I have occupied three chairs in the behavioral health system’s relationship with justice-involved people: the client in the residential program with a record behind him, the counselor across the desk, and the director deciding who gets the bed. Most practitioners spend a career in one of those chairs. Having sat in all three, I have come to believe the system’s biggest failures with this population are not clinical. They are relational — and they are correctable.
My road into the field was the long way. Addiction, homelessness, time behind bars, treatment. Then a rescue mission, where I assisted in the development and oversight of a high-capacity residential program in a homeless ministry capacity, and later directed a high-capacity, long-term residential recovery program. I am a master’s-level human service counselor now, practicing in addiction treatment and teaching at the college level. In December 2024, the Governor of Tennessee signed a full pardon with my name on it. The record did not vanish — the pages are still on file — but the verdict is newer than the record. That sentence, I have learned, is roughly how recovery works too.
The scale of the population we are discussing is not marginal. An estimated 65 percent of the United States prison population has an active substance use disorder (National Institute on Drug Abuse, 2020). These are not two systems with an overlap; they are, to a large degree, one population passing between two doors. What happens at the seam between those doors is lethal: in the first two weeks after release, former inmates face a risk of drug overdose death many times that of the general population (Binswanger et al., 2007). The intake appointment a justice-involved client attends — or misses — in those first weeks is not an administrative event. It is frequently the highest-stakes clinical encounter that person will ever have.
What the client’s chair taught me: shame suppresses engagement before treatment begins. When I sat in the intake chair, every form, every look, and every tone told me whether this program saw a person or a record. Research bears out what I felt: shame-proneness predicts worse substance use outcomes, while its cousin, guilt — responsibility for an act rather than condemnation of the self — predicts better ones (Dearing, Stuewig, & Tangney, 2005). Programs routinely confuse the two. An approach that leads with the record — the conditions, the violations, the “accountability” framing before any alliance exists — activates precisely the self-condemnation that drives concealment, and concealment is the enemy of every clinical goal we have. The practical correction costs nothing: sequence dignity before documentation. Learn the person’s name and story before the file’s. The file will still be there.
What the counselor’s chair taught me: retention is relational before it is programmatic. In residential treatment, length of stay is among the most reliable predictors of post-treatment outcome, and what keeps a person in the building long enough to benefit is less the curriculum than the community and the alliance (De Leon, 2000). Justice-involved clients arrive with finely tuned detectors for institutional insincerity; they have survived institutions. They do not disengage because the workbook is wrong. They disengage the first time the program behaves like the last institution that processed them. Every staff interaction is therefore either evidence for or against the proposition that this place is different. That is not a burden reserved for clinicians — the intake coordinator, the cook, and the night monitor are all delivering treatment, whether or not anyone told them so.
What the director’s chair taught me: the system’s impossible decisions land on the staff, and nobody screens for what that costs them. As a director I made capacity decisions — who got the bed, who waited, who was discharged for a violation I understood better than I could say aloud. Those decisions are the ordinary machinery of a constrained system, and they exact a specific occupational wound: moral injury, the damage done by perpetrating, failing to prevent, or witnessing acts that transgress one’s own moral code (Litz et al., 2009). The concept emerged from military psychology, but any frontline supervisor in behavioral health will recognize it — the case manager who enforced a discharge she believed was wrong, the counselor who watched a waitlisted client return to jail. We screen our workforce for credentials and background. We do not screen for the accumulating weight of the decisions we require them to carry, and then we call their departure “turnover.” Peer and lived-experience staff carry a compounded version of this load: they are maintaining their own recovery inside a building saturated with the thing they recovered from, and disclosure of strain can feel like an admission of being the wrong hire.
Three practices follow from the three chairs, and none requires a budget line. First, audit the first hour of contact for shame: every question that can be asked after the alliance forms should be. Second, treat retention as everyone’s job description and train the whole building accordingly — the evidence locates the therapeutic effect in the community, not only the counseling hour (De Leon, 2000). Third, give the staff the same honest check-in we ask of clients — leadership first, because no team answers honestly about a practice its director has not undergone. The people who carry everyone else are the least likely to check their own gauges, and the collapse, when it comes, is almost never loud.
The behavioral health system did not fail me; parts of it saved my life. But it saved my life at the points where individual people decided the record was not the final word about me. The task ahead is to make that decision structural rather than heroic — to build programs where the person who was once the intake can become, without exceptional luck, the counselor, and one day the director.
This article reflects the author’s professional experience and the cited literature; it describes no specific client or facility.
Jeffrey T. Crick is the founder of ReDefined Mission in Knoxville, Tennessee. He can be reached at [email protected], 865-257-7653, or through redefinedmission.com.
References
Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J. G., & Koepsell, T. D. (2007). Release from prison — a high risk of death for former inmates. New England Journal of Medicine, 356(2), 157–165.
De Leon, G. (2000). The therapeutic community: Theory, model, and method. Springer Publishing.
Dearing, R. L., Stuewig, J., & Tangney, J. P. (2005). On the importance of distinguishing shame from guilt: Relations to problematic alcohol and drug use. Addictive Behaviors, 30(7), 1392–1404.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706.
National Institute on Drug Abuse. (2020). Criminal justice DrugFacts. U.S. Department of Health and Human Services, National Institutes of Health.
