In the wake of societal discussions surrounding the intersection of psychiatric illness and criminality, the spotlight on mental health has intensified, particularly in the aftermath of tragic events like mass shootings in the United States.
However, this increased attention has, at times, led to a distorted perception that individuals grappling with mental health issues are inherently prone to acts of violence and aggression. The beliefs are often fuelled by the media’s portrayal of people struggling with mental health conditions as “crazy”.
Contrary to these prevailing beliefs, a wealth of data underscores a different narrative—one where individuals with mental illness are more likely to be victims of violence rather than its perpetrators.
According to a SAMHSA report, while an estimated 18% of the general population contends with mental illness in the US, an alarming 44% within correctional facilities share this struggle. Similarly, substance use disorders afflict 11% of 18–25-year-olds and 6% of those above 25, with 63% of incarcerated individuals and 58% of those in prison experiencing such disorders.
Within this complex milieu, it becomes evident that mentally ill offenders are often misunderstood and subjected to a criminal justice system inadequately equipped to address their underlying mental health needs. It is in navigating this intricate interplay of mental health and criminality that seasoned psychotherapists such as Alexander McLeod emerge as stalwarts.
Boasting over a decade of experience in the field, McLeod has dedicated his career to offering therapeutic support to individuals who have historically been marginalized and underserved.
He says, “A criminal history report or psychiatric record doesn’t tell you what makes a person likable, interesting, talented, or capable. It doesn’t tell you what they care about, who they love, who loves them, or who they are doing the therapeutic work for.”
He believes in meeting his patients where they are, thereby standing true to the commitment that he made as a psychotherapist.
As we delve into the insights and experiences of Alexander McLeod, Psychotherapist at Eden Therapy Center, this interview seeks to unravel the intricate nuances surrounding the treatment of individuals contending with severe mental illnesses.
Alex, can you share about your journey from being a corrections officer for juveniles to becoming a psychotherapist?
After my undergraduate, I wanted to be a probation officer. I asked to do my internship in the probation field. When I interviewed, the person interviewing me saw and asked about the cauliflower ears I had developed from years of wrestling and Jiu-Jitsu and recommended that I do facility work (the jail) instead.
To work in the jail, an officer has to be professional, but they also have to have the fitness to defend themselves if necessary. I had an education and self-defense skills and seemed to fit the need. I was placed to work in the Juvenile Sex Offense Unit because I had an undergraduate degree and treatment was a requirement in that unit.
I didn’t want to work in sex offenses. People often don’t, but I didn’t have any experience under my belt, so I took what I could get. After that, I got a job in a Juvenile Therapeutic Shelter work where I assisted in groups.
From there, I transitioned to a Juvenile treatment center as a corrections officer where I was a part of a multidisciplinary team of Psychologists, Social workers, and other professionals assisting in the treatment of Juvenile Sex Offenders where I played a direct role in their treatment and was educated on the underpinnings of Dialectical Behavioral Therapy (DBT).
I assisted in groups and had 1 to 1 check-in for clients and their treatment. I was also a float on other units where populations ranged from misdemeanor theft to high-level felonies. Because the program was therapy-based, I developed a lot of my skills as a therapist there.
What inspired this transition?
I remember this exact moment vividly. I rarely get emotional about work, but I cry every time I tell the story and it impacted my decision to take lower pay and pursue a path toward mental health. I can’t share details, but I can say the following: I remember working on one of the units at the treatment center and one of the kids had called home. He had a high-level charge, but he would be discharged from programming soon.
I didn’t know what happened on that phone call, but he was angry. A colleague and I spoke to him and when the anger faded, he began to cry. He was terrified about what he was going to do and how his family and community would treat him. I remember his face when he told me, “You are the last person who is ever going to love me.”
I don’t think I knew what heartbreak was until that moment. He asked for a hug, and I was shocked. Until that moment, he had been on my case every day. Depending on the day, he called me names, demeaned my authority, and purposefully did the opposite of whatever I said.
I thought that he hated me, but after all this time here he was asking me for a hug. As I began to explain to the client that I couldn’t give him a hug, he ran down to his room where he screamed and cried. I had never heard a sound so desperate.
The professional in me made the right call, but the human in me feels that there is no moment I regret more than not giving this child a hug. My shift ended a few minutes later, and I never saw that client again. I started looking into a career change the next day.
I took a lower-paying job in the administration of probation where my immediate supervisor who believed in me made it possible to begin a Master’s program. I knew that I wanted to work with clients who had severe trauma and behavioral issues. As long as it was their choice, I wanted to keep working with them when the court order ended.
How has your experience in corrections and the criminal justice system influenced your approach to psychotherapy?
Because of my experience in corrections, there are certain things that I am used to that other people are not. My career over the past 10 years has involved a heavy subject matter that some don’t dare to touch. I have been doing this for ten years now, so very few things shock me and that made me a great fit for trauma work.
I like to think I can be as empathic as any other therapist, but I can also hold a hard boundary. I can separate my feelings and experiences from a client’s feelings and experiences so when they need emotional validation, I can provide that, but I can also model and provide the accountability required for emotional and behavioral change.
I work almost exclusively with adults now and one thing I notice is that people tend to have empathy for juvenile clients who commit crimes or have behavioral issues, but they tend to have less for adults. Somewhere along the way, people lose their compassion.
We tend to think that children can change but adults can’t. I try to lend the adult the tools and accountable boundaries they need and give them the compassion that their inner child is often desperate for.
As a Certified Trauma Professional and EMDR practitioner, can you discuss how these modalities have shaped your therapeutic interventions?
Neurology has given me a lot of insight into the world of clients who experience trauma disorders. We are beginning to understand the different ways that traumatic experiences shape the function of the brain’s nervous system. You cannot treat trauma disorders without a basic understanding of that impact.
To uphold my certifications, I attend tramining often and I try to read at least three scholarly articles a week to stay up to date on the latest methods and science. As a trauma, EMDR, and DBT certified practitioner, my focus areas are the pre-frontal cortex (impulse and decision-making), and the limbic system (emotional regulation).
EMDR and trauma work is complicated, and when I can provide psychoeducation to my clients about how the methods work in a way that they can understand, they seem to trust me and take to the therapeutic process faster. Without proper psychoeducation, therapy can seem like fairy dust and wishful thinking to many clients.
Those complex treatment modalities influenced my decision to not just use empirically valid methods, but help clients understand those methods so they aren’t questioning at the end if any of their trauma or their progress was real. Clients deserve to know what is happening to them.
Being a Certified Personality Disorder Treatment Specialist, what unique challenges and rewards come with focusing on Cluster B personality disorders and trauma disorders?
When a person has a personality disorder, it means that they have a pattern of behavior that is rigid and inflexible. Cluster B is known as the “Dramatic and Erratic” cluster. When a person has an inflexible pattern that is “dramatic and erratic” they can be intimidating, obstinate, or ‘flighty.’
Stern once said of the Borderline Personality Disorder that they are “resistant to the couch.” Anecdotally that is true. Clients experiencing Cluster B disorders traditionally have a tough time staying in therapy because of an inclination toward impulsivity, sudden hospital or jail stays, or emotional disruption. Occasionally, my clients will get angry with their lives, the world, or me. I have had clients storm out of my office in a rage more than a few times.
I tell all my clients in the first session, “Someday you might not like me. It could be something I say, something I do, something I don’t do, the tone in my voice, or a look that I give you. But someday, for some reason, you might think of me as ‘the bad guy.’ You might think to yourself that you want to tell me off and quit therapy. Sometimes it is just a part of the process. When that day comes, I need you to remember I am on your team, and you can come back.”
This might seem like a bizarre practice, but it has been quite effective. A client will get upset and sometimes they don’t show up for a few weeks. Then they come back and tell me that they almost quit as they did with their last therapist, the one before that, and the one before that. But they remembered what I said.
It was expected, and they could come back, so they did. That is the moment that I get to thank them and tell them “Congratulations,” because they just broke their first so-called ‘inflexible’ pattern. To see the look on a client’s face when they realize this is true, you would think they watched me pull a rabbit out of a hat. That is a rewarding moment.
In treating “deep water” clients, what strategies do you employ to build trust and rapport with individuals who may be at high risk of self-harm or engaging in criminal behavior?
I organize my office in a purposefully mindful way. When clients walk in, the first things they see are Pokémon cards on the walls, comic books on the desk, and pictures of television show characters I like. I do this so that they can tell I am a real person with real interests outside of work.
While seated on the couch, a client sees that directly behind me are my degrees, certifications, books, and research that I read. When I provide psychoeducation, they can trust what I say because I can pull out the book or study where I got the information. Clients get to immediately hold two versions of me at once. The real-life person, and the clinician.
I use a common language when I speak with clients. I curse, I tell jokes, and I laugh. Personality Disorder diagnosis is based on trait theory. The DSM-5-TR tells a clinician what traits are clinically disruptive for the client. What the DSM-5-TR doesn’t tell you, is that people who experience Cluster B Personality Disorders possess strong trait humorousness.
They like to tell jokes and they like to laugh, and it is often a coping and defense mechanism. Trust is the ability to accurately predict another person’s behavior. My clients can trust that if they make a joke, even if it is dark, even if it is at their expense or mine, I will laugh… as long as it’s funny.
Laughter is how a client knows I’m a normal person. Laughter is how a client knows they are not being judged. How could I not laugh? God as my witness, they are funny. When you laugh, you bond. When a therapist can help you feel comfortable in the uncomfortable, you tend to stay with that therapist.
How do you balance the emotional toll of working with challenging clients while maintaining your own well-being and self-care?
I am violently mindful. I love martial arts and I intermittently practice Jiu-Jitsu. It is a physical sport, but it is also a mindfulness practice. Mindfulness is the ability to attune your focus wholly and completely to one thing. I found that when I practice Jiu Jitsu, it is hard for me to continue to focus on the stress of my day while someone is attempting to tactfully break me in half.
I can’t ignore that I am being “attacked” and I must attune to the moment. I think of martial arts and Jiu-Jitsu as a sort of “compelled mindfulness” in this way. The best part is that it is just a way to play with my friends as an adult. Rough house play, yes, but play all the same. Few people can say that and I’m grateful for it.
In your role as a dispositional advisor for the Minnesota Board of Public Defense, how did you contribute to the defense of clients through research and providing historical and psychiatric information to the courts?
I acted in this role as a part of my graduate field placement. It was my job to go down to the jail, meet with a client and interview them. Often what I found was that a client had what we called a “golden thread” of trauma in their life that came to a head at the moment they were accused of a crime.
Based on their life experiences, I would research relevant articles that might explain a client’s behavior in which they allegedly broke a law or social norm. For example, if they had a substance abuse problem, I would identify the golden thread detailing the many ways that the client’s substance abuse disrupted their life.
By understanding a client’s pattern of behavior, I assisted attorneys in the formulation of their argument that a client stands to be better served by treatment than incarceration as they pay their debt to society.
If a client had a traumatic brain injury, depending on the circumstances, they may not be fit to stand trial. The brain injury may also stand to be a mitigating factor in their case related to their alleged behavior.
I would be in contact with psychiatric experts who would perform a battery of mental health examinations and try to help court officials and prospective jurors make sense of what can often be dismissed as psycho-babble.
What have been the most significant lessons you’ve learned from working with individuals who have faced high-level felony offenses and psychiatric conditions?
The client that you see on paper is not necessarily the client that you get. When I worked at the Juvenile Shelter or the Treatment Center, clients could sometimes have large criminal histories.
There were several times when my clinical directors nearly denied clients access to treatment because it was possible that the client’s behavior could disrupt the programming. When those clients were given a chance, they often ended up being the most dependable group leaders.
A criminal history report or psychiatric record doesn’t tell you what makes a person likable, interesting, talented, or capable. It doesn’t tell you what they care about, who they love, who loves them, or who they are doing the therapeutic work for.
The client takes a big leap of faith when they select you as a therapist based on a few paragraphs in your profile, so when their history is alarming or concerning, I’m willing to meet a client where they are and do the same.
How do you approach the treatment of clients with misunderstood and hard-to-treat disorders, and what successes have you witnessed in your practice?
My approach is one where I try to be a good clinician, but I also try to be a real person. I allow for side tangents and pleasant discussions about non-treatment-specific things. I have fun with the clients. I am clinical when I have to be. I do my homework and I am well-studied on what I treat.
I have familiarized myself with Borderline Personality Disorder to the point that some clients momentarily thought that I could read their minds. I also do my homework to review my notes and listen in sessions to understand the person, their interests, hopes, dreams, and goals.
I try to keep in mind that for heavy trauma and Personality Disorders, there is no perfect system or treatment modality. These are long-term disorders, and they require long-term treatment. So, I take my time.
These are patterns of behavior, so I expect that the pattern will persist until the stars line up just right for the client to receive and use what I give them to make a change. Success depends on the client.
For some clients, it is a significant change that they stay in therapy for more than a few weeks, and I’m pretty proud of my retention rate. For others, it is being able to make decisions on their own without having to ask permission. For others, success might mean getting off probation or ending patterns of self-harm, dangerous thrill-seeking, or suicide streaks.
Can you elaborate on your philosophy that people are not defined by their worst decisions or the worst things done to them? How does this philosophy guide your therapeutic approach?
When we talk about the worst thing that has ever happened to someone, we often describe them as victims. To define someone as a victim alone steals the power of the client’s potential from them.
Therapy isn’t about saving a person from past trauma. It can’t be done. The trauma has already happened. A clinician has to draw on a person’s strengths in the present. You would be surprised what a person who has faced severe adversity is capable of when they can recognize their strengths.
As for perpetrators of crimes or abuse, I grapple internally with this often. I don’t have a perfect answer either. Ask yourself what the worst thing you have ever done was. Is that you? Is that all that you are? I would bet not. What else are you? Who are you to someone else?
I saw clients in jails who would tell me that they were the hardest, meanest person that you could meet. That they had no feelings. That same person is a different person on visiting day.
When that person sees their mother for the first time in a month they say, “Hi Mommy!” When that person sees their kids, they say “Hey little man! How is my little buddy?” Research indicates that even psychopathic individuals have some level of care about their children.
With that said, there are some obvious historical cases where I would have to concede that I would have trouble finding a redeeming quality. Still, very few people are solely just one thing.
The public will call a person a criminal, but someone out there calls them “Mommy, Daddy, Auntie, Uncle, Baby Boy or Girl, Brother, Sister.” Part of my job is to access that part of a person and build on it. It is not always easy, but not always impossible.
What role does gratitude play in your work, and how do you use it as inspiration in your practice?
My family is very close, and I grew up with privileges that many don’t. I had lots of support even when I screwed up or the chips were down.
When I started working at the shelter, I only had experience as an intern and a pizza man. Barb, the director took a risk on me and hired me. She was a strong woman and hard on me, but she molded me into a decent mental health worker.
My immediate supervisor in juvenile probation Kayla, went above and beyond to make sure I was able to attend school and work full time and she wasn’t under any obligation to do that.
My former professor, Sharyn, picks up my calls for consultation at no charge even though I no longer require her supervision as a fully licensed clinician. My current clinical director, Nancy, has been a support to me in ways that extend far beyond any of her responsibilities.
All of the people mentioned here were kind to me for no reason other than the fact that they had the option. They put in extra work when they didn’t have to. If not for them I wouldn’t be where I am today. I make a point to remember that.
If a client struggles at the end of the session and I have the time, I take the extra time free of charge. If a client scores high-risk behavior and a low success rate in treatment, I tend to take them on anyway. The gratitude I was given, I try to pass on.
*(I have permission to use the first names of all mentioned people)*
In your opinion, what are the key qualities that mental health clinicians should possess when working with challenging populations, and how do you embody these qualities?
- Be humorous. I laugh every single day of my life. If you can do that, you will find you can handle more than you think.
- Be patient. Long-term disorders require long-term treatment. Clients may repeat the same behaviors over and over even though they know there are other options. Often it is the case that a client has had to live a certain way with a limited number of tools for a long time. You as a clinician are doing fine. Treatment will take time to sink in.
- Attend to your physical health. A good trauma therapist knows that stress and trauma are stored in the body, so take care of it.
- Acknowledge and moderate your emotions. Notice positive emotions and have gratitude for what the source is. Notice negative emotions and the purpose they serve to help you get your needs met. Even anger helps you hold a boundary. Moderate it.
How do you envision the future of mental health care, particularly in addressing the needs of individuals who may be considered “hard-to-reach” or challenging to treat?
I think that the future of neuroscience and biology is going to have a big impact on the fields of social work, mental health, and psychology. The more I learn about neuroscience and biology, the more I feel that people have reasonable, simple, and tangible options that can help them.
Some people get stuck in patterns that they know do not work for them, and just a few small changes can impact a person’s perception of the self, the world, and their ability to function effectively within it. I strongly recommend Anna Lembke’s book, Dopamine Nation: Finding Balance in the Age of Indulgence.
How can your unique journey and experiences serve as a call to action for others in the mental health field, and what advice would you give to aspiring clinicians interested in similar paths?
If you are still in school, consider doing your field placement at a shelter or corrections facility. I learned more about mental health and behavior in those settings than many others. In school, a lot of aspiring clinicians will talk about the need to serve populations who are underserved.
We talk about valuing the innate human dignity and worth of the person, the mental health needs of the incarcerated, or valuing an ability to suspend our judgment to meet clients where they are at but turn them down as clients when the referral comes in.
I don’t think that I am better than anyone else for choosing to do the work that I do. It is important for a clinician to understand who is and who is not within their scope of practice to give clients the best care possible.
But if you are a clinician and there is even a small part of you that thinks the trauma and PD field is fascinating, take maybe one or two clients who are court-ordered or who have a Cluster B disorder. Do your research and take training on different treatment methods. You might be more capable than you think.
