SC Lawyer, January 2012, #2. The Lawyers' Epidemic: Depression, Suicide and Substance Abuse.

• Author: By C. Stuart Mauney

South Carolina BAR Journal

2012.

SC Lawyer, January 2012, #2.

The Lawyers' Epidemic: Depression, Suicide and Substance Abuse

South Carolina LawyerJanuary 2012The Lawyers' Epidemic: Depression, Suicide and Substance AbuseBy C. Stuart Mauney In a recent period of 18 months, six lawyers died by suicide in South Carolina. Within the last year, three South Carolina lawyers died by suicide within seven months. A student at the Charleston School of Law recently committed suicide. Around that same time, a student at the USC School of Law died of alcohol poisoning.

The South Carolina Bar formed the Health and Education for Legal Professionals (HELP) Task Force in November 2008 to shine a bright light on these problems. The HELP mission was to raise awareness and promote prevention of substance abuse, mental illness and suicide within the legal profession. The HELP mission was designed to complement the two confidential services already in place for its members.

Lawyers Helping Lawyers (LHL) assists lawyers who suffer from substance abuse and mental illness. LHL can also help members who have family members or staff with such issues. Robert Turnbull and Beth Padgett are Bar staff members who lead LHL. They can be reached toll free at (866) 545-9590. Members of the Lawyers Helping Lawyers Committee comprise a support network of recovering judges and lawyers who assist in carrying the recovery message. LHL provides referral services, peer support, monitoring services and education.

LifeFocus Counseling Services provides up to five free hours of intervention counseling for lawyers experiencing emotional or stress-related issues. The toll-free number is (866) 726-5252 for a referral to a counselor near the caller.

HELP complemented the work of LHL by educating lawyers, law firms, law students and judges about the services available through LHL. HELP also promoted a better understanding of mental health issues in the legal profession. HELP set as a goal saving lives and restoring integrity to our profession by bringing an end to the epidemic of depression, suicide and substance abuse among lawyers.

Prevalence of depression

Statistics abound about the prevalence of depression found in the legal profession. Some studies estimate that of the one million lawyers in this country, approximately 250,000 suffer from some form of depression. Daniel Lukasik, Depression is the Law's Occupational Hazard, The Complete Lawyer (Mar. 3, 2008). A quality of life survey by the North Carolina Bar Association in 1991 revealed that almost 26 percent of respondents exhibited symptoms of clinical depression and almost 12 percent said they contemplated suicide at least once a month. Michael J. Sweeney, The Devastation of Depression (research conducted by Campbell University).

As to law students, according to studies conducted by Dr. Andrew Benjamin, et. al., in the 1980s and 1990s, depression among law students approximated that of the general population before law school (about 9-10 percent). However, it rose to 32 percent by the end of the first year of law school, and rocketed to an amazing 40 percent by the third year, never to return to pre-law school levels. Susan Daicoff, Depression is Prevalent Among Lawyers-But Not Inevitable, The Complete Lawyer (Dec. 2, 2008).

Symptoms of depression

Clinical depression is more extreme and more prolonged than the blues or the ups and downs experienced by all. The lows are lower, and the periods spent in these emotional depths are longer. Depression in its most severe forms can render people unable to carry out the day-to-day necessities of life and can lead to suicide. Greg Miller, The Depressed Lawyer, 70 Texas Bar Journal 218 (Mar. 2007).

At least several of the following symptoms must be present during the same two-week period in order to meet the diagnostic criteria for a major depressive episode:

* Depressed mood

* Loss of interest or pleasure * Change in appetite or weight * Change in sleeping patterns * Fatigue or loss of energy * Speaking and/or moving with unusual speed or slowness * Feelings of worthlessness or excessive or inappropriate guilt * Diminished ability to think or concentrate, or indecisiveness * Recurrent thoughts of death or suicide * Suicide attempts The Diagnostic and Statistical Manual of Mental Disorders (Am. Psychiatric Ass'n 4th ed.) (1994).

Causes of depression include functional abnormalities or chemical imbalances in the brain, heredity, biological factors and environmental influences (job, marriage, family, economic and social influences). Medical research outlines the biological and physiological factors involved in mental disorders, including depression.

Effective treatment for depression is available for 90 percent of those with a depressive illness. The most important component of a treatment protocol is information, with accurate, current facts on causes, symptoms, treatment options and tips for coping.

The most important-and sometimes most difficult-step toward overcoming depression is asking for help. Although effective help is out there, attorneys often have a hard time availing themselves of it. Trained to be impersonal and objective, lawyers are often reluctant to focus on their own feelings. Attorneys tend to be more comfortable in the role of counselor, solving the problems of others, than being the person seeking help. Miller, supra at220.

Suicide

In 2006, suicide was the third leading cause of death among attorneys, after cancer and heart disease. The rate of death by suicide for lawyers is nearly six times the suicide rate for the general population. Fifteen percent of people with clinical depression commit suicide.

Suicide can be prevented. While some suicides occur without any outward warning, most do not. We can prevent suicide among lawyers by learning to recognize the signs of someone at risk, taking those signs seriously and knowing how to respond to them.

Warning signs of suicide include observable signs of serious depression: unrelenting low mood, pessimism, hopelessness, desperation, anxiety, withdrawal and sleep problems. Other suicide warnings are increased alcohol and/or other drug use, recent impulsiveness and taking unnecessary risks, threatening suicide or expressing a strong wish to die, making a plan (e.g., giving away prized possessions or impulsive purchase of a firearm) and unexpected rage or anger.

An article on prevention appeared in the November 2007 issue of South Carolina Lawyer. Written by David Woolridge originally for The Alabama Lawyer, it is available on the Bar's website and through Casemaker. In part, it suggests that you use QPR-Question (the person about suicide), Persuade (the person to get help) and Refer (the person for help).

We need to take warnings seriously. Seventy-five percent of all persons who commit suicide give some warning of their intentions to a friend or family member. Be willing to listen. Take the initiative to ask what is troubling them and persist to overcome any reluctance to talk about it. If professional help is indicated, the person cared about is more apt to follow such a recommendation if he has been listened to.

If the person is depressed, do not be afraid to ask whether he is considering suicide, or even if he has a particular plan or method in mind. Do not attempt to argue anyone out of suicide. Rather, let the person know that you care and understand, he is not alone, suicidal feelings are temporary, depression can be treated and problems can be solved. Avoid the temptation to say, "You have so much to live for" or "Your suicide will hurt your family."

Seek professional help. Be actively involved in encouraging the person to see a physician or mental health professional immediately. Individuals contemplating suicide often do not believe they can be helped, so you may have to do more.

In an acute crisis, take the person to an emergency room or walk-in clinic at a psychiatric hospital. Do not leave him alone until help is available. Remove from the vicinity any firearms, drugs or sharp objects that could be used in a suicide attempt. You may need to call your local emergency number or the national suicide prevention lifeline at 1-800-232-TALK.

Substance abuse

The National Institute on Alcohol Abuse and Alcoholism estimates that 10 percent of the U.S. population is alcoholic or chemically dependent. In the legal profession, the abuse may be as high as 20 percent. Alcoholism is a factor in 30 percent of all completed suicides.

Most substance abusers are functional in the workplace. Nearly three out of four are employed, though the risks for the employer are high. The defenses of denial, rationalization and justification often make it difficult for people abusing substances to recognize they have a problem.

The CAGE Questionnaire was developed in 1970 by Dr. John A. Ewing and is used for screening of patients for alcoholism. According to Dr. Ewing, two or more "yes" answers indicate a positive history of alcoholism.

Cut Back? Have you ever felt the need to reduce the level of your consumption?

Annoyed? Have people ever annoyed you with their criticism of your drinking or using habits?

Guilty? Have you ever felt guilty while you were drinking or using?

Eye-opener? Have you ever started the day with a drink or drug, either to wake yourself up, to relax or to cure a hangover?

Signs of substance abuse are sometimes subtle and can be mistaken for other problems, such as depression. Some of the observable signs are smell of alcohol, bloodshot eyes or a puffy face, slurred or rapid speech, hyper-vigilance or suspiciousness, failure to return from lunch or break, pattern of being late or a no-show on Mondays, leaving early from work, failure to return phone calls, missing appointments, failure to meet deadlines, change in mood or general demeanor, and deterioration of personal appearance or hygiene.

How to help

You may want to explain to your friend that you know that alcoholism is an illness. Treatment works, so urge the person to get an assessment, go to treatment or even head straight for the nearest AA meeting.

There are those who call for help on their own, go to AA, go to outpatient or inpatient treatment, and stop drinking or drugging. But, the truth is that most active alcoholics and drug addicts are not ready and willing to quit simply because someone suggests it. Lawyers may be particularly resistant to admitting a drinking or drug problem.

Education about the illness is available through Lawyers Helping Lawyers or another source. Get assistance and coaching from the experts. Someone who has recovered from the same illness may be an ally when one has these conversations; that person has instant credibility.

Leverage a bad day. Timing is sometimes important. Approaching someone who is struggling with the negative consequences of his addiction or dependency on a bad day may be more receptive to suggestions than during the "good" times.

Do not try to talk to someone when he is impaired. It does not work.

Do not label the individual with a diagnosis. Expressions of concern, offers of hope and specific ideas for a solution are helpful. Speaking honestly about how the individual's drinking or drug use has affected you, giving specific examples, is recommended. Labeling someone an addict or an alcoholic will backfire.

Be armed with solutions. Offer ideas about how to get help. Have phone numbers available and offer to get the individual to help immediately. If the person seems even remotely receptive, act quickly; the small opening in the hard shell of addiction will not stay open long. One may not get another chance.

Do not enable. Never do for John what John can do for himself. Stop protecting him from consequences. Be honest. Do not cover up, lie, stand in or do his work. Do not ignore the problem. Do not be a scapegoat. Do not try to control her drinking or his drug use. Respect his dignity. Be realistic about events. Allow success or failure. Share your hope for recovery.

Closer to home

Why are lawyers more prone than anyone else to the dangerous disease of depression? Psychologist Lynn Johnson points to two personality traits many lawyers have: perfectionism and pessimism. Lynn Johnson, Stress Management, Utah State Bar J., (Jan./Feb. 2003).

Research suggests that those who suffer from intense perfectionism are at higher risk for suicide. They are driven by an intense need to avoid failure. To these people, nothing seems quite good enough, and they are unable to derive satisfaction from what ordinarily might be considered even superior performance. Dr. Sidney J. Blatt, The Destructiveness of Perfectionism: Implications for the Treatment of Depression, 49 American Psychologist (1997).

It is no secret that the legal profession attracts perfectionists and rewards perfectionism. Perfectionism drives us to excel in college, in law school and on the job. Perfectionism has a dark side; it can produce "a chronic feeling that nothing is good enough." Johnson, supra.

According to Johnson, perfectionism raises levels of stress hormones, and high levels of such hormones lead to various health problems, including depression. And when we make the inevitable mistake, perfectionism magnifies the failure. "Perfectionists are more vulnerable to depression and anxiety, harder to treat with either therapy or drugs, and much more likely to commit suicide when things go very wrong." Id.

Less intuitive than the prevalence of perfectionism is the prevalence of pessimism among lawyers. A Johns Hopkins study in 1990 showed that in all graduate school programs in all professional fields except one, optimists outperformed pessimists. The one exception: law school.

Pessimism helps lawyers excel; it makes us skeptical of what our clients, our witnesses, opposing counsel and judges tell us. It helps us anticipate the worst and thus prepare for it. The pessimism is bad for our health; it leads to stress and disillusionment, which makes us vulnerable to depression. Raymond P. Ward, Depression, The Lawyers' Epidemic: How You Can Recognize the Signs, The Legal Underground (Mar. 16, 2005).

Milestones

HELP accomplished much of what it sought to do and completed its work in 2011. Its mission will be carried on by LHL.

HELP secured additional personnel to assist Robert Turnbull in the person of Beth Padgett. Together, they have begun a monthly presence in both South Carolina law schools.

HELP secured through the House of Delegates and Supreme Court a requirement every three years that lawyers subject to mandatory continuing legal education requirements complete an hour of instruction in substance abuse and mental health issues. The clock began running on the first three-year period on March 1, 2011.

HELP proposed, and the House of Delegates adopted as Bar policy, a commitment to bring an end to the epidemic. That resolution is found on page 607 in the 2011-12 Lawyers Desk Book.

HELP published articles and presented numerous seminars in an effort to fulfill its mission of raising awareness and promoting prevention of substance abuse, mental illness and suicide within the legal profession.

Whether you are the husband, wife, employee, judge, law student, law firm partner or associate, or friend of a person challenged by substance abuse or mental illness, your understanding of the nature of the problem can play a vital role in helping that individual to achieve and maintain recovery. Please remember that there is hope, and there is help. You are not alone.

SIDEBAR

It's Not "Meddling"

When Jim was 55 years old, he had a major heart attack and had to have open heart surgery. He had seven bypasses, the most the hospital had ever performed at one time. He was on the heart-lung machine for eight or nine hours. Jim took a leave of absence from his law firm for approximately eight months to recuperate from this surgery.

After the heart surgery, the doctor told Jim to cut back on his drinking, to exercise and to take his medication regularly. Jim didn't really alter his lifestyle habits. He was used to representing corporations in foreign countries. He was frequently out of the country generating business opportunities for the firm, with much emphasis on eating and drinking on these trips as part of the entertainment. He did exercise at first at the hospital, then at the YMCA, but then hardly at all. He was still in the Marine Reserves and said he would do their exercise requirements and no more. He was very haphazard in taking his medication. When challenged about his non-compliance with his medical advice, he would say he would rather live a shorter length of time on his own terms than live a longer life.

When Jim was 56 years old-a year after his bypass surgery-he became very depressed and began seeing a counselor. He then went to a psychiatrist and was prescribed anti-depressant medication, but it seemed that he got even more depressed. Jim then changed psychiatrists. About this same time, Jim began acting out in different ways at home, although his law partners never mentioned any unusual behavior at work.

When Jim was approximately 59, he switched to a third psychiatrist and by this time, his behavior had gotten really wild. For his 60th birthday, he threw himself a party and invited everyone he knew and had on display a lifetime of pictures of himself. It was as though his depression had flipped into bipolar disorder, complete with the wide range of behaviors. Although he was eventually diagnosed as such, I did not learn of the diagnosis until the last year of his life.

Shortly after turning 60, Jim left his law firm, though he never expressed a reason for the move. He maintained an office with a secretary and a paralegal, doing primarily estate planning. He lasted about a year or so there before he moved his office again. He continued to act very peculiarly; the mania was increasing. Jim was doing such things as talking on the phone excessively in the middle of the night, and he again moved his office-this time to our home.

During the manic periods, Jim's driving was terrible. He finally agreed he needed to hire a driver because his driving was really unsafe. He changed cars a lot during this time. He had a Mercedes, a sports car and a boat.

Because Jim's behavior was really wearing on me, Jim and I agreed that he should leave the house. Jim packed his belongings, including all his office equipment, and was gone in 15 minutes. He moved into a house where he lived and worked.

For six months in 2000, Jim was basically gone from our house. During this time he was traveling all over the country, going to Europe, giving money to both the Democratic and Republican parties-he even went to both their conventions that year, hedging his bets he said. He wanted to fund the movie industry that was opening in Charleston. He wanted to invest in buying an island and other real estate. He went through a substantial percentage of our assets during this time.

In the summer of 2000, Jim visited each of our two grown daughters for one week by himself. At one of their homes, he stayed in bed in a fetal position most of the time. Looking back, I think Jim knew he was making his last visits with his children.

In September of 2000, our younger daughter was married. Jim decided he needed to lose weight for the wedding, which he did, and he behaved himself beautifully at the wedding. He was a proud father of the bride, and I was thankful that he was able to enjoy this occasion.

After the wedding, Jim entered into a very deep depression-sleeping late in the mornings and constantly saying he just didn't know what to do. He tried to close his law office and really wasn't able to work. He kept his suitcase packed at all times.

On December 11, 2000, Jim successfully completed closing my father's estate, which had been a difficult process. As we walked out of the courthouse, I told him he could relax now that he had that ordeal behind him.

The next day, December 12, 2000, I accompanied Jim to his appointment with his psychiatrist. I remember thinking when we went into the appointment how well Jim looked, but I told the psychiatrist that I thought Jim needed to be hospitalized. The psychiatrist pointed his finger at Jim and said, "This man does not need to be hospitalized." He asked Jim if he were willing to go to the hospital, and Jim said he was. However, the psychiatrist did not admit Jim. Later on that same day, one of Jim's employees called to tell me that Jim had killed himself.

Jim left a number of notes: two to me, one to each daughter, one to his law partner, one to his CPA and one to his secretary. He said in effect that he couldn't go on, that he was pulling everybody down, and that everybody would be better off without him.

As the widow of an attorney who made a difference in the lives of a large number of clients, I choose to tell Jim's story in hopes that the legal profession will be more mindful of colleagues who need help. The practice of law, by nature, is a very adversarial and stressful profession. Practitioners work long hours and see each other under very stressful conditions. It is reasonable to assume that colleagues might be the first to notice that a co-worker is in need of help. But the fear of being wrong frequently prevents attorneys from reaching out. This fear should be secondary when a life is at stake. It is not "meddling" if an intervention saves a life-a valuable life.