Substance Use Isn't the Whole Story, with Dr. Graham Husick

ABOUT THE EPISODE:

Your kid has been to a program. Maybe two. Maybe four. Each one handed back a diagnosis list a little longer than the last, and none of it ever explained why nothing is sticking.

My guest uses a comparison in this one that stopped me cold. If your child had stomach pain, no surgeon would just open them up and look around. They would scan first. And yet with our kids we tend to go straight to treatment, treatment, treatment, without asking who this person actually is underneath the substance use. He calls it treating the problem inside the person instead of the person with the problem, and once you hear it you cannot unhear it.

Dr. Graham Husick is a clinical psychologist in Coeur d'Alene, Idaho, and the director of clinical assessment at the Lakeside Independence Program, which works with severe and complex mental health cases. Part of his job is reading the evaluations other people wrote about kids like ours, and he can tell you precisely what keeps getting left out of them.

We get into why he includes IQ testing in every evaluation, what your child's preferred substance choice tells him that they could never say out loud, and why he will usually steer a family toward paying out of pocket rather than running a psych eval through insurance. He also names something I had never heard put into words: why a kid who is finally doing well will sometimes walk straight back into the thing that nearly took them out. I did not have any of this intelligence when my son was in it, and I have thought about that a lot since.

If your child has cycled through program after program and you still cannot answer the question "but what is actually going on with them," start here.

YOU'LL LEARN:

• Why Dr. Husick recommends not testing in active addiction, and the window he actually wants
• What a diagnosis list eight items long tells you, and what it can never tell you
• Why he includes IQ testing every time, even when nobody asked for it
• What the substance your child reaches for most says about what they may be needing
• The recommendation he sometimes has to put in writing that parents least want to read

EPISODE RESOURCES:

• Dr. Husick’s website
• Lakeside Independence Program website

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Transcript

[00:00:00] I had a particular patient. You hear this often, the idea of, like, opiates being like a warm hug in that way. That's telling us something very different from the person who loves cocaine in that way, right? 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. But the drug itself is useful information. The reason why they might be using it really is what we're, we're getting to there

Welcome to Hope Stream, the podcast for parents of teens and young adults struggling with substance use and mental health. I'm Brenda Zane. I've walked this path with my own child's addiction and high-risk lifestyle. Each week, we help you gain clarity, learn new skills, and most importantly, find real hope in what might feel helpless. You're not 

[00:01:00] helpless, and you're not alone anymore. Find more resources at hopestreamcommunity.org. Hi, friend. Thanks for coming and hanging out with me today. While you are busy being a Seal Team parent and juggling all the things I know you're juggling, it says something that you are taking the time to be here, to listen and learn and grow. It's almost like you have a side gig, you know, learning all of this stuff, because while regular life is just rolling right along, you now have a complete part-time job over here trying to learn all the things that you need to learn about your child, about substance use, mental health, and all of the various options that might exist to help.

Which means I know you are probably exhausted, which is why I also know you probably need to take two 

[00:02:00] or three very deep breaths Wow. It is one of those things that you are totally in control of, which feels great, and that physiologically changes your body quickly, which is awesome. It also just changes the overall state that your body is in right now.

Highly, highly recommend. So while I introduce you to Dr. Graham Husick, please close your eyes, take a few deep breaths, the ones that completely fill up your lungs, and then completely blow it all out like you are blowing up a balloon. Dr. Graham Husick completed his doctoral training at the University of Indianapolis, where his research focused on improving scientific rigor in institutional research settings. His clinical background spans a broad range of settings and 

[00:03:00] patient populations with a focus on psychological testing, psychodynamic psychotherapy, mood illness, autism, and personality disorders. When he is not working in his private practice, he serves as the Director of Clinical Assessment at the Lakeside Independence Program in Coeur d'Alene, Idaho, which is a unique treatment facility that specializes in severe and complex mental health presentations.

I sat down with Graham to talk about an often overlooked and misunderstood action that can be hugely beneficial and directional if your child is struggling with mental health and substance use, and that is psychological evaluations or testing. Dr. Husick gives us a baseline understanding of what psychological testing is and isn't, which I think is very helpful because as a parent who went through this entire experience end to end, 

[00:04:00] I had never heard of such a thing until my son was already in wilderness therapy. Graham explains testing types and emphasizes evaluation should build a psychological profile beyond a diagnosis, helping the teams that are working with that individual treat the person with the problem versus just the problem within the person He shares what I think is a helpful comparison in that if your child complained of stomach pain, you wouldn't just sign them up for surgery.

You would first start with lower-level interventions, maybe exploring food and diet, maybe having an MRI or a CAT scan, but surgery certainly wouldn't be the first step. Often, though, if we have a young person with problematic substance use, we immediately think treatment, and that may be the right step.

But without good testing and insight about the human, the human who is experiencing the substance misuse, 

[00:05:00] we might head in the wrong direction when it comes to the treatment that they need and that would be most effective. Graham and I commiserate over the ever-frustrating insurance coverage issue, and he explains why, as much as we would love to have insurance cover a thorough psychological evaluation, sometimes, most often, it is best to pay out of pocket, and he explains why that is.

Dr. Husick shares his thoughts on why, although it might sound unrelated, he always tests for IQ, and he shares some really helpful thoughts on why the substances our kids use give him insight into what might be going on inside of them. This, my friend, is a fascinating conversation that I so wish I would have had earlier on in our journey.

I think it may have given me at least some additional direction and information to work with. I know you wanna dive in, so please 

[00:06:00] enjoy this enlightening conversation with Dr. Graham Husick Hey, Cram. Welcome to Hope Stream. I'm so thrilled to have you here today. I appreciate you taking some time out of what I know is a busy schedule- Yeah ... of someone in your role to chat with me. So thanks for coming on. 

Absolutely. I'm really happy to be here. I know our mutual friend Joanna connected us, so a little shout out to her. Yes.  Yeah. I've really been looking forward to this, and hopefully we can help families in just 45 minutes. We'll see. 

I know, right? It's like there's so much. Every time I do a podcast, I'm like, "Oh, but there's like seven hours more that we wanna share." But-  Mm-hmm ... 

at least we can let people know a little bit more about what I think is a very underutilized tool in this journey. If you have a kid who's struggling, both with mental health, with substance use, I think we often just go straight to treatment, treatment, treatment.  Mm-hmm.  And I think this is a really important step that I had 

[00:07:00] never heard of when my son was in this whole thing until he got to wilderness therapy, and they said- Mm "We think he should have a psych eval." And I was like, "A what what?" "What are you... Like, I've never heard this term before."  Uh-huh.  So super happy to have you here. I think before we dive into other stuff, would you just lay a groundwork so we're all sort of working from a baseline of what is testing, what is evaluation-  Mm-hmm so that we are at least all jumping off from the same place? 

Yeah. Yeah. That's... It's a great place to start. So there's almost as many types of testing as there are therapy. Anyone coming in from the outside knows that us therapists love our acronyms, so I'll try and kind of pare this down- Okay ... as to what's gonna be most useful for the families that are listening here or even the ed consultants, too.

So testing can encompass... I mean, there's types of testing like academic, where we're looking at things, you know, does this child have a significant learning disability, dyslexia, 

[00:08:00] dysgraphia, these kinds of things. There's testing, they call it forensic testing, and so that's more in the lines of, like, child custody, fitness to stand trial. So, right, I mean, you can see it's a tool that gets used across a lot of different areas. The area that I specialize in, and that I think is gonna be most useful to these families, and that I know has been because I go to a lot of these different programs and do the testing within them, is basically, you know, it's the psych eval, psychological testing designed to...

well, it's designed to do a lot of things. It's not just diagnosis, and that's one of the points that I wanted to make here. Mm. The idea is, like you said, so many people, they, they go treatment, treatment, treatment. We're in pain. We're anxious. We want this to stop. We want it to disappear. Yes.  Please make it stop.

Right. And I obviously understand where people are coming from with that. The issue is if we dive in and start treating without really knowing what we're working with- You know, does a surgeon go in and just say, "Oh, this person has stomach pain. I should cut in there and see what's 

[00:09:00] going on"? No, they usually do an MRI first and a CAT scan or something like that. So that's the idea behind testing is, you know, before we launch into all these different kinds of treatment, all these different kinds of settings, right? There's wilderness, there's residential, there's therapeutic boarding schools, all these different things. Can we get basically a psychological profile of this person?

Not of their diagnosis, but of this actual person. So what happens a lot is that when we rush to begin treatment before really understanding what we're working with, we start to treat essentially the problem that's within the person rather than the person with the problem. So we see this all the time in depression.

So many people considered depression to be this solid concrete entity that is almost always the same thing. The story for a long time was the chemical imbalance, that kind of thing. And what basically all the research shows is it's a nonspecific symptom. So it's kind of like 

[00:10:00] fever in physical pieces- Mm. In physical health, right? You can reach depression in a million and one different ways, sometimes biological, often psychological. There's so many different pathways to it, and if we just jump in and say we're treating depression- What are we treating? We don't know. Right. And so it factors in the same way with any of the more serious conditions or substance abuse or anything like that.

We can zero in so much on the substance abuse, for example. We lose the understanding of the person along the way. So that is at least the ideal goal of what testing can do. We can talk maybe a little bit about what tends to happen in the field nowadays. We don't always reach that ideal, but at least that would be the reason why testing would be worth the time and the cost that it takes, 'cause it's not a short or cheap process.

It's really involved.  Yeah. I was gonna ask about that, but I really love what you said about treating the problem in the person Mm-hmm ... versus the person with the problem. 

[00:11:00] That is so true. Mm-hmm. We are just... I think everybody's just so laser focused on the problem, and, you know, we spend a lot of time at Hopestream talking about the problem is not the substances. Mm.  Like, that's actually, in a very weird and twisted way, keeping your kid alive-  Mm ...  because it is treating, in a very unhealthy way  Right ... 

something that's going on. And excuse me. So what you're doing is you're trying to get in there and sort of excavate, like, what is this- Mm-hmm ... that's going on? And from what I hear from you is that you're less going after a diagnosis and more going into kind of the human factor, like what's- Mm-hmm going on, and you may end up with a diagnosis. Is that true? Am I putting words in your mouth? 

No, you're exactly right. So what tends to happen... I mean, diagnoses are real. I think fewer in the DSM than we would think. I think we have, like, 400 different diagnoses- Gosh ... 

[00:12:00] pos- possibly in the DSM before we even start to get into comorbidities and things like that. If you look at the validators, really about 15 to 20 of them really stand out as discrete disease entities in a way. So it's not that the diagnosis isn't important, right? If we really do have an undiagnosed mood illness, for example, someone who goes through these cycles of, you know, mania or extreme depression, and we don't diagnose that and we don't actually get a handle on what's going on there, that would be a problem.

Same thing with a developing psychotic process like schizophrenia. I mean, these pieces are real and they have to be attended to. But- Most often, unless we're dealing with this kind of the special dual diagnosis population, the diagnosis itself tends to just really describe symptoms more than it does describe the underlying workings of the person, and that's where we really wanna get in there and understand basically where might the deficit be, where are the areas of conflict, where are the basically the 

[00:13:00] psychological defenses failing so that substances have to take their place in that way.Yeah. Yeah. Um, yeah. So it's not exactly the diagnosis is unimportant or that we never reach one. It's a part of psych testing. Maybe this is a good kind of bridge here. I mean, that, the issue is that is where often a lot of psych testing is ending nowadays- Mm ... because diagnosis basically has taken the place of conceptualization.

I mean, I'm kinda sounding like a broken record here, but what are we actually treating? What are we actually looking at? What are we actually working with? And unless it's one of those really more severe diagnoses, we're working with the person way more than we are with any particular sort of thing that lives inside them in that way.

Yeah. That's so insightful because I- and I see this in young people. There tends to be this o- almost like a identification with my diagnosis, right? Yes. Like, I 

[00:14:00] am this or I am that or I have this, and, you know, like you said, that's wonderful if that's true, and that can lead to maybe the right medication or the right kind of treatment. It's wonderful, but it really does stop short of, "Okay, but what about you as a person?"  Mm-hmm. 

You know? You are not just this diagnosis. In your perfect world, let's say you could just, like, create the perfect world with a family who has a kid who's, you know, maybe in their late teens- Mm-hmm ... been to treatment, been to treatment again, been to treatment again. Mm-hmm. They've never had an evaluation. What would your sort of perfect situation be there as far as getting that family some help? 

It's a good question because the way you're asking it frames it like what's my perfect situation, you know, what's the ideal for me versus maybe what ends up 

[00:15:00] walking through the door, right? Can be very different. Yeah. So generally, I think caveats are probably needed here. So if somebody's in active addiction, I mean, they're really just going between being intoxicated or being in withdrawal, usually not the time for psych testing. The data that we're gonna get from that is not going to be very useful because we're really looking more at the effects of the substance on the person than we are at the person themselves.

So my ideal situation doesn't have to be that they are actually that stable, it just has to be that they're really not in that active addiction piece.  Mm-hmm. 

The place where I'd, again, ideal, the place where I'd ideally like to be able to sort of get in there and start involving myself with the family and the kid and their whole system around them to really understand what's going on with them would be when they are, you know, essentially a few weeks out detoxed and probably still within their initial program, whether it's in wilderness or, you know, that kind of thing. Mm-hmm. Where 

[00:16:00] they're in a stable enough environment and where clinicians have also, or, you know, and staff have also seen them for a few weeks at least at a time, because that's gonna give me a lot of information, too. You know, it's tough with the deinstitutionalization movement that started with Reagan, right?

I mean, there were terrible abuses in these hospitals and institutions, facilities. At the same time, the good ones, the ones that really were working in humane ways to help people, were working with people for sometimes years at a time. Right. And that actually, in my opinion, is what's needed for some families. Very difficult to find nowadays. Very few places are doing that kind of thing. Yeah. 

But if it was possible for people to stay, not even years, six months, a year, that kind of thing, the transformations that I've seen out of people, especially when they get a psych testing, psych eval done at the beginning of that kind of course of treatment is, is night and day from the kind of endless cycle of particularly insurance-driven 30-day programs or just the 

[00:17:00] detoxes or that kind of thing. 'Cause again, those are typically oriented at can we get the particular symptom to go, go away or at least drop low enough where we can release them back into their environment And of course, I know from your story, I mean, that tends to... I think the stat you mentioned was it fails for 80% of people. Yeah. Yeah.  Yeah. 

Yeah, it is so tricky, and I know when I was going through this, I don't know if it was for good or bad, but like insurance didn't really cover anything. Mm-hmm. I think it maybe covered his one therapy session a week when he was at Wilderness, and the same when he was in residential treatment. It just never actually even occurred to me to really try to get insurance coverage, 'cause this again was back in 2013, '14, and then on.

And the parity law was in effect, but nobody was really acting on it. Now, parents are starting with insurance. Mm-hmm. It's like, well, of course it should cover. Like it covers if they have a broken leg, like it should cover if they have this. Mm-hmm. And I 

[00:18:00] know I've talked to enough people who do what you do to know that there's all kinds of problems with having insurance dictate -  Yeah how you do your testing, how long it can be, how thorough it can be. So I think sometimes that can be scary for parents to be like, "Well," and then that you don't know what you're getting. Right. 'Cause if you're using your insurance, you might not be getting the same results as you would get if you were to pay out of pocket because- Mm-hmm

this is just, and tell me if I'm wrong, because you are limited by the insurance company of what you're gonna get reimbursed for. Is that a true statement? Yeah. It's- Yeah. This is some of the spicier takes or- I know. We don't have to go down a rabbit hole, but- It's okay. Sometimes it's just more useful to call things for what they are.

Yeah. I mean, I think good therapy can happen under insurance. It's not always easy, but it can. I've never seen really the extent of what testing can do be properly basically reimbursed by insurance. Yeah. The incentive structures are basically just broken when it comes 

[00:19:00] to this- Makes sense ... because when I'm working with a family or a teen or a young adult, the testing process is, it's iterated, right? We have several sessions, including the one big or two big testing days. We have meetings beforehand, and we have after, after meetings, feedbacks, you know, continued assisting and support to get where they need to go depending on what the results showed from the testing, and that usually takes me probably 15 to 20 hours per testing case. Yeah. And insurance typically pays for about six hours.  Oof.  So at that point, as clinicians, you have a choice. You can try and do what you can, do more with less, essentially, which is what the pull so often is nowadays in mental health, or you can try and go outside the system, which of course has its benefits, right?

You're actually able to do the thing that you believe can best help families, but it also means that so many fewer families are able to access it. Yeah. And so you have to try and find ways to make it more accessible to people, and yeah. So it's not 

[00:20:00] that good testing doesn't exist. It's just a lot harder to find maybe than it used to be. Hey, friend. If you've ever finished an episode of Hope Stream and thought, "Hmm, but what do I actually do when they come home tonight?" That is what the Stream was built for. The Stream is a private online membership for moms who are navigating all the same difficult things you are, like those nights when your kiddo comes home at 2:00 AM and you don't know what to do and things are escalating.

It's where knowing about things like CRAFT and the Invitation to Change become real and you start actually using it, and right now you can try it free for two weeks. No credit card required and no long-term commitment. There's nothing to cancel if you decide it isn't for you. What you will have is full access to our special community and the women who have been 

[00:21:00] or are in your exact kitchen situation. They've had those difficult conversations. Even on your busiest, hardest weeks, there is something here that fits for you. You can engage as little or as much as you want, and of course, you get to show up in the way that feels best for you. Go to hopestreamcommunity.org/try to get that free two-week offer, and I will see you inside. Okay, let's get back to the show Right. Yeah, that's such a conundrum 'cause you wanna get the best, and then to find out that there's these limits put on, and I know every medical provider faces that. Yeah. It's not unique to what you do, but... So let's say a family has a young person who's been to a program, and they do have an eval of some sort.

What do you find tends to be missing from those? Yeah. Like, what are you digging into and saying, "Ooh, I wish they would've asked this," or, "I wish they would've done this." Like, what is- 

[00:22:00] Right ... what is typically missing? Because there are so many kids who go through program after program after program, and you just wonder, "Why is this not-" Mm-hmm sticking?"  Yeah. Yeah. So and that unfortunately happens all the time. So I'm the director of clinical assessment at the Lakeside Independence Program here in Coeur d'Alene, and it's a aftercare-type program. And so we do get people coming in, actually most of the time, who have had various evals, a lot in Utah.

You know, it seems to be one of the main places, at least in this half of the country, where people go. And the way that it typically looks is the person came in k- kind of a, like a rolling stone. They picked up a bunch of diagnoses along the way, and of course, if you know the history of s- psychology and psychiatry, there are kind of diagnostic fads that happen.

Mm-hmm. It was bipolar for a while, and then it was, now it's kind of ADHD or autism is one of the big ones now. We'll see where it goes next. They pick up these diagnoses, and well-meaning testers are going in and saying, "Okay, if they 

[00:23:00] have a diagnosis list that's eight diagnoses long, that tells us so much and in reality so little at the same time. What do we target first? What influences what? Where did each of these come from?" It's kind of baffling. Yeah. 

And the thing is, God or nature or whoever usually is not cruel enough to give people multiple different diseases at the same time. If there is an underlying diagnosis, it is typically one of the major ones like I've mentioned, mood illness, schizophrenia-type, you know, spectrum kind of things, PTSD, OCD, eating disorders.

I mean, each of these can be devastating in their own way, but when I take a look at these reports that I get from, that these kids have had usually in the past two or three years when we take a look at them- What usually happens is the diagnosis list hopefully got narrowed to maybe two or three, and then the recommendations that come out of that are usually copy-pasted. We treat this particular diagnosis with this 

[00:24:00] particular approach, and that's what the research can show. But a lot of the times, it doesn't actually help the families or help the kids progress. I mean, they, like you said, the end result is we're still in and out of programs. We're still having all kinds of difficulties.

Yeah. Why hasn't this really shifted anything? Most of the time it's because, again, the testing was oriented at looking at the diagnosis rather than at the person themselves. So in the testing that I do, and obviously it's not just me, I, I happened to be trained by some of the people who designed the testing protocol from the Menninger Clinic- Oh, yeah

back when they were in Topeka, Kansas. Mm-hmm. Now that they're in Houston, I'm not so sure how much of this they do anymore. But back in those sort of golden days, I think it was the, maybe the '70s and '80s, there was real innovation happening there, and so they've managed to take that through into today.

It's just that most of them happen to be 70, 80 years old at this point, so they're kind of trying to- Mm ... give it to the next generation. So I didn't go searching for it. I was just lucky enough to be around when they were, and lucky enough to be sort of open to the idea. So in the testing that I 

[00:25:00] do- Right. What are we looking at in the people? I've been talking about this the whole time, where we're gonna look at the person, not the problem. Okay, but what about the person? So there's a lot of different aspects, a lot of different facets of people that we look at. Some of them are basically how their brain works, and then some of them are how their mind or their personality works.

Mm-hmm. So for example, pretty standard with insight testing is IQ testing. That can be enormously helpful. I know there have been controversies over IQ in the past. I essentially don't give a testing without including that, and the reason is because it can be pretty shocking, the kind of peaks and valleys in somebody's abilities.

So for example, somebody can present really well because they are verbally just sharp as a tack, and they have this processing speed that is lightning fast, and they're very sort of, uh, facile in that way, and they can charm anybody. And underneath what it turns out is that every other capacity, including memory, comprehension, all that, is really 

[00:26:00] lacking. And so it's no wonder that when you start therapy with somebody like this, where basically they're leaning on their strong sides like this, and then we really start to get into areas of abstraction and not knowing, we get beyond the surface, is where the person kind of falls apart and isn't able to absorb any new information or carry it into the world out, kind of outside of therapy in that way. Right. 

So IQ is massively helpful in that way. It also can tell us what kind of learner somebody is. I'm sure you've heard of learning styles before- Mm-hmm ... you know, visual, auditory. The data's kind of mixed on how useful that is in schools, but in therapy it can be really useful because if the person is not that much of a verbal learner and they really need the kind of visual spatial or the sort of something in front of them to be able to sor- absorb things, as a therapist, if you're good and you can flex with what the needs of the patient are rather than just doing what you know how to do, it can really be super...

It can just change the course of the treatment in a way that wouldn't be possible otherwise without 

[00:27:00] knowing that about the person going in. So a, a lot of, of kind of, you know... Spoiler alert, skip to the end. A lot of the reason for the testing is actually to assist the therapist and the treatment team in helping the person.

Right. Of course, some of it's going to be for the families. Can, you know, should they go in this kind of program or this kind of thing? It could be helpful for the education consultants to see this kind of report. But overall, there's a lot of actually advice in there to the treatment teams to be able to help the person and- That requires the handoff to be able to trust the treatment teams to do that.

But in my experience, if you write good recommendations like that, therapists actually are really... They're really curious, and they're wanting to learn, and they're wanting to get better, and so they're able to take the recommendations from that and really run with them in a way that changes, again, the course of what might be able to work or not in that program.

Yeah. What do you do if you end up with results and you say, "Ooh, this is not the right kind of program for this person"?  Mm-hmm. I mean, is- that must be a difficult conversation to 

[00:28:00] have, right? If you're like, "I think based on what you now know- Mm-hmm ...  this other either modality or whatever it is, is, if it's not a right fit," are you having that conversation with the family, and then they're...You sort of leave it up to them to- Mm ... communicate that or... I know that's a little logistical, but I think families get really confused. Like, "Okay, I have all this information now. What do I do with it?" 

Right. You know? Yeah. Yeah. Yeah. That is a problem that happens often. E- here's the diagnosis, here's the feedback.

Bye, kind of thing. Right? And, right, the idea being to be able to... S- I mean, and the ed consultants are wonderful for this, but being that kind of liaison between the different isolated pockets of treatment or help. And, I mean, what I do is I will talk with their ed consultant, their program, their therapist, that kind of thing.

The nice part about testing and being the, the assessor in that way is you can be a little bit more Blunt, just straightforward and factual. Right? At the end of the day, this is not a magic 

[00:29:00] bullet, and this is the opinion of a clinician, hopefully backed up by data and facts like you're getting from the testing. But it really is up to the families then to decide what to do with it. But you wanna make sure that you're delivering the results in a way that the family at least knows this is the opinion, this is what might have to change. Do you think that's possible in your life? Yeah. 'Cause you can recommend things out the wazoo for families to do, but if it's not possible, not just sort of financially, but there's a huge cost to having kids in treatment that goes way beyond just money.

I mean, it hurts to have that. Mm-hmm. And it can be embarrassing for families where they're coming from environments where at least on the outside it looks like everybody has it all together. And so when... Right.  I know that feeling.  Right. So and I came from a similar place. I grew up in Seattle. I think we've got some connections there.

Oh, yeah. But yeah, I mean, there's so many costs in there. The idea is, again, just you wanna work with the people in the setting rather than just diagnose a problem and give generic solutions- 

[00:30:00] Yeah ... in a way. You really wanna tailor what you're recommending, not just to what the person is dealing with, but to their entire family situation and who they are as people. And that's where we can maybe talk about personality a little bit too. 

Yeah, I would love that because what I'm hearing is, yes, there are some diagnoses, but I'm wondering what else might you uncover. So let's say you're like, "Okay, this person has bipolar- Mm-hmm ...  disorder," and... And then what is the and? Like what else- Mm would you be sharing with that family that isn't a quote unquote diagnosis- Mm-hmm ...  but that would be going into the mix of everything to consider for the next step for that person? Right. Yeah, and so that's where we get maybe a little bit more into the nitty-gritty. I think you can probably tell I'm a testing nerd, and so, you know- Love it

I can go way too deep way too quickly. But the metaphor I use here a lot is basically like if you ever had trading cards as a kid or played sports video games, you're using the joystick and you're controlling the player, let's say in, 

[00:31:00] like, an NFL football game, and for some reason or another this player is supposed to be really good, but they keep dropping the pass. Or they can't shed the block in the way that... Who knows? You're not gonna know why until you go deeper into that person's essentially statistics and you see- Mm ... oh, these things are real strengths, but this is where they really drop off, and that's why they're not able to perform the thing at the end that we would like to see.

So what that looks like is basically these different psychological capacities for people. So, like- There's something we call reality testing. How well do this person's perceptions line up with generally what other people perceive, right? The really extreme end of this is psychotic thought process, but there's variation within that before we get to the really extreme parts where this person usually can see things really well, but when a particular either physiological state comes up, extreme fatigue, or again, the use of the substance or that kind of thing, and that's where they really spin out and start to have, whether it's full-on 

[00:32:00] hallucinations or delusions or those kinds of things. It can also affect people's reasoning. There's a lot of different ways that people's reasoning can go. You know, their normal reasoning might be A, B, C, and somebody's reasoning might go A, B, F or- Hmm ... 

interestingly, F therefore A, B. That, we call that confabulation. So the idea is rather than taking information and using it to construct a conclusion, we start with the conclusion, and then we basically build all the stuff around it.

Hmm. What must be true given that usually false con- conclusion. And so if a person has that tendency, well, it actually points to that a lot of different cognitive interventions are needed before the person's gonna be able to engage in any kind of exploratory or more abstract therapy where they're gonna be able to grow developmentally.

It points basically to how much scaffolding somebody is gonna need when they're going into the therapy because people know therapy usually as, like, talk therapy. You go, you talk to somebody, they're supportive, they try and help you see parts of yourself that you may not 

[00:33:00] be aware of, you know, blind spots, that kind of thing. That works great for people who have the basic capacities to be able to do that, but a lot of the time when somebody doesn't, we just throw our hands up and go, "Well, I guess therapy doesn't work for them. We've got to go with just-" Right ... "a, a management approach." And the idea there is no, there, there actually are things that we can do, but we have to be aware of what's going on for this person.

Other capacities, there's emotion regulation. What happens for a person when they start to get dysregulated or overwhelmed? What issues does that typically happen around? Within testing, this, this is a point I really wanted to say. 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.

Hmm. 

So, like, in the reality testing example, they're not gonna say, "Oh, well, when I get really fatigued, and also when I'm having a significant conflict with people who I love, I start to get paranoid." That's really- Right ... rarely somebody has that insight and able to- Right ... kind of see that. But if we're able to see through the testing, whether it's through the 

[00:34:00] interactions just with me, and you've made a lot of data outside of just the tests, whether it's projective testing, the Rorschach inkblot test. It's real and it's really useful. It's not just in movies.  I was gonna say, I've seen it in movies. 

Right. Yeah, yeah. Mm. So, and that's, that's the idea behind testing, is so many... There have been... By the time people get to me, there have been so many clinical interviews where we've gotten the extent of what the person is able to tell us in their own words, even when they grow to trust the person.

The point of testing is we're able to go a little bit deeper and to see the conditions under which people start to come apart, and therefore what we need to do in treatments or even at home that might be able to kind of head off and scaffold and support people so that they don't end up diving off the deep end and going back further into addiction and things like that. Yeah. Speaking of addiction and the substances in particular, because most of the parents who are listening here have a kiddo who's in some phase of-  Mm-hmm ... using, 

[00:35:00] dependence, addiction, or in starting to get into recovery. Mm. So I have so many questions, but one would be, does their substance that they tend to use the most tell you something, or how do you think about that in the mix of what you're doing?

Yeah. And this is where things really get fun, I would say, when we start to think about the people, because yes, right? It's not the only piece of information that's useful, and particularly nowadays when you have kind of drugs that are outside the norm, kind of the designer drugs or things like that, it can tell you less.

You wanna be able to ask the person what it's like for them. Mm. 

But generally, yes. I mean, if somebody is using benzos compared to stimulants, these kinds of things, it can tell us... I had a particular patient, and this is, you hear this often, the idea of like opiates being like a warm hug- Yeah ... in that way.

That's telling us something very different from the person who loves cocaine in that way. Mm-hmm. Like, cocaine doesn't usually feel like a warm hug for people. It usually 

[00:36:00] 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. But- Right ... the drug itself is useful information. The reason why they might be using it really is what we're getting to there, and there are sort of the classic stories about why people might be using. The common ones, the guy who drinks to forget. That kind of thing. Or I know you talked about your son a little bit this way, I forget the exact term for it, but basically that it becomes part of their, just who they are, their identity- Yeah

who they hang out with. It substitutes in that way for the lifestyle, for- Yeah ... for lack of a better word. Yeah.  Drug culture in that way and that kind of thing. But those are the ones that people typically know about. There are others psychologically that we can kind of ferret out using testing that are a little bit deeper.

It's not usually just one of these, but you don't want to forget about some of the deeper ones. So for example, modulation. So some people have just 

[00:37:00] different levels of basically need for stimulus. This is more towards the brain idea. So you can typically see this in, like, young boys who would be diagnosed with ADHD kind of thing.

They need a huge amount of stimulation just to stay focused, just to do things. It's why stimulants, you know, work for them. Yeah. 

Compared to the person who needs way less than what the world has to offer, you know, the world has never been noisier than it has now. Right. 

I mean- And so you can get people who really isolate themselves and then also use substances to kind of modulate that rather than doing other things that might help more, or at least in less damaging ways But then there are the even deeper ones.

There's something called facilitation, where this is like the person who is usually a pretty calm and docile person who, when they get drunk, they become, they're rageful, right? Mm-hmm. 

And so it's not like alcohol puts rage into them. This is a part of them, but it's having trouble finding its way into 

[00:38:00] expression, particularly into healthy expression.

And so they're basically using a substance in that way in order to feel and experience and use something that they're not able to otherwise. So- Right ... that's not something that's usually talked about or understood in substance abuse treatment, and yet sometimes it makes all the difference, particularly when they're then using that in order to kind of facilitate trying to work through something, some kind of typically trauma, and that can get dangerous, right?

So like I had a patient many years ago, she was generally healthy, generally functioning well psychologically, but she'd been sexually assaulted multiple times when she was young. And seemingly inexplicably, every so often she would get really drunk, you know, go to a bar, get really drunk, get in somebody's car that she know that she shouldn't, and get into a situation where that might happen again, and she would have to fight them off and then come to therapy and tell me about it. And the idea was she couldn't put into words the- Mm-hmm ... the 

[00:39:00] experiences around the trauma. It was unformulated. It was intruding into her everyday experience. And so sometimes people try and basically remaster old experiences by putting themselves in those kinds of painful situations again. The situation I just gave, it's actually amalgamation of a few patients, and that's a pretty extreme example.

Yeah. But this kind of thing happens all the time outside of people's awareness. And so if we're just looking at they drink too much, it's just a physiological dependence problem, these kinds of things, we totally miss what psychological motivations there might be underneath. And so we might treat the problem, and then the symptom pops up again later, rather than helping them develop in a way that can help them not have to go back to that again.

Wow, that is super fascinating because... And what came to mind for me in less extreme ways than what you described- Mm-hmm ... is a lot of our kids, I hear it all the time, is why does he or she self-sabotage? Like, they get- Mm ... to 

[00:40:00] this specific place where they're doing really well, and then they do the thing, right? Like- Mm-hmm ... w- and it is so baffling to watch- Yeah ... you know, to watch that happen. So that really resonated because I think there could be, who knows what the reason is, but that's a good- Thing to be aware of is that there may be some deeper underlying reasons why they are doing that. They're not just crazy, you know?

Right. They're not just trying to shoot themself in the foot. And then the other thing that I was thinking about, I could be completely off, but in some of that, like would you look at your results potentially and then say, "I was thinking IFS would be really interesting- Mm ... for someone like who's got these different..." Like, "Why do I keep doing this?" Mm-hmm. Would you then recommend maybe a treatment modality like IFS or like CBT or DBT- Mm ... based on what you learn, or is that- Mm ... like completely different? 

[00:41:00] No, that's not out of the realm of possibility here. So, you know, the idea basically is within therapy, there are different sort of tiers of what is possible for different people. So, and this is, of course, th- this is going to be tainted by the way that I practice therapy, 'cause I come from the psychoanalytic or the psychodynamic tradition. This is where we think very deeply about people like that. IFS kind of being an offshoot of that. Mm-hmm. And so in order to engage in the type of therapy that I typically do with people, you do have to have that, those different capacities generally in order, right?

So you have to be able to tolerate some level of emotional discomfort without converting it into action too badly. That is what substance abuse is often. And so to be able to do this kind of work in a treatment setting is really the only place we can do that. Now, it, again, it all depends on level of severity, right?

Because I see lots of people who have all kinds of substance abuse issues or substance use issues, but it's not completely tearing their life apart- Right ... or their family's lives apart. So it, 

[00:42:00] you know, everything I'm saying here is gonna depend on level of use and severity and impact in their lives. CBT I like CBT. It is a, a wonderful place to scaffold in that way. You know, if somebody really needs to be able to, like I was talking about, you know, sort of check their own thinking so that things don't spiral out of control in that way, CBT is great. I've known amazing CBT therapists. There's also a reason that I decided to go in the direction of therapy that I did, which is basically what's after that.

You know, how do we think even more deeply, where at, even more deeply than just how our thoughts might be affecting our feelings and our behaviors in that way. Right. So yeah, I mean, depending on what the person is like, how much they can handle abstraction or the way that they approach the treatment relationship.

I ha- I haven't talked about that yet. I mean, there's, do they see people as kind of whole and integrated versions of good parts and bad parts, or do they typically see people in a more split way, where they're a- all good or all bad? 

[00:43:00] We refer to people who have that kind of issue typically in the more personality disorder range of things, borderline narcissistic, these kinds of things.

It's not that psychoanalytic treatment isn't good for that. There's specialized treatments for that, too. It just really all depends, can we... This is sort of the calling card, right? Can we dig into this person's capacities so that we can predict with some level of accuracy what progression of treatment might be helpful for them?

Do we wanna start with the more sort of basic ground-up kind of stuff, or can we jump in with the proper supports on the outside into a little bit deeper work in that way? So yeah, again, it's about the clinicians and the treatment programs being able to flex for the people- Mm-hmm ... rather than saying, "This is what we do. This is the treatment we provide. Hopefully, it works for this person." Yeah. 

That was what was so amazing about Menninger for so long, and again, I don't know what they're doing now, but the way that it was described to me, that the idea would be, "Okay, we all know how to do these things really well. We can..." It's kind of 

[00:44:00] like classical music. We can repeat the experience over and over in a very effective way, but now can we start playing a little bit of jazz? Mm. Can, can we flex with this person? Can we judo roll with the different, you know, different, out, things out of left field that come up, especially using testing so they don't totally come out of left field. That's how we really help people. Mm. That's a really great way to put it. It's- Mm-hmm ... 

and it's hard. I think it's hard to find that, and the other part, the other layer of this that I just want to acknowledge for parents is that- Often you are not doing this in a calm, peaceful- No ... leisurely time of life when you have time to consider all these things- Mm-hmm

and do a ton of research, right? It's usually some level of crisis, and there's time-bound issues and money-bound issues, and it just is so complex to navigate. I think we all wish that we just had the brain space and the time to do this 

[00:45:00] so intentionally and thoughtfully, and to the best of your ability, obviously, you want to do that. But- Mm-hmm ... just to acknowledge, 'cause I know for me, like, uh, we were just in such chaos for so long, that if somebody had said, "Oh, yeah, we need to do this, and, and this is gonna lead to that," I would've been just like, "What? Uh, what?" Uh 

Right.  So we didn't do any testing until he was in treatment, because that was the first time it was ever mentioned to me.

Mm-hmm. You know? I know I need to let you go, but I'd love to know, just to give parents an idea, not a before and after necessarily- Mm-hmm ... but maybe an, a scenario, I guess you could call it, of when somebody does get the right testing- Mm-hmm ... and they're able to put that into action, what does that make possible?

You know what I mean? Like, how does that potentially look different in the end than someone who either doesn't get testing or gets a shallow version that's kinda like, "Well, yeah, you have this diagnosis, and then this is- Mm-hmm ... what we're gonna do for you"? Right. 

[00:46:00] Yeah. And I'm gonna try not to oversell it here, but- given that it's what I do- Yes ... um, I just... I would not be able to do something like this that requires this level of intensity, particularly around the intensity of chaos and the emotions that are flying around during this time, without really believing in what this can do and what I've seen happen. So- Mm-hmm

if you do end up getting, you know, the right diagnosis in a way, let's say if all along there was a bipolar process going on and you can start on the proper medications and that kind of thing, totally life-changing in that way. Yeah. Somebody who was self-medicating in that way to deal with it, you put them on a little bit of lithium and suddenly way more stable.

Not all better. It's never all better, but enough where they can start to engage much more in the treatments that they might be able to benefit from. Or let's say that they've got a diagnosis that really isn't the case. We have misdiagnosed, there's any kind of iatrogenic harm in that way, you know, sort of doctor-led going down the wrong path. Well, if you can de-prescribe in that way, I've worked with so 

[00:47:00] many people where they were on stimulants that, where they really should not be, and simply getting off of some of the medication- Mm. Made things better. But then in the more complex way, right outside of just that diagnostic piece- Yeah ... when there's not a really an understanding along the way in the process, 'cause almost nobody's just gonna go to one treatment program and then have it be all good and all done.

A lot of the times there's this very long process and you get a lot of different people taking a look at your kid, all with their own backgrounds, all with their own understandings of things, and if no one pauses to say, "Can we get the full picture here? Can we take the chaos and slow it down enough so that we can get an understanding of this person well enough to direct things?"

It might save a lot of time and money in the end to be able to say, "This is what's going on." Yeah. And for example, the kid where it becomes their life in that way, the drug culture and all that kind of stuff, I mean, the brutal reality you can give as a recommendation in testing is this kid should not come home.

[00:48:00] Yeah.  At least not for a very long time. I heard that. Yeah. I heard that, yeah. Right. Yeah. So that's... You can... Again, I never wanna oversell anything, but the change in treatment trajectory that I've seen by doing this kind of thing has been monumental, totally life-changing for some people, and that's why I do it.

And very hope-giving, I would say. Mm. Because it can get easy to lose hope and to lose sight of, like, could this actually get better? Could this person that I love beyond-  Mm-hmm ...  have a healthy, productive, independent life where they're thriving and doing all these things? And I think this is such a big part of that, that again, gets overlooked, which is why I wanted to highlight it again on the- Yeah

podcast because, man, you gotta have as much information as you can. It is not a simple thing. It is not just, "Oh, it's alcoholism." Mm-hmm. "Oh, it's, you know, it's this." It's 

[00:49:00] never just that. Mm-hmm. And the more that we can excavate that- Yeah ... 

true reason. Yeah. And sometimes that's really painful, and I gotta say, as a parent, sometimes you're just not really wanting to know what that is, right? Mm-hmm. Like, there's a lot going on there. So- Yeah ... 

it can be really intimidating, but I think the end benefit, like you said, of somebody being able to just, like, completely change their life is worth the slog that it might be to get through- Yeah ... a difficult process. 

And there's one more thing that I forgot that I really wanted to include here, which is we're talking about the person and the testing as if we're kind of doing this all to them and then delivering the results to them, that kind of thing. It's a very collaborative process-  Mm ... 

with the person themselves. I'm checking in with them along the way, how they are understanding some of the results that we're getting along the way. One of the benefits that this can really bring is when people are used to having treatments done to them, as- Yeah ... is, 

[00:50:00] as happens a lot, doing this kind of testing in the collaborative way, it can instill a sense of curiosity about themselves.

in a way. And that actually tends to be one of the things that changes things most. Now, good therapy will do that too. In fact, I think it's a requirement of good therapy for the person to start being curious about themselves in a way that's not overly judgmental or harsh in ways like that. But doing it through testing, I have seen change people's course of treatment just through that alone too.

Doesn't happen with everybody. Some people can be so deep in denial and everything that it is too painful to become curious in that way just through the testing. Mm-hmm. But that's one extra piece I wanted to put in there, is it can really recruit the person in as well, rather than just having things done to them.

Yes. Thank you for saying that. I think that's super important, because it does start to feel like, and my son has talked about this, like, "Well, you were always taking me to talk to someone, and y'all were always talking about me." And-  Mm-hmm ... he, you know, he was young when he was tested for ADHD 

[00:51:00] and giftedness and all of that. But- Mm-hmm ... I think that's such an important reminder to, this is, you know, either a team effort, or if they're older, maybe it's just them, but it is collaborative and so insightful for them. And, you know, even for me to learn, oh my gosh, my son is highly ADHD- Mm ... but also highly gifted in- Yeah ... he had the verbal, like he has this amazing- Mm

vocabulary and ability to be so articulate. And I think, like you said, that was masking a lot of other things that were super challenging, so. Yeah. 

Oh my goodness. Well, I think we could probably talk for days, but thank you- ... for this, for at least getting us a download of this information. We will make sure and get links in the show notes to you so that people can find you and learn more.

And just, you know, again, it's another step towards more hope for somebody who might look like they're really- Mm-hmm ... really lost. And with more information, I think 

[00:52:00] that can change a lot. So thank you, Graham, so much for joining me. Thank you. Yeah, appreciate everything you do too, so hopefully we get to talk again.

Yes. Thanks so much. Okay, my friend, I am so glad that you are here with me today. Do you want the resources from this episode? If you do, head to hopestreamcommunity.org, click Podcast, and you will find this episode, along with 300 or so others, and every link that we mention. And if you haven't tried it yet, we offer a free two-week trial of our online community for moms, The Stream.

No credit card needed, no commitment, just go to hopestreamcommunity.org/try, and we can get you set up with a free two-week membership. And if this is your first time here or if this whole approach feels new and uncomfortable, that is normal. You can grab a free e-book I wrote called Worried Sick. 

[00:53:00] It will help you start seeing new ways to respond to your child and find new ways to approach this whole situation that feels very confusing.

You can find that at hopestreamcommunity.org/worried. You, my friend, are an elite-level parent. You are doing an incredible job. You do things most parents never have to do, and I am so honored to be walking this path with you. Take ridiculously good care of yourself, and I will meet you right back here next week