex interplay between clinical understanding and sociocultural forces shapes grief integration within SU treatment. Apparently, grief is not routinely overlooked. Rather, professionals address it through relationally attuned practice and linguistically adapted approaches. However, clinical understanding alone proves insufficient: effective grief integration requires addressing sociocultural norms and systemic barriers that limit grief work, highlighting the importance of developing SU treatments that balance emotional attunement with conditions that enable sustained grief processing.