Why Psychological Testing Is a Missing Step When Your Teen Has Substance Use Problems

What psychological testing actually is — and is not When Brenda first heard the term 'psych eval' during her son's time in wilderness therapy, she had never encountered it before. That unfamiliarity is common, and it's part of why Dr. Graham Husick wanted to start with a baseline. Testing, he explained, spans many areas — academic, forensic, and more — but the kind most relevant to families navigating substance use is the psychological evaluation designed to build a profile of the whole person, not just arrive at a diagnosis. 'The idea is, before we launch into all these different kinds of treatment, all these different kinds of settings... can we get basically a psychological profile of this person? Not of their diagnosis, but of this actual person.' — Dr. Graham Husick He used a medical comparison that stuck: a surgeon doesn't open someone up because they have stomach pain. They do an MRI first. Psychological testing, he said, is meant to serve that same function before families and clinicians decide on wilderness programs, residential treatment, therapeutic boarding schools, or any other path. Treating the person, not just the problem One of the clearest ideas Dr. Husick offered was the difference between treating the problem within the person versus treating the person with the problem. When everyone zeroes in on the substance use itself, he said, the understanding of the human underneath often gets lost. He pointed to depression as an example — research shows it is a nonspecific symptom, something like a fever in physical health, with many different pathways to it. If clinicians just treat depression without understanding which pathway applies to this particular person, they may not be treating anything meaningful. The same applies to substance use. Dr. Husick noted that a long list of diagnoses picked up across multiple programs often tells clinicians so much and in reality so little at the same time. He observed that when he reviews evaluations that kids have had in the past two or three years, the diagnosis list has hopefully narrowed, but the recommendations that come out are usually copy-pasted — matching a diagnosis to a standard approach — without actually helping the family or the young person move forward. What good testing looks at beyond diagnosis Dr. Husick described several psychological capacities he examines in a thorough evaluation. One is reality testing — how well someone's perceptions line up with what others generally perceive, including the conditions under which that breaks down. Another is reasoning patterns, including what he called confabulation, where a person starts with a conclusion and builds reasoning around it rather than the other way around. This matters because it shapes what kinds of therapy a person can actually engage with. He also discussed emotion regulation and what tends to tip someone into dysregulation, IQ testing — which he said he always includes because the peaks and valleys in someone's abilities can be shocking and directly affect how therapy works — and how someone approaches relationships, including whether they tend to see people as whole or in a more split, all-good or all-bad way. 'The point of testing is to be able to tell things about a person that they're not able to just vocalize to us themselves.' — Dr. Graham Husick He also described something he called facilitation — where a person who is generally calm becomes rageful when drunk, not because the alcohol created the rage, but because something in them has had trouble finding expression. He gave a detailed example of a patient who, outside her awareness, was using alcohol to try to revisit and remaster a traumatic experience. This kind of dynamic, he said, is not something usually talked about or understood in substance use treatment, and yet sometimes it makes all the difference. What the substance someone uses can reveal Dr. Husick said the drug itself is useful information, though not the only piece. He drew a clear contrast between opiates and cocaine as an example. 'You hear this often, the idea of like opiates being like a warm hug... That's telling us something very different from the person who loves cocaine in that way. Cocaine doesn't usually feel like a warm hug for people. It usually feels like they are king of the castle kind of thing. And that's gonna tell you something different about somebody's personality and what it might be essentially substituting for in that way.' — Dr. Graham Husick Beyond the substance itself, he pointed to what the use is doing for the person — whether it's modulating an unusually high need for stimulation, filling a social and identity role, or facilitating access to an emotional experience the person can't reach otherwise. Why insurance coverage is a real obstacle Dr. Husick was direct about the tension between what thorough testing requires and what insurance will pay for. His testing process involves multiple sessions — meetings beforehand, one or two major testing days, feedback sessions, and ongoing support afterward — totaling roughly 15 to 20 hours per case. Insurance, he said, typically pays for about six hours. That gap forces clinicians to either do more with less or work outside the insurance system, which means fewer families can access it. He said he has never seen insurance properly reimburse the full extent of what testing can do, and that the incentive structures are basically just broken when it comes to this.