Heather Haslem: CASAT Podcast Network. Welcome to season six of CASAT Conversations, where we sit down with professionals who have spent decades in their fields like mental health, addiction treatment, business, sociology, and more. In this special season, our guests share valuable wisdom from their careers, reflect on what has kept them grounded and inspired, and, and offer advice for future generations. Whether you're new to the field, uncertain, about your next steps, or feeling burned out, these conversations provide guidance and reassurance from those who've walked this path. Let's dive into today's episode. Today I welcome Saul Singer to CASAT Conversations. Saul is a licensed marriage and family therapist, a licensed alcohol and drug counselor, an instructor, and an author with five decades of experience in behavioral health and addiction treatment. Welcome, Saul. We're delighted to have you here today.

Saul Singer: Thank you, Heather. And thanks so much for this opportunity for me to share my life's work and talk about what I've learned over the years from great mentors, but most impactfully, from more than 1,000 couples or families of more than 1,000 individual clients. you know, I'm 76 years old, and I hope to promote and continue my legacy work, which is about passing on what I've learned to younger therapists, interns, and students. my clinical work began in the 19, 70s. I've been a private practice therapist. I also, work with clinical, child welfare, juvenile justice, and adult corrections. I've had contracts with a variety of community, and state mental health and addiction treatment programs over the years. And, as you mentioned, I'm a university instructor. I teach, Dynamics of Family Interaction at Texas Tech University. and yes, I'm the author of a book. I wrote a book called Beef Therapy for Clients with Challenging or Unique A, Clinician's Guide to Enhancing Outcomes. It was published in 2023, and I'll probably talk about it a little more as we continue. I'll tell you, my clients have been amazing teachers, but it took me a while before I could recognize how to absorb and apply their wisdom and subtle teachings. As, therapists, we can get stuck in therapeutic process and assessment and diagnosis, especially trying to master clinical models and satisfying demands of agencies or supervisors or referral sources or insurance companies. And as we're trying to figure stuff out, we. We too often miss the clues from clients about what they really want and need, about their strengths, their expertise over their life, and how even before they began therapy, they already started a process to find solutions. I'm saying that we can become model driven instead of client need driven. So over the years, especially after the first 15 or 20 years, I, was finally able to open my mind to the possibility that there was a better way to accomplish client engagement and success outcomes. Outcomes with authentic and lasting change. But first I had to internalize and grow in new ways of thinking, such as, it's our clients who are the experts over their life and change. We're merely catalysts. And, I've learned that there are no throwaway clients. Therapists need to figure out how to engage and join with each client. The truth is that if we don't know how to engage or communicate with our client, it's not the client's fault. We need to stop blaming clients for what we don't know or understand. So I want my impact to be about how we can better engage and join with clients, about identifying what each client needs to help that client in front of us, to apply their strengths, their resources to resolve whatever issues brought them to therapy. And, for them to complete a process so that they'll internalize problem solving methods that, that they have acquired in the therapeutic process. We need to give them some, Some personal skill in how to solve future problems.

Heather Haslem: Well, thank you for sharing your impact. what's, yeah, the impact of your life's work and what you're hoping, the legacy that you're hoping to leave. can you share the key experiences and influences that led you to choose marriage and family therapy and addiction counseling as your path?

Saul Singer: Okay. Well, my college studies began in 1966. That was eons ago. And at that time, clinical ideas and interventions were markedly different. I was originally a pre med major. A pre med major. For the first two years, I was thinking more about psychiatry, maybe with working with families as a psychiatrist. and I had completed most of my science requirements, during my first two years and began to focus on psychology and social theology classes. And I happened to write a term paper for a psychology class. I don't recall the exact title, but it was about families. I recall that I was curious about some things, maybe I had some apprehensions. And so I included some questions in the paper, which was not usual for a term paper such as the one I had written. And the paper was graded by a graduate assistant. We used to call them GAs. Now they're teaching assistants. We call them TAs. his name was Louis. Something in the paper must have caught his eye and inspired him to offer me an opportunity to partner with him in a clinical study that was modeled after research at the Mental Research Institute, which at the time I had never heard of it was in Palo Alto. and they were doing very advanced work on things such as family therapy. he had been, Louis had been involved in family research specifically to look at the impact of an in home family crisis intervention program. It was about calming down arguments between parents and adolescents when drugs or alcohol were involved and then working with a family on their family dynamics and cooperation. And here I was, 20 years old at the time, and never heard of a program like this, a diversion study. Didn't know anything about therapy. But Louis was a part of this diversion study. and again it was, it was an alternative for parents to calling the police. It was offered by the juvenile court. When your 16 year old comes home at 2am and he's high and you, you're getting into it with him, don't call the police, call this number and we'll have a team come right out and try to work this out. So they'd call us in the middle of their family argument. And so we would do in home family intervention using methods that were being researched at the Mental Research Institute in Palo Alto. These were strategies and procedures that were not only different but they were totally contrary to the ideas in psychology that I was learning in my classes. It was an eye opening experience. A different way about thinking, a different way of thinking about families. It was a total life changer for me. My adrenaline surged during every intervention. I mean here I am, a 20 year old novice walking into the middle of this family argument, wondering if the ceiling was going to come down or whatever. but Louis was a great mentor, a great teacher. what was important was I was learning about family systems and family dynamics. My professors had not yet become familiar with the idea of thinking about families as systems and, and understanding dynamics, as part of system interactions. So you know, keep in mind this was a very different time. In college I was introduced to the DSM 2. It was highly biased around conformity with 1950 standards of behavior and a lot of religious values. And homosexuality was seen as deviant and treated as a crime in most places. And in the mental health arena, homosexuality was treated as a mental illness. In fact almost anything seen as socially deviant at the time was considered mental illness. It wasn't unusual for clients to be in therapy for years without resolution. Clinicians were seen as the experts over their clients lives and therapy was mostly a directive process. and yes, therapists would provide services for children, but the family was always left out. Fortunately there were Some brilliant minds who were paving a new direction in behavioral health and family therapy. The Mental Research Institute in Palo Alto was demonstrating concepts and methods with strong results, results that were contrary to clinical ideas. I mean, they were way ahead of their time. Imagine M. Murray Bowen was proposing that families were systems. How radical. Paul Wattslowek, Richard Fish and John Wickland were insisting that therapy could be brief and effective. At the same time, Virginia Satir was explaining family dynamics and multigenerational influences. And strategic therapists such as Jay Haley and Chloe Medatis opened the door to understanding family dynamics and the functions of behavior. Neuro linguistics were being studied. Client centered clinical processes were being studied for the first time. And I was fortunate to receive training and mentoring from several of the early founders in family therapy who were researchers at the Mentler Research Institute. And then later, as I went along, getting my licensure, I had the privilege of studying and training with people like Steve Deshazer, Aninsu Kimberg, Salman Noucci and Mauricio Andolfi and Bill o' Hanlon. and marriage and family therapy was just being conceptualized at the time. What, I've learned, from my experience is that marriage and family is a separate and distinct body of knowledge, offering curriculum and training and system dynamics and family structure, family hierarchy and clinical interventions that involve the whole family. Working with the system as a healing ground creates many possibilities in clinical work, and there is no blame. Dynamics and roles can be understood and a functional balance can be achieved where the whole family participates. Systems thinking is powerful when it's applied to individuals, couples and families. It allows for the inclusion of many approaches, you know, whatever approach is fit for the client and family, not just one approach. Being a part of family therapy process with Louis opened the door to my understanding of families. and along the way, as I did my internships, I was even more convinced by the wisdom and power and systems thinking. I worked in juvenile justice and what I saw was kids would be sent to, either treatment programs or correctional centers. They'd be gone from their families for about a year. But the reports, on their progress, they just raved about what wonderful job these children were doing, what great behaviors, they had, how well they were doing in school, how cooperative they were. The predictions were for them to have a great future. And then they returned back to their families. Same system, same roles, same dynamics. And within a few months, they reverted back to previous behaviors in spite of working with therapists, providing them with individual therapy. And if they were lucky, eventually a family Systems therapists would intervene and work with the whole system. So the family is truly the healing ground. And knowing all this MFT was my choice.

Heather Haslem: Thank m you for sharing really such a broad perspective on the different shifts that you've seen throughout your career. as you look over the past 30 years, how have you seen the clinical approach evolve, particularly when working with clients who are mandated to services or struggling with hopelessness?

Saul Singer: You know, after, about 20 years of private practice, I came up against a clash of ideas. Many of my colleagues believed that 30% of their clients would fail no matter what they did. Blaming the client, labeling them as resistant or uncooperative or having a borderline personality. And as I said earlier, I believed it was ludicrous to blame the client when the therapist did not know how to engage that client. So during the last 30 years of my clinical practice, I made it my mission to focus on clients others considered difficult, even impossible. I wanted to know if there was a solution to it. and many of my clients, from that time had been coerced or mandated to therapy. I sought out referrals of those difficult or impossible clients from other therapists, from M EAPs, from Managed Care, insurance. Insurance companies knew right away after a time, if they had a client failing with another therapist to refer that client to me next. I worked with community resource centers and agencies with inpatient treatment facilities, with juvenile justice and child welfare agencies, with family court and drug court programs. I was also able to work with foster children. And if the agency didn't have enough money, I would see those children pro bono. I worked with immigrant families whose culture was not being understood. I learned myself a lot about culture and understanding and, and eliciting, cultural information from clients in ways that did not put them on the defensive. because oftentimes they already came into therapy with sort of a chip on their shoulder because, and they had good reason to be sensitive about their culture because of criticism, ah, they had heard from different sources, in their short time in this country. I worked with families in multigenerational poverty. Multi generational poverty is not very well understood. what I know is that multi generational poverty is a culture unto itself. instead of middle class values, they have to have values that focus not on the future, but on the present. It's about survival. It's about taking care of basic needs first. And so they're often not understood. And that old mantra, why don't you just get a job that doesn't work? Because, there are so many complications in them working, taking care of their children, giving up maybe fictive kin that are helpful, having to give up their social life. The only thing I ever heard from a supervisor about working with multi generational poverty is don't ever make an appointment before 11am because they don't get up. Well, they don't get up because their whole life revolves around late night activities with friends. It's a whole different culture that we often misunderstand, but we can work with them in order to help them to overcome their issues and if it's their choosing to become self sufficient. I worked with families whose kids were medicated into zombies by psychiatrists. What would happen is schools would complain about their behavior. To keep them in school, Paris would send them to a psychiatrist, they would be given off label medication or over medicated. And these kids as I said, were absolute zombies. It was so sad to see. And one of the first things I would do is I would call a psychiatrist and I would tell them I'm working with this family, I need to baseline this child's behavior. If you could taper the child off the medication, that would be really helpful and so that I can measure progress that the child is making in family therapy psychiatrists, I never had one say no to that. And so I would not only help the kids get off the medication and work with the families, with the children being an active partner in therapy, but none of those children would go back on medication. so essentially what I'm getting at as far as my referrals, if you didn't want that client because they were difficult, impossible, borderline or for whatever reason, that was the client I was seeking. I refused to accept that there were impossible clients. I believed it was my responsibility to figure out what worked for each of them. And I found that I could engage clients with individualized client need driven collaborative interventions. And after a relatively short time I was able to constructively engage nearly every client, determine their real agenda. And what I mean by agenda is what the client really wants. I'll talk more about that in a minute. But working with them on the agenda to start makes them customers. my belief evolved into a firm conviction that there are no throwaway clients and the therapist is responsible for establishing a collaborative therapeutic relationship with the client hearing what they really want. Again, the client's real agenda. And ah, a client's agenda is not necessarily what that referral source wants or the therapist wants or the judge has ordered. Oh, it sounds like a Good thing to want. Once we have that collaborative and we begin work, on what the client wants, the client generally becomes a customer over therapy and change. And I'm talking about real change, permanent change, around what the client really wants. And it was around this time when I had an epiphany. I was clinically supervising seasoned therapists for a federally funded study of, families in the child welfare system. And I would hold case staffings to review each therapist and details of their work. And during those case staffings, I saw a trend. Families that were failing were being subjected to the same clinical model, to the same process questions, session after session, in spite of the fact that they were not making progress. Same questions, same processes, no progress. And when I asked clinicians to explain how come they were doing the same thing over and over again, and even though it didn't work, they would tell me, to a person, because it's evidence based. Well, my perception has come to be that whatever works for that client in front of you is best practice. Evidence based is not necessarily the gold standard. So that's why I had to write a book about decades of amazing clients who overcame adversity. And the tool strategies and, words or word substitutes. Sometimes words don't work, that work for the clients. and a little about the thinking behind my book, Brief Therapy for Clients with Challenging or Unique A Clinician's Guide to Enhancing Outcomes. In the book, there are more than 20 client stories that feature solution empowerment and client engagement processes to accomplish collaborative engagement and how to mold clinical interventions to fit for each client's unique needs and tolerance. No two clients are the same. for example, there was a mother and daughter referred to me after six sessions without progress because that therapist said she couldn't get them to stop arguing in session. Whatever was brought up, the two of them would argue. so talk therapy was not possible. So I had to find another way. There were clients who felt hopeless and defeated, clients who didn't want to be in therapy, clients who'd failed several times, failed several times in therapy, or felt disparaged or over the years continued to recidivate and relapse in spite of time in therapy. and you can't just go into evidence based clinical process with those clients. A different approach with a different language is needed. Neuro linguistics is needed. Coping questions, complements and processes to demonstrate understanding, generally give hope and settle the mood enough for the client to continue therapy. That's what's important. It doesn't work just to plug a Round hole client into a square hole clinical model. And as mentioned previously, the bottom line is that collaborative engagement with a client need driven approach, identifying a client's real agenda, wordsmithing and tailoring the intervention to fit the client's culture, family history and tolerance will work for even the most challenging and unique clients. When we seek their agenda, begin with their agenda, and we're really good listeners. And again, I can't emphasize enough how important that listening and understanding piece is. The book is my legacy work. I want to share with other therapists and future generation strategies and tools that I know are effective.

Heather Haslem: So I'd love for you to talk. You mentioned collaborative engagement. if you can share, what does that mean to you and how does it shape your approach to working with clients?

Saul Singer: You know, there are a number of critical pieces required in building collaborative engagement and building that relationship. And let me just say it goes beyond, and it's in addition to the Rogerian elements and process of joining engaging, engaging that we generally learn in school. But not to discount Rogerian elements, we still need to include them. They're important. So a collaborative shared therapeutic relationship is built on a client need driven approach that has at least six what I call pieces, or pillars. the first pillar is to assess and proceed from the client's position to establish cooperation. Clients can be visitors, complainants or customers when they enter therapy. And we need to work with the client for from their position, not automatically as if they're customers. If we work with them automatically as customers, we're going to lose them. and clients can be visitors over one issue, a complainant over a second issue, and a customer over a third issue, which can make things a little more complicated. Visitors are not going to buy into therapy and believe it's worthwhile complaints. Acknowledge, yes, there is a problem, but it's everyone else's fault, it's their problem. And customers believe that, yeah, there's a problem and I need to cooperate in therapy to resolve it. So obviously we want everybody to become customers, but again, we need to work with the client from whatever their position is initially until they become customers. If we don't, we're going to lose them. And for example, you know, what do you do with a visitor? Well, we have to just try to encourage a visitor to continue to come back. Because one thing about visitors is if we don't hit that nail on the head in this first session with them, they're not going to return to therapy. So I might ask some questions such as what needs to happen Today for you to say that our time together was worthwhile and eliciting that information to try to make the time worthwhile for them in that initial session. A complainant, I might say, how will you know when you don't need to come here anymore? and for example, if I have, as a complaint, a mom, let's say she has a son named Billy, and her complaint's about his behavior. It's driving her crazy. He doesn't do what she has. He misbehaves in school, he misbehaves at home. she doesn't know what to do. It's ruining her life. you know, what am I going to do? Well, I know that with complainants, if you give them a task can only be an observation task. It can't be a behavioral change task. And knowing that our agenda is about her son Billy, I might say to her, mom, what I would like you to do over the next week, this could help me figure out how to help you, is to observe Billy's behavior and notice the days and times when he's behaving a little bit better, Especially days and times when he's doing what you're glad he's doing what you want him to do. And bring that list in to me. Well, what am I doing? You know what? I'm not only asking her, to observe and record times when his behavior is good, but I'm giving her some hope that this does happen, and I'm going to be able to inquire with her when what was different at those times. What did you say to Billy? What did he say to you? And get a, sort of a schematic of how things are working in that family. that might make mom eventually a customer, to know that there are things she can do that impact his behavior. but again, with complaints, I can't give them a behavioral change task. I can't ask mom to do something different until she is a customer. Visitors, they won't do tasks. They won't set goals. Again, if you try, you're going to lose them. But we can move all of our clients to customers. And customers, what's so nice is they will do tasks about behavioral change or observation, and they will set goals. So, right away you've made steps forward with them. The second tier, or pillar, is, understanding and empathizing, but a little different maybe, than what most of us have learned in school. We need to hear and respect the client's point of view, culture and family values. Yes, Empathy is critical. Hearing the client's definition of the problem, not the referral source's definition, the client's definition, and eliciting exceptions to the problem from clients will uncover client driven solutions that are already happening. And no problem is 24 7. So that we know there are times when clients are doing something else and that something else is maybe the solution. And, to recognize that each family has its own unique individual culture. So we need to do a family cultural assessment without stereotyping. Culture is much more than race as ethnicity and country of origin. and I see books sometimes that say how to work with a Hispanic family or how to work with an African American family. And, I just cringe when I see that because, for example, just to sort of burst the stereotype, I've seen African American families where the father was the head of the household and Hispanic families where the mother was the head of the household. And you know, traditionally that's not what you see. So every family is unique. the third piece is about identifying and prioritizing a client's agenda. And as I mentioned, it's what the client really wants, not what the referral source wants or the boss, or the spouse wants. the client may not say the agenda directly or we may just miss it. A list of the client's real agenda can require a series of what are called fast forward questions and other neuroistic inquiries. and then we need to begin with the part of the agenda that is changeable. Because there are usually parts of a client's agenda that are intractable, that can't happen now, no matter what. So we need to begin with the parts, that are changeable. One thing I might do, for example, for a client's agenda is ask what's called a miracle question. You know, when you go to sleep tonight, while you're sleeping, a miracle happens. All your problems are gone, but you don't know that that miracle's happened. You don't know your problems are gone because you were sleeping. So when you wake up, what's the first thing you're going to notice that's going to cause you to say, wow, something's different here. And what are your kids going to be doing that's different? What are they going to be saying? What's your partner going to be saying? and then I take them through a whole day. So for example, I might say, well, yeah, a miracle would be if my wife made breakfast and the kids were sitting there and we were all talking together about what our days were going to be like. So that tells me a little bit what the client wants in their family life. Maybe more communication with the partner and with the children and more, interaction and more cooperation, maybe. So I can inquire about that and maybe get out of that couples counseling instead of individual counseling or even family counseling if need be, to satisfy the client's agenda. What I know is that clients are going to be customers over their real agenda. The fourth pillar is positive expectancy, that a client has strengths and resources needed. Expectancy is more than hope and a positive outlook. Expectancy is believing and anticipating success. Both the client and therapist need to believe that the client will be successful. And what's interesting is more important than what the therapist actually believes is what the client thinks, the therapist beliefs. So we need to somehow communicate to the client that we have hope. Therapeutic compliments help. Noticing small increments of change along the way and asking a client what will be happening next, that will tell you you're on track to getting there. and then what will be happening. And throwing success in the client's face as those benchmarks are met can be really powerful. But again, every session we need some kind of renewal piece where the client's going to know that we believe that they are going to be successful. The fifth out of six of the tiers or pillars or pieces are respecting the client as the expert over their domain. This is why we elicit a client's ideas, client's exceptions to the problems and solutions, rather than telling the client what to do. And again, we're not going to have a collaborative relationship where we tell the client what to do. Telling may create compliance or first order change. In other words, temporary external change. I mean, we all slow down when we see that highway patrol cruiser parked on the shoulder, but when it's out of sight, we speed up. That's compliance. That's not change. And if you get a ticket and might lose your license or your insurance, you slow down for a while after that threat passes, you're probably going to resume to your old driving habits. That's only first order change. That's just temporary change. Clinicians are fooled. We are fooled all the time. Discharging their client looks so good and then they end up recidivating. Why? Because it was first order change, not second order change. Second order change is internal, permanent change. It's change that is owned by the clients. Through eliciting, a client can begin a process to accomplish authentic change. you say you're a three in terms of, your depression you've moved from a zero to a three. So when you're a four, what will be different? What will be happening different? And how will I know it? And then when the client tells us about things have improved a little, this is happening, we can say, wow, you're a four. That's what you said would happen. So when you're a five, what will be happening next? So we basically can continue to give a client hope and seeing that, yes, change is happening in the way I want. I'll tell you this. One of my very wise mentors, his name was Phil Woodison, he was from Iowa, as a matter of fact, originally. He once told me, if telling a client what to do really worked, our prisons would be empty. And that has stuck with me. It's so true. So we need to elicit, not tell. And then the sixth and final piece that I see as part of collaborative engagement, our neuro linguistics was a client centered, solution, focused, clinical process. The words we use are important. Some words promote change, whereas others hint to change and can lead to more problems. For example, I don't use the word why because clients can see why did you do that? As accusatory on blaming. Instead I use how come why did you do that? Is not as engaging as how come you decided to do that. I want them to know I'm curious. I'm not blaming them or trying to catch them at something. And there are many words that force the change and many words that interfere with change. We also know that talking about problems, session after session, leads to more problems, whereas talking about solutions leads to more solutions. And so beginning each session with what's better and insisting that something must be better, just a little better will help a client and therapist to hear about small increments of change, maybe subtle change that otherwise would be overlooked. And from there we can build hope. Maybe the subtle change we hear will be how the client's now a 4 instead of a 3 on that depression scale. The bottom line in neuro linguistics is that we use words that create possibilities for change and give our clients hope. And part of the collaborative process is that I want my clients to learn the language of hope, the language of possibilities and the language of change.

Heather Haslem: I love that. The language of hope, the language of possibilities and the language of change. how would you define gold standard and best practice in clinical work? and how does that align with going beyond evidence based research?

Saul Singer: I think, you know, I love that question. So the gold standard is about what works for that client in front of you. Evidence based is about efficacy and is not well understood by most clinicians. The academic research's promotion is that a particular evidence based therapy will work best for that client in front of you. But that can be misleading. Here's what I learned about efficacy. The truth is that studies have ah, specific criteria and efficacy is non effectiveness. The results of a study may not fit for your client. Subjects are generally screened and accepted or eliminated based on that study's criteria. These are not random clients or a cross section of clients who seek treatment often excluded. An initial selection of certain geographical, cultural, diagnostic or so called not appropriate populations for this study criteria could involve certain age groups, a specific diagnosis with co occurring diagnosis, certain level of education and subjective factors that might indicate maybe a measure of stability. history of certain issues in medical treatments can be exclusion factors. Exclusion factors can be for many things. Could be for juvenile justice or adult corrections or history of arrests or court orders of clients or English as a Second language or history of substance abuse or addiction or clients overseas 60. That's ageism, by the way, certain physical disabilities, chronic illness or chronic disease, previous behavioral health or addiction treatment could be an exclusion. Socioeconomic issues such as multigenerational poverty could be an exclusion. And co occurring or dual diagnosis, could also be an exclusion. They're looking for a pure diagnosis for the study. So study subjects and not the clients who randomly walk through your door. And some studies pay subjects for completing treatment. How many more of your clients will complete treatment if you pay them to complete treatment? So significantly, studies who do not fare well, I mean, sorry, subjects who do not fare well initially or who lose interest and may be discharged without being counted and subjects who do not fare well or who lose interest may be discharged without being counted in the study is what I'm trying to say. It's common in studies that subjects who drop out Perhaps during the first 30 treatment days are not counted as ever having been in the study. So we don't get that data. And real outcome in measures and targets may be limited to general or specific findings and excludes some subjects. So the results you see might not be all the results including any downside. and how many subjects do not complete treatment or get worse or recidivate. So as a result, large twaths of the population are often missed due to exclusions and different study criteria and may not be counted because they don't complete treatment. But the model is identified as efficacious generally with about 60 or 70% or less of subjects completing or meeting the study criteria for discharge. Again, not counting exclusions or early dropout and discharges for other reasons. Additionally, not all the research even has to be published. So studies that yield poor results can be withheld. Then what does evidence based mean? Evidence base is about efficacy. And what does efficacy mean? Efficacy in a research setting is that there is empirical evidence based that the methodology works. Typically when about 60 to 70% of those subjects who finish therapy meet the criteria for success at completing, the completion, the model is considered efficacious. Don't get me wrong, efficacy is a good thing. But we need to understand that these studies do not reflect engagement and outcomes for much of our client population. I would be more persuaded if these studies were constructed so that all clients who walk through the door were accepted and all outcomes were counted. But that's not going to happen. and so personally what I know from my work is that what works for that client in front of you is just is best practice, not just plugging a client into a model. Because again we're going to lose at least 30 or 40% of those clients on average. And that's why those colleagues of mine believe that 30% or more of their clients were going to quit therapy or recidivate. so anyway, so that's about best practice, the gold standard.

Heather Haslem: Thank you so much. Important information, for clinicians to consider as they work with clients. So this is a topic near and dear to my heart and that is that therapists and counselors often focus on the well being of others. but self care is crucial. What are some of the self care practices that have been most valuable for you, and your colleagues?

Saul Singer: Heather, you are so right. self care for clinicians is crucial. Burnout is debilitating and much too common against really good practitioners. I've seen it so many times. and I really feel for the individuals who put their heart out there and work with clients and ended up damaging themselves. That's not what we want. And to talk about me, I've been totally invested in my clients well being. So nothing I would do to avoid burnout was ever going to be about neglecting my clients needs. And we need to understand that taking care of ourselves doesn't mean we neglect or shortchange clients in any way. I was fortunate for much of my private practice because I had a colleague who was an excellent therapist and someone who I could depend on. We would cover for each other during time off and during personal family time. Client calls went through an answering service and the Answering service had instructions regarding who was available so they would know who to contact. We did not give clients our cell phone numbers and accept text messages. I think that is such a mistake. If you're looking to get burned out, give clients your cell phone number and accept text messages because essentially you're going to be working 24 7. texting outside of a portal is not secure anyway. So why people even text with clients, I'm not clear on it is clearly a violation of HIPAA to text clients unless you're doing it inside a portal. Texting is never secure. So everything about after hours, contact when we were working with clients or any emergencies was explained in the informed consent. Clients were given a copy at the front first meeting. This is a contract to say, here's how you can respond in an emergency, Here is how you can contact us or other, resources that might be helpful to you. so clients are given that initially and then our time off was our time off except when we alternated after hours coverage. We rotated that coverage and I might cover two weeks in a row because, my colleague had some place to go and then they would cover two weeks. So we split that up. Obviously we were very fair about it. There was never any issue, over, splitting up that time. And of course we call each other when necessary. If a client had an emergency that needed an immediate response, my colleague would call me and say, I got a call from so and so client of yours. I say, spoke to them and, I really think you need to speak to them about this. do you have some time to call? And then I usually would, but that was rare. That was three times a year. Maybe that that would happen where we weren't able to cover a call for each other. Family time is important, so we would schedule clients around our family time needs. And I would work some evening hours and saw clients on Saturday. And when I needed to take, normal, time off for family events such as birthdays, youth sports or school meetings, I'd make up that time on other days. But it was always family first. And I think we need to work with that creed in mind. My colleague and I limited ourselves. This was an agreement we had with each other. We would limit ourselves to a maximum of 25 clinical hours a week. And I'll tell you, that is a lot that would leave time for progress notes, reports, consultations, workshops, and other duties such as supervision that we might have, but we would not feel so overloaded. I know clinicians who try to do 30 to 35 hours a week. and that is just too much, especially if you're doing evening work and weekends to accommodate clients. You're on the track to burnout if you do that. And you're not going to be any good to yourself, your family, or your clients when you get burned out. And another thing that was very important to me personally was making therapy fun. You know, I was a solutions therapist, so I focused more on solutions than problems. And I would laugh with clients and I would enjoy time when, for example, I used metaphor and storytelling. if I have a chance to talk about what I think therapists need. You know, we need a lot of fun stories or metaphor to help a client get sort of a different perspective and also to be able to watch our clients laugh and laugh with them. But bottom line is I just love doing clinical work. And you have to enjoy your work, in order to do a good job. that's my belief anyway. I used any disappointments I had along the way, any client setbacks or whatever. I used those disappointments to reflect on what I learned. Again, that solution thinking. I used also my personal light. I used it to reflect on what I learned that could make me a better therapist. and, my colleague and I spoke with each other. Decompress. You need somebody in the field who will understand who you can, who you can talk to. I tried to get some exercise, play golf, baseball, softball, walk, run, and take real family vacations. My gosh, out of town. Get away from it. when I was involved in working with agency staff away from my office, I tried to open and share my feelings with them, especially when the work was difficult. Because some of those programs we worked with very high risk clients, clients multigenerational poverty clients in the child welfare system, clients in the juvenile justice system, adult correction system. So the work could be very stressful. So I made it a point to open up to them and hopefully I was somewhat of a role model if they hadn't done that before. but I varied my work and I changed my work around and I changed my focus with different agencies or clients or contracts or. I've done a lot of workshops. that variety I think really helps with burnout. You know, create variety for yourself. learn new things, do different things, begin to take a different type of referral, learn how to work with a different population, and teach, classes, to, younger therapists. That is very rewarding to me. And one thing, a very wise mentor who was once a supervisor of mine, taught me was ask for what you need. Really we are so hesitant as therapists to ask for what we need. we are sort of programmed to listen to what other people need. Ask for what you need whenever you need it. and another thing is, client feedback. I lived in Carson City. I lived in Nevada for 50 years. I'm in Texas now. I lived in Carson City for more than 40 years. And I lived in an area where, you know, my wife and I, we'd go to restaurants, I'd run into previous clients in restaurants and parks and theaters. Three generations. When you've done 50 years of clinical work, my wife and I got to see three generations of clients and client families. I'm talking about hundreds of people that we would run into who had been clients or children of clients or grandchildren of clients. and I would hear things like kids. Saul was our family therapist. When Tommy was 14 and I was 10, Grandma and Grandpa took us to see him and he saved our family. And I would say, no, no, no, no, your parents were the heroes. They loved you so much that they saved your family. So that's another thing. I never take credit for my clients work. But over the years, and again I sometimes when I do workshops, tell people about this. Your work today is going to spill over four generations and you're going to see that feedback. Especially if you live in a place where things like high school graduations or acceptance to college or even local newspaper, or like my wife worked in, community recreation. She was a recreation director for 24 years. She got to know every family in Carson City. So, you're going to hear this feedback and see the progress clients make. And that is so rewarding. And even today I get phone calls and text messages, from different clients, over the years who tell me what they're doing and that they're doing well. That is wonderful to avoid burnout. There's nothing more rewarding than seeing generations of the family you help. And it makes me cry every time. I spend a lot of time in tears. and it certainly can diffuse the tensions from work. You know, just a short call from a previous client who's doing well can mean so much. So open the door for that. one thing that I used to do sometimes with clients is automatically schedule a 90 day follow up session with them, if we had a session left over to do that, basically to see how they're doing, give them feedback and give them a pep talk. But it Also gave me a pep talk just to see that they're making progress.

Heather Haslem: Yeah, it's fun to hear what has been rewarding for your career and meaningful, and how that's fueled you, throughout the decades you've been practicing. So I know that you are an advocate of no wrong door philosophy. How do you see this approach benefiting individuals seeking help through community and state agencies?

Saul Singer: Yes, I am an advocate of wrong door philosophy for families. I, you know, I've done work with, as I said, with various state agencies, under contract or four different programs for sometimes for up to seven years. and I don't have all the answers, but I know some things and I have some concerns, about the way, our public agencies are structured. Families have multiple needs that are sometimes complex. They need social systems that are flexible and comprehensive. But what we have are agencies that instead are silos with specific and limited paradigms. They view families and children through the lenses of their paradigms and their training and resources focus on addressing their service paradigm. For example, I'll keep some clear examples. Child welfare has a paradigm of bad parents, so children need protection. Juvenile justice has a paradigm of bad children, so society needs protection. Community mental health's paradigm is often about a focus on the mental health needs of an individual rather than a focus on the whole family. Addiction treatment programs have a paradigm, a paradigm that the substance user needs help. So depending on where you're referred, the assessment, the treatment plan and services you receive are going to reflect that agency's paradigm. No wrongdoer simply means that individuals and families instead are referred into a comprehensive system for a holistic individual, family and cultural assessment without preconceived ideas, and then provided a smorgasbord of services that address all the individuals and family needs and issues. One stop shopping whole family assessments and referral services that address all needs. I think we've got to get rid of those silos that pigeonhole individuals or families that are so limiting and don't get all the best outcomes I believe that we could have by being more comprehensive and inclusive.

Heather Haslem: Thank you. So as we wrap up our time today, is there anything else you'd like to share or discuss that we haven't covered yet?

Saul Singer: Well, if we have time, maybe I can summarize my nickelsworth on what therapists in general need. And I think that term, I love that term. M. Nichols Worth. I think that came from Lucy in the Peanuts cartoons where she would have her, her counseling booth set up and say, you know, counseling 5 cents or whatever it was. So, other people have adopted that and I sort of stole in that. But let me, let me talk about what I think therapists or what we as therapists need. We need a toolbox of approaches, models, metaphors, stories and clinical strategies. You know, it's not one stop shopping. We need a whole variety of ways to engage, and, work with clients. we need to really listen and hear clients. I said that several times today. I can't emphasize that enough. again, if we are sort of used to or programmed to understand things in a certain way, and a client is culturally different than us, what they're saying, those words may not mean what we think. When I do workshops, I do this, sort of, experiment in the beginning where, the participants look at these sentences and read them out loud, but they're not the way they read them. They're not what, is up on the screen. because again, we're programmed to see things or understand things in a certain way. and until we are able to separate from that socialization of ours and really listen to clients and understand and check out with them that understanding, we're not really hearing our clients. I think we have to believe in enough hope for our clients. Positive expectancy is powerful, and what the client believes, you believe is most important. As I said, I cannot tell you how many times I have worked as a partner with agencies where I've heard clinicians complain about their clients. That is just poison. that therapist does not belong with that client. And if you are going to complain about a particular client, you know, refer that client somewhere else because you're probably not going to have success with that client and certainly you're not going to enjoy therapy. learn from the client about their culture and traditions. respect the client as the expert over their domain. Again, we are not the experts over their life or their solutions. They are the expert. Identify and work from your client's position. Visitors, complainants or customers. Don't get ahead of your client. You will lose them. They will believe that therapy does not really work. If you hear that, it's probably because they've had that experience somewhere. Address feelings of hopelessness. before you engage a client with a clinical model, and there are ways, and I talk about it in my book, there are ways to address that client's, hopelessness. again, outside of the clinical model, we need to let them know that we care and we believe in them and we do understand and we are there to support them. a lot of times we have the situations where a client, looks at us as their father or, their parent instead some way, and again, that will hurt the relationship. treat setback, treat setbacks as feedback, not failure. A setback. My client has a setback. It's not their fault. It means that I needed to do something different to capture second order change. And I will admit to a client, you know what I tried, what I thought, you know, I knew, I thought you were making progress. But obviously we need to do something different. Let's talk about what that might be. Don't, blame your client for setbacks. Begin from a client's real agenda, not the agenda of the referral source. And avoid triangulation. So many times I've seen therapists friends with the referral sources, they keep referring people, so we have this alliance with them. That alliance works against the client. Triangulates the client out. Your loyalty needs to be with your client, not with the referral source. So again, you're working with and you're advocating for your client. so keep that in mind. And if you need to change your relationship in terms of referrals, do that. focus on each client's strengths and use genuine compliments throughout. The compliments really have to be genuine. If they're not, the client knows. help your client identify their problem solving skills. And you know, even the fact that they made it to their appointment to see you after all they've been going through deserves acknowledgement. Even court ordered clients have a choice. We sometimes think, well, they have to be there. No, they have a choice too. So again, compliment the fact that with everything going on, all that overwhelm that drove them to therapy m or caused them to be referred to therapy, they made it to your appointment. elicit exceptions to the problems and solutions from your client. Again, clients don't experience problems 24 7. And telling a client what to do will not foster real, permanent, lasting change. Understand neuro linguistics. Some words and questions promote change. Others restrict and sabotage change. And be aware that talking about problems creates more problems. And talking about solutions of visualizing what change will look like will more often lead to that desired change. I like to use fast forward questions with presupposition. Give hope and possibilities. accept your client's definition of a family. the best definition I ever heard for a family is whatever my client says is their family. Families are not always comprised of traditional family members, but they are family nonetheless. Especially for lower income single parent families and families. Overwhelmed with challenges. Fictive kin matter. My aunt Betty, who's, no, not a stepparent, not a step aunt, not related to me by blood. She is the one that used to, take us to our appointments and spend time watching us when we were kids. When my mom wasn't able to be home. my uncle Bob was actually the custodian in our building. he had chickens at home and he brought us eggs so that we could have breakfast. Otherwise we wouldn't have had breakfast. and, he was like an uncle to me. And he always would be fun, say positive things. And we knew if we had a problem and mom wasn't home, we could go to him for help. These are like families. So if people consider them family, you consider them as family. legally, you may not be able to put them down as family in your therapy session, but don't exclude them. just have them there as a family support. Keep sessions light and encouraging whenever possible. Humor and client compliments help. Metaphor and storytelling can be powerful. I must have, I don't know, a couple of dozen metaphors and a couple of dozen stories that clients find entertaining that I can tell sometimes to lighten the mood. but always to pass on something to a client that will help give them hope and help them start on a process for the change that they want to accomplish. Recognize that therapy can be brief. Sessions can be more powerful and successful, when we focus on client strengths and solutions. I'm not the therapist who's going to talk to you for 20 years about how awful your mom treated you. We're not going to talk about that. We're going to talk about how that's affected you and what you're doing about it now and what you can do about it to overcome that. And if you want to forgive your mom, you can talk to me about that too. Maybe I can be helpful. Give clients credit for their successes. Again, we're only the catalyst. I never take credit for my clients successes. And as I said earlier, collaborative engagement is the foundation for good work. We need to begin with collaborative engagement and put the clients in a good place, to engage in therapy with us as real partners. not one step down, but equal. And that's my nickel's worth for a therapist.

Heather Haslem: Well, thank you, Saul, for sharing all of the wisdom that you've gained throughout the years and your perspective on, being a clinical.

Saul Singer: Thanks. I'm so lucky. I really am. what I've seen and felt and people I've met and all the opportunities that others made for me and the great work of my mentors, In teaching me, how I could look at things to make life good for me and others. I can't thank everybody enough.

Heather Haslem: Thanks for sharing your passion and purpose.

Saul Singer: Thanks.

Heather Haslem: Thank you for listening to CASAT Conversations, your resource for exploring behavioral health topics. We hope you found today's conversation timely and meaningful. Please share this podcast with your friends and colleagues. If you want to learn more, visit us at our blog at www.casatondemand.org CASAT Podcast Network This podcast has been brought to you by the CASAT Podcast Network, located within the Center for the Application of Substance Abuse Technologies, a part of the School of Public Health at the University of Nevada, Reno. For more podcast information and resources, visit casat.org.