Psychological distress, alcohol abuse, and substance abuse have no professional boundaries. Like other professionals, lawyers face the stress of demanding jobs, the need for perfection, and expectation of success. But let’s face it, at least for trial lawyers, when the dust settles in the courtroom, someone walks away a loser. Demands, expectations, and stress make lawyers susceptible to poor coping mechanisms. Because lawyers have important roles as advocates for private and public interests, often serving as influential advisors or public officials, society has a vested interest in the quality of their performance. Alcohol or drug abuse and mental health problems, such as depression, adversely affect how lawyers do their job. Studies of the mental health of lawyers, although limited in number, indicate that lawyers have higher rates of alcohol abuse, depression, and suicide than the general population.

 

Extent of the problem

Heightened concern for the mental well-being of lawyers appears in studies of the 1990s. Researchers at Johns Hopkins University examined the prevalence of major depressive disorder among members of 104 occupations. While only about three to five percent of the general population suffers from major depression, five professions, including law, had a prevalence that exceeded ten percent. After adjusting for socio-demographic factors that affect depression, lawyers topped the list, evidencing a rate of depression three to four times that of non-lawyers with similar socio-demographic status. In a survey by Benjamin, Darling, and Sales (1990) in Washington State, 19 percent of lawyers showed depressive symptoms considered high enough to require treatment, far exceeding the three to nine percent norm for the general population. Lawyers who reported significant symptoms also reported suicidal thoughts and social isolation, factors known to increase the likelihood of suicide. Some 18 percent of lawyers in this study indicated alcohol abuse, almost double the approximate ten percent of the general U.S. population. As lawyers age, the problem gets worse, with 25 percent of the lawyers in practice 20 or more years being problem drinkers. In a 1991 study, 37 percent of North Carolina lawyers reported feelings of depression, and 24 percent reported suffering depressive symptoms at least three times a month during the previous year. Also of note, 11 percent of the lawyers had thoughts of taking their own lives during the previous year. Studies by Beck (1995–1996) noted that a large percentage of practicing lawyers experienced not only depressive symptoms but also a variety of other psychological distress symptoms beyond that of the general population. Beck believes that these problems stem from personality traits that are indigenous to successful lawyers (obsessive-compulsiveness, sensitivity in interpersonal relationships, and anxiety).

 

Three steps in dealing with distress

There are three steps in dealing with any distress: (1) recognition, (2) willingness to change, and (3) accessing resources for change.

 

Some general rules in recognizing the problem

Although depressive episodes predictably follow major losses, such as a divorce, death of a spouse, sibling, or losing a job, individuals slide into depression with a slow onset in other cases where recognition becomes more difficult, signaled only by changes in mood, productivity, and sensitivity. When a person is edgier than usual, less flexible or more rigid in mind set, or when work productivity slumps, we should ask if those changes are due to depression or drug use. One way to start is to ask, “what’s going on?” But be ready to suggest helpful resources if you suspect depression or drug use. Also, expect denial but don’t let that denial interfere with your pursuit of help.

Everyone experiences occasional brief periods of feeling sad, “down” or “blue.” Depression is distinguished from these brief periods by its persistence (two weeks or longer for major depression, for example), and by its profound effects on emotion, thoughts, and physical well being. Symptoms of depression include a low mood or an inability to find pleasure and enjoyment in activities (sometimes called anhedonia) and changes in appetite or sleep. Sleep problems manifest as difficulty falling asleep (insomnia), disturbed sleep, or staying asleep (early morning awakening), or conversely as excessive sleeping, difficulty waking up and becoming active. Other symptoms include a slowing in physical activity or thinking. Changes in thinking can include indecisiveness and decreased concentration and memory. Depressed individuals frequently report that it takes them longer than usual to do the same work as before they were depressed, or that they cannot seem to accomplish anything. Some individuals experience feelings of worthlessness and inappropriate or excessive guilt. Thoughts of death or suicide may escalate to a suicide plan or attempt. Depressed persons may show some of these symptoms.

 

Willingness to change

Willingness to change is perhaps the most difficult step in dealing with problems of mental health. When confronted with denial one must illustrate the reasons one thinks there is a problem. One should try to be non-accusatory but supportive (easy to write about but hard to practice). Being supportive also reduces the stigma from the inquiry, so that the need for help may be more easily recognized by the individual. Without a motive to change, most treatment simply does not work in the long run. Sometimes it takes a long time for persons to reach the point where they want their lives to be different. Stick with it, however, and you will eventually make your point.

 

Making treatment available

Once a lawyer recognizes depression, help him or her take action. Left untreated depression persists, causing significant and protracted suffering, leading to relationship and employment dysfunction, and in suicide for about 15 percent of affected persons. There is no good reason to avoid treatment because depression is a highly treatable illness with one large American study reporting a success rate of about 66 percent. For mild depression, both drug therapy and psychotherapy are generally effective. For moderate to severe depression, the most effective treatment appears to be a combination of psychotherapy and medication.

 

Psychopharmacology

Anti-depressant medications restore normal neurotransmitter function among brain cells and typically provide relief within about two weeks of starting treatment, with four to eight weeks of treatment before maximal benefits accrue. Understanding this time lag in response to medications is important. A patient who expects quick changes in mood and behavior may prematurely terminate treatment, erroneously concluding that the treatment is ineffective. Also, there are different classes of anti-depressant medications that sometimes necessitate a change in medications should the patient not respond initially or who encounters undesired side effects. In the medical field this is known as “going up, down, or sideways” with medications to find the right level and combinations of drugs for optimal efficacy. In difficult cases, a combination of anti-depressants or even a combination with another medication designed to augment the effects of the anti-depressant can be effective. The important message here is that the patient needs to communicate with the prescribing physician so that an effective pharmacology can be found.

 

Psychotherapy for depression

Psychotherapy can help the individual understand the factors that contributed to the onset and persistence of the depression, assist the patient in changes in life circumstances that help alleviate the depression, or change the way the depressed individual thinks about stressful circumstances, thereby reducing the likelihood of future episodes. Common types of psychotherapy used to treat depression include interpersonal therapy and cognitive-behavior therapy. Both approaches focus on current difficulties and are generally time-limited. With interpersonal therapy, the focus is on resolving interpersonal conflicts and improving the quality of the patient’s relationships, since interpersonal difficulties are frequently a major component of some depression. Cognitive-behavior therapy focuses on patterns of distorted thinking that contribute to viewing experiences in ways that generate negative emotions, affect behavior, and interfere with recovery efforts.

 

Finding help for depression

To find a qualified medical or mental health professional one may start with a family physician, internist, and many obstetrician-gynecologists for a first line of treatment. However, those practitioners may not be as experienced in providing care for complicated and treatment-resistant cases, nor will they be as familiar as psychiatrists are with non-drug based treatments. Consequently, many patients prefer to seek initial treatment from mental heath professionals, such as psychologists or social workers who are accustomed to working with physicians. Local lawyer assistance programs help identify mental health professionals in the community who have expertise in treating depression. For those living in the Houston area, the Houston Psychological Association can provide referrals, as can the Houston Psychiatric Society. The Texas Lawyers Assistance Program (TLAP) is a confidential crisis referral program for attorneys challenged by substance abuse and other mental health problems.

 

Seeking Treatment for Alcohol and other Substance Abuse

Alcohol abuse or dependency, like other diseases, has certain symptoms, is a progressive disease that, if untreated, passes through progressively worsening stages and can lead to death. Alcohol abuse, like many other psychiatric illnesses, has both genetic and environmental components. When a person’s use of alcohol or other mood-altering substances causes or exacerbates problems in a person’s life and the use continues, use becomes abuse. Some persons seek treatment at this stage and are able to reduce their use so that they do not escalate to dependency. Others eventually develop an overwhelming compulsion to use. Alcohol or drug dependency is diagnosed once the individual develops a physical dependency and a tolerance for the drug, i.e., it takes larger amounts of the substance to create the same effect.

Professional assessment is warranted when an individual uses alcohol or other drug to cope with stress and problematic emotions. At work, missed appointments, failure to return phone calls, missed deadlines or court dates, arriving late on Monday mornings, becoming preoccupied about when there will be an opportunity to drink, are all signs of a potential substance abuse disorder. Despite these signals, affected persons will minimize their dependency and tend to deny the significance of the problem. Once a person shows signs of a substance abuse or dependency, the person should receive a professional assessment, followed by appropriate treatment.

While alcoholism and chemical dependency are permanent and chronic illnesses, they are treatable. When a physical dependency has developed to a drug, medically supervised detoxification is needed to protect the person. Following detoxification, there are different types of treatment available, ranging from long-term inpatient treatment (often 4 to 12 weeks), intensive outpatient programs, and participation in Alcoholics Anonymous or similar groups, such as Narcotics or Cocaine Anonymous. Many locales have peer groups with other attorneys and professionals who can help share their experiences with abuse and who can provide support at critical times. Treatment includes education about the chronic and progressive nature of the illness, the need to abstain, and help the individual to develop more effective strategies for coping with situations that formerly trigger the use of mind-altering substances.

 

Final thoughts

Being a lawyer is stressful; excessively long hours, advocating in adversarial situations where outcomes can have substantial consequences, and where there are high performance expectations. Such stressful work takes its toll on individuals who tend to be conscientious, perfectionist, and success oriented, leaving them open to stress related illness, including mental health problems such as depression and substance abuse. However, there is available and effective help. We should offer ourselves and our colleagues the same degree of care that we offer our clients. Taking care of ourselves is one of the most important jobs we have and is one of the greatest gifts we can give to our families and our colleagues.

Camille Lloyd, Ph.D., is a clinical psychologist working in the Professionals in Crisis Program at the Menninger Clinic. She can be contacted at the clinic’s main number, 713-275-5000.

Ray Hays, Ph.D., is a clinical psychologist at Ben Taub General Hospital, an attorney, and a professor at the Baylor College of Medicine. He may be contacted at Ben Taub, 713-873-5133.