Introduction to Overlapping Issues

Wellness describes a healthy balance of the mind, body, and spirit. It plays an important role in protecting and promoting our health in every area. This balance results in an overall feeling of wellbeing. Many of your clients will have multiple challenges in their lives that affect their health and wellbeing; this is referred to as having "overlapping issues."

A client who has two or more health problems may have symptoms that are difficult to assign to one condition or the other. Work with an experienced clinician or a medical provider, as appropriate, to be sure that the client's symptoms are being identified appropriately and interpreted correctly.

Some clients will have health conditions that coexist but do not have an effect on each other. For example, a client can have both heart disease and a developmental disability, with neither condition causing or even affecting the other. However, clients may also experience health problems in one area that do cause or affect health problems in other areas. For example, a client who has experienced years of chronic pain from an old injury may also experience depression because the pain prevents him from doing things he used to enjoy. Emotional health may also affect physical health, such as with a client whose stress that causes her to develop tight muscles and headaches that affect her ability to do day-to-day activities.

This chapter will present and review common areas of health and wellbeing that may present overlapping issues. Separate chapters are devoted to the following overlapping issues and related topics: Co-occurring Disorders, Behavioral Health and Medical Conditions , Medication Management, Fetal Alcohol Spectrum Disorders, Involuntary Commitment of a Mentally Ill Person, Foster Care and OCS, Clients with Incarcerated Family Members, and Impacts of Diminishing Resources.

People who experience developmental disabilities, substance abuse, mental illness, and/or homelessness are all often subject to prejudices, negative attitudes, mistreatment, abuse, and discrimination. They may be discriminated against by employers, social and health services, and housing providers. They experience painful emotions due to feeling out of control or losing all they have. They need:

• Respect, including taking the time to understand their unique situation.
• Societal support to provide the necessary quality of services.
• Commitment to include them in every aspect of treatment.
• Alternatives and choices for their services.

Although all of these conditions can overlap with each other, they should not be seen as the same thing. To avoid making wrong assumptions, providing faulty service planning, and potentially discriminating against clients, it is important to create a treatment plan that identifies each unique condition and plan for treatment, as needed. For example:

• Developmental disabilities and mental illness are often confused, even though they are very different. With mental illness, conditions can often be cured or controlled using medications and psychotherapy. Developmental disabilities are lifelong conditions involving an intellectual disability and possibly a physical disability.
• Substance abuse and homelessness are often mistakenly thought of as going hand in hand. However, these are separate conditions and many people experience one condition without experiencing the other.
• Although mental illness and substance abuse can overlap, the needs and treatment options for each can be very different.

People with mental illness generally need mental health care, which may include medication and/or psychotherapies. There is no one single, universal cause or outcome of mental illness.

• Mental illness can have genetic causes, develop in response to a life event, or be related to difficulties processing thoughts and coping with emotions.
• Mental illness can be due to social and/or psychological causes, such as bereavement or the loss of a job.
• Mental illness can disturb various functions of day-to-day living, including a person's senses, thoughts, feelings, reasoning, and/or decision-making.

The overlap of mental illness and substance abuse often develops because the client wants to manage uncomfortable mental health symptoms. For example:

• A depressed person who uses substances such as marijuana or alcohol to numb the pain of his depression.
• A person with social anxiety who drinks to feel more comfortable in social situations.
• Someone struggling with panic attacks who takes benzodiazepines like Xanax or Valium without a prescription to calm symptoms or stop attacks before they start.
• A person with low energy and motivation who starts using cocaine or crystal meth to increase her drive to get more things done.

Substance abuse refers to when a person uses a substance inappropriately. Substances are often used by people with mental illness in attempt to manage their symptoms.

People who regularly abuse or are dependent upon a substance may be at a greater risk for experiencing the following situations that can affect mental health:

• Anxiety related to being able to find or use their chosen substance.
• Worries about being caught using the substance.
• Making poor decisions while intoxicated that result in situations they later regret.
• Chronic substance use that contributes to vulnerable situations or unhealthy relationships..

When there is a co-occurring diagnosis of substance abuse and a mental illness, it is important that the client be treated for both disorders at the same time. Untreated symptoms of a mental health disorder can cause the client to be unable to stay sober or keep clean from substances, while an untreated substance abuse problem will undermine mental health treatment.

Primary care providers, mental health providers, and addiction providers typically treat people with co-occurring (comorbid) substance abuse problems and mental illness. Primary care providers are generally unable to devote large amounts of one-on-one time to individual patients. At the same time, mental health and addiction providers often provide specialized care for mental illness or substance abuse disorders respectively but lack the expertise to diagnose and/or treat comorbid disorders. These potential gaps make it especially important that the client has well coordinated care with ROIs in place.

• The substance use disorder may be treated first because the symptoms of mental illness may be difficult to tease out until the substance use is managed.
• Multiple providers treating the same person may or may not coordinate care. Not coordinating care may mean they miss important information that would help them serve the person better.
• Treating providers must remember that many medications have physical side effects when mixed with legal and illegal substances. Mental illness and substance abuse may impair the person’s ability to manage medications as prescribed and the person may require extra medication management support.
• Individuals with mental illness may use substances as a means of self-medication. However, for individuals with a long history of overlapping issues related to substance use and mental illness, it can be difficult to determine which was the original issue.
• Overlapping environmental factors such a stress, trauma or abuse, and early exposure to substances are common factors that can lead to an addiction, a mental illness, or both.
• Overlapping genetic factors may make a person vulnerable to both an addiction and other mental disorders once one of these appears.

Mental illness and substance abuse are both long-term health issues. Choosing the right treatment approach is important and, in villages with limited resources, creativity and flexibility are essential.

Anyone seeking help for either a substance disorder or a mental illness should be assessed for both. When coordinating treatment for a client who may experience these overlapping issues, refer the client to a master's-level clinician who can conduct an integrated assessment covering both substance use and mental health.

Finding support outside of therapy will be very helpful in the long-term health of the client. Support can be found in many different places, such as family, friends, church, and support groups such as Alcoholics Anonymous or NAMI.

Some clients who experience mental illness are also homeless (i.e., do not have a permanent place to live).

• Severe mental illness can interfere with people's ability to carry out day-to-day activities, such as those required to keep a job. This can then impact their ability to get and keep secure housing.
• Symptoms of paranoia, depression, anxiety, schizophrenia, and/or bipolar disorders often push away clients' caregivers, family, and friends who could have helped them to avoid becoming homeless.
• People who are homeless are more likely to experience violence that may lead them to develop a mental health disorder.

Substance abuse also often co-occurs with homelessness.

• Clients with mental illness who are homeless are more vulnerable to the use of substances.
• Clients who are homeless can have a difficult time keeping up with medication prescribed for the mental illness and may resort to street drugs to self-medicate the symptoms.
• Homelessness may affect both physical and mental wellbeing, leading the person to look to substances.

Homelessness may be caused by or related to mental illness and/or substance use. The combination of these overlapping issues can make it more difficult for people to connect with the necessary services and resources. Homelessness often presents additional issues related to clients' physical health that can include respiratory problems, joint pain, muscle problems, back problems, and/or stomach problems. People who experience homelessness often die at a younger age.

Developmental disabilities are not mental illnesses. However, because developmental disorders and mental illnesses both affect thought processes and behaviors, many people lump these different types of conditions together. Understanding key differences in the thought processes and behaviors of these conditions will help you to serve those who experience these overlapping issues:

• Developmental disorders are present from an early age, while mental illness can begin at any age.
• Developmental disorders are a lifelong disability, while mental illnesses may be chronic, temporary, or episodic.
• Developmental disabilities may affect progress in school or work, daily routines, family situations, friendships, and social gatherings. Many mental health disorders can impair or affect learning, but mental illnesses and their effects can often get better with medication and therapy.
• A developmental disorder may be an obstacle to learning or understanding a situation; in contrast, a person with depression may lose motivation to engage in situations but will not lose the cognitive ability to understand those situations.
• People with an intellectual disability have a limited mental capacity and difficulty with adaptive behaviors such as managing money, following and changing schedules, and managing routines or social interactions. A person with severe depression or a psychotic disorder may have problems with the same adaptive behaviors but for different reasons.
• People with developmental disabilities are often seen as fundamentally different by their friends and family instead of as people with similar emotional needs, and true signs of distress may be dismissed as part of their disability instead of as signs that they need help.
• Intellectual disability can be caused by genetic factors, environmental factors such as infections, or a lack of oxygen supply to the brain during pregnancy or at birth. Mental health disorders can have a different genetic basis than a developmental disability.
• People with developmental disabilities may have permanent impairment in cognition, language, motor skills, emotional and mental flexibility, and/or social skills. People who do not know them may mistake their impairments, such as slurred speech, as being caused by substance use. At the same time, symptoms that are actually caused by substance use can be mistakenly attributed to the disability.
• When a person with a developmental disability has problems resulting from substance use, the substance use may not be initially suspected as the source of the problem.

As a BHA/P, you may work with clients who suffer from multiple conditions and difficult circumstances, including combinations of developmental disorders and mental illnesses. Treatment planning for a person with a developmental disorder who also has a substance abuse problem or mental illness can be challenging. Be sure to consult with your supervisor and other members of their treatment team to create and follow a treatment plan that is unique to your client.