14 May Mental Health Awareness: Ten Tips for Lawyers’ Well-Being
Defining the Issues
While there are a large number of hardships faced by attorneys practicing law, the following are some of the most common and most serious:
A. Anxiety Disorders.
Disorders relating to anxiety range from a general Panic Attack (which is Panic Disorder with or without Agoraphobia[i]) to specific phobias such as Social Anxiety Disorder (SAD), Obsessive-Compulsive Disorder (OCD), Posttraumatic Stress Disorder (PTSD), Acute Stress Disorder (ASD), Generalized Anxiety Disorder (GAD), Substance-Induced Anxiety Disorder, anxiety due to a medical condition, and anxiety disorder not otherwise specified.
Generalized Anxiety Disorder is prevalent in the legal community, although most lawyers would argue that its symptoms sound like what one experiences every day when practicing law:
- Excessive anxiety and worry (apprehensive expectation) which occurs more days than not for at least six months about a number of events or activities (such as work or school performance);
- The person finds it difficult to control the worry;
- The anxiety and worry are associated with three (or more) of the following six symptoms present for more days than not for the past 6 months:
- restlessness or feeling keyed up or on edge;
- being easily fatigued;
- difficulty concentration or mind going blank;
- muscle tension;
- sleep disturbance (difficulty falling or staying asleep or restless unsatisfying sleep);
- The focus of anxiety or worry is not about another disorder (panic, social phobia, OCD, PTSD, etc);
- The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupation or other important areas of functioning; and
- The disturbance is not due to the direct physiological effects of a substance (drug of abuse, medication, etc.) or a general medical condition and does not exclusively occur during a mood disorder or psychotic disorder.[ii]
B. Substance Use Disorders and Process Addictions.
Approximately 20% of the lawyers in the United States are affected by substance use disorders compared with about 10% of the general public.[i] The substances used to excess include: alcohol, amphetamines, methamphetamine, caffeine, club drugs, cocaine, crack cocaine, hallucinogens, heroin, marijuana, myriad prescription drugs, nicotine, sedatives, steroids and a combination of all of the above (polysubstance abuse/dependency).
Substance use disorders span a wide variety of problems arising from substance use. The following are the 11 different criteria for diagnosing a substance use disorder under the recently established DSM-5[ii]:
- Taking the substance in larger amounts or for longer than meant to;
- Wanting to cut down or stop using the substance but not managing to;
- Spending a lot of time getting, using, or recovering from use of the substance;
- Cravings and urges to use the substance;
- Not managing to do what should be done at work, home or school, because of substance use
- Continuing to use, even when it causes problems in relationships;
- Giving up important social, occupational or recreational activities because of substance use;
- Using substances again and again, even when it puts one in danger;
- Continuing to use, even when known that there is a physical or psychological problem that could have been caused or made worse by the substance;
- Needing more of the substance to get the effect wanted (tolerance); and/or
- Development of withdrawal symptoms, which can be relieved by taking more of the substance.
C. Depressive Disorders.
Lawyers often present with symptoms of depressive disorders, including Major Depression, Persistent Depressive Disorder (formerly referred to as Dysthymic Depression), Compassion Fatigue, and Depression Not Otherwise Specified.
1. Major Depressive Disorder: A major depressive episode is a period characterized by the symptoms of major depressive disorder when five or more of the following are present during the same two-week period:
a. depressed mood most of the day, nearly every day, as indicated by subjective report or observation made by others;
b. markedly diminished interest or pleasure in all or most activities most of the day, nearly every day;
c. significant weight gain or loss (when not dieting) or decrease or increase in appetite nearly every day;
d. insomnia or hypersomnia nearly every day;
e. psychomotor agitation or retardation nearly every day;
f. fatigue or loss of energy nearly every day;
g. feelings of worthlessness or excessive or inappropriate guilt nearly every day;
h. diminished ability to think or concentrate, or indecisiveness, nearly every day; and/or
i. recurrent thoughts of death, recurrent suicidal ideation without a plan, suicide attempt or a specific plan for completing suicide.[i]
2. Persistent Depressive Disorder: This is a disorder involving a depressed mood that occurs for most of the day, for more days than not, for at least 2 years with the presence of at least two of the following six symptoms:
a. poor appetite or overeating;
b. insomnia or hypersomnia;
c. low energy or fatigue;
d. low self-esteem;
e. poor concentration or difficulty making decision; and/or
f. feelings of hopelessness.
Additionally, for Persistent Depressive Disorder to be diagnosed, the person must not have been without the symptoms above for more than two months at a time during the 2-year period of the disturbance and must not have experienced a major depressive episode, manic episode, or hypomanic episode in that time. Finally, the disturbance must not occur exclusively during the course of a chronic psychotic disorder, must not be due to substance use or another medical condition, and must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.[ii]
3. Compassion Fatigue and Burnout. Compassion fatigue has been defined as “a combination of physical, emotional, and spiritual depletion associated with caring for persons in significant emotional pain and physical distress.”[iii] Its components are the presence of Secondary Traumatic Stress (STS) in combination with a condition commonly referred to by lawyers as “Burnout”:
a. Secondary Traumatic Stress. Secondary Traumatic Stress is the presence of traumatic symptoms caused by indirect exposure to the traumatic material. The following are characteristics of this kind of trauma: (1) Symptoms are similar to Post Traumatic Stress Disorder except the information about the trauma is acquired indirectly from communicating with the person who personally experienced the traumatic event. (2) The traumatic event is persistently re-experienced in one or more of the following ways: recurrent and intrusive distressing recollections, dreams, acting or feeling as if the event is reoccurring. (3) Persistent avoidance of the stimuli associated with the trauma (the client, the case, the deposition, specific facts, etc.) and numbing of general responsiveness develops. (4) Persistent symptoms of increased arousal such as difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hyper vigilance, or exaggerated startle response.
b. Burnout. Burnout is the term used by many lawyers to describe the psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment. Burnout symptoms include: increased negative arousal, dread, difficulty separating personal and professional life, inability to say “no,” increased frustration, irritability, depersonalization of clients and situations, diminished enjoyment of work, diminished desire or capacity for intimacy with family and friends, diminished capacity to listen and communicate, subtle manipulation of clients to avoid them or painful material, diminished effectiveness, loss of confidence, increased desire to escape or flee, isolation.
If you are concerned about suffering from Compassion Fatigue, you may be interested in taking the self-assessment test at http://www.compassionfatigue.org/pages/cfassessment.html.
A recent study by the Air Force (2010) found that suicide prevention training included in all military training reduced the mean suicide rate within the population studied by an unprecedented 21%.[iv] In light of this recognition of the major impact training and education can have on suicide, it is appropriate that LAPs have made it a priority to inform lawyers about this issue. If you want to know how to carry on a conversation about suicide, how and when to get a client, friend or colleague to professional help, or how to handle a suicide emergency, explore the resources on TLAP’s website at tlaphelps.org. [v]
Ten Helpful Tips for Lawyers Dealing with Stress, Mental Health, or Substance Use Issues
When dealing with the spectrum of problems faced by attorneys, there is no single solution which will take care of everything, but many tools are useful for both mental health and substance abuse issues. The following are ten practical tools which any affected attorney should consider using for prevention or to help solve a problem:
1. Take Action! Whether a lawyer is living in the darkness of depression or lost in a routine of substance abuse, there is a solution but it depends on action. Taking action requires courage. By expressing the need for help to someone, the process to peace begins. With the expansion of telehealth, professionals are more readily available for any lawyer to confidentially share a desire to change the way he or she is living and to assist the person in getting the help needed. Once an attorney is able to take even the smallest action toward solving their problem, life gets better quickly.
a. Get Professional Help. Lawyers are slow to utilize professional assistance, perhaps due to fear of what people might think, how it might affect their practice, or being ashamed of not being able to figure it out alone. Of all people, lawyers know that using a professional who specializes in solving a particular problem is wise. If what you are doing is not working and you would like to confidentially get professional help but do not already know a suited professional, a LAP can help guide you to licensed professionals who are a good fit for you and who are experienced in working with lawyers.
b. Take The Steps Which Are Suggested. Having discovered and accepted the fact that a problem exists, it is important to accept help from people who have experience in solving that problem. Once a plan is made, it is important to accept and follow the steps suggested for getting better. Professionals and doctors may prescribe certain actions to address your problem and which may bring about major changes in the way you function and feel. Likewise, there are many 12 Step programs[i] which provide guidance for recovery from a variety of problems and which suggest specific actions which bring about change in the way a person thinks and lives so as to overcome the “problem.”
c. Get proactive. Know that this profession can wear you out. So, get an annual physical. Take a vacation (or “stay-cation”). Develop a team of experts for yourself: peer support, primary care physician, therapist and psychiatrist. Act now, do not wait to address your burnout, sense of dread, lingering grief, daily fear, or excessive substance use intended to numb all of the above.
d. Seek Professional Help. The only way to ensure that the situation changes for you is to take action. It may be hard to figure out what action to take. If you are wondering what to do, LAP’s experienced and professional staff is available to answer your questions about substance abuse, mental health and wellness issues. Your calls will be to attorneys with resources and helpful ideas to better your life. LAP services most often include confidential support, referrals, peer assistance, customized CLE and education, mandated monitoring, and volunteer opportunities. Without proper intervention and treatment, substance abuse and mental illness are both chronic health conditions that worsen over time. Please call and find out how your LAP can help. You can find your LAP in the directory here: www.americanbar.org/groups/lawyer_assistance/.
2. Set Boundaries. Boundaries are important for a person practicing self-care. Personal or professional boundaries are the physical, emotional and mental limits, guidelines or rules that you create to help identify your responsibilities and actions in a given situation and allow you take care of yourself. They also help identify actions and behaviors that you find unacceptable. They are essential ingredients for a healthy self and a healthy law practice. In essence, they help define relationships between you and everyone else.
How does one establish healthy boundaries? Know that you have a right to personal and professional boundaries. Set clear and decisive limits and let people know what you expect and when they have crossed the line, acted inappropriately, or disrespected you. Likewise, do not be afraid to ask for what you want, what you need and what actions to take if your wishes are not respected. Recognize that other’s needs and feelings and demands are not more important than your own. Practice saying no and yes when appropriate and remain true to your personal and professional limits. Do not let others make the decisions for you. Healthy boundaries allow you to respect your strengths, your abilities and your individuality as well as those of others. [ii]
3. Connect with Others. Connecting with others who know first-hand what you are going through can help reduce the fear and hopelessness that is often connected to mental health and substance use disorders. A growing body of research shows that the need to connect socially with others is as basic as our need for food, water and shelter.[iii] Fortunately, there are support groups available for lawyers.
4. Practice Acceptance. Acceptance is a big, meaningful word which encompasses a variety of important tools for a person seeking a positive life change. First, being able to honestly accept the place where you are at present is an important step in making a change. Until a person is able to accept that the future is not here yet and that the past is gone, he or she cannot be present to focus on what is within grasp that day. Furthermore, accepting that something is wrong is a step many lawyers resist. Perfectionism and pride play a role in learning to be a good lawyer, but the effects of those can be limiting on a person who needs to get honest about a difficulty.[iv] Acceptance of the fact that you have an issue for which help is needed is a major part of solving the problem.
5. Learn to Relax. For attorneys, relaxing can seem almost impossible. The mind is an instrument, but sometimes it seems that the instrument has become the master. Breathing exercises, meditation, and mindfulness[v] practices have been very effective for attorneys who need to relax, or “quiet the mind.” Much has been written to express how impactful these tools can be to bring about peace in the life of an attorney.[vi] There are countless variations of breathing exercises and resources to learn how to build control of your thoughts and worries.[vii] TLAP’s website includes links to several of these wellness resources at www.tlaphelps.org .
Suggestion: Calendar what you want to do. Wishing and wanting to change are important ingredients for change but action is important. If there is something that you want to do, what would be the first thing to accomplish to move toward that goal? Calendar it. First things really do come first. Try it!
Finally, in order to relax, cultivate interests unrelated to the practice of law. This will provide you with opportunities to take a well-deserved break from your work, and, quite frankly, helps to make you a far more emotionally well-developed and interesting person. You will also meet a host of new friends and contacts who will help give some additional perspective about your life and your choices.
6. Practice Positive Thinking. There is a growing body of research showing the powerful positive effects of positive thinking and positive psychology.[viii] The goal of this movement is to help people change negative styles of thinking as a way to change how they feel.
Suggestion: Make a Gratitude List. One way to practice positive thinking is to focus your attention on what is right in your life. This is a proven and effective way to escape the sometimes overwhelming thoughts of all of the things that may seem to be wrong. Become conscious of your gratitude. Studies have shown that taking the time to make a list of things for which you are grateful can result in significant improvement in the way you feel and the amount of happiness you experience.[ix] Try making a list of three to five things for which you are grateful each morning for a week and see what happens.
7. Help Others. Service work sounds like just one more thing to add to the list of things you do not have time for, and it may not be easy to do during the COVID age, but this is something that helps us a lot. Consider really making time to do, even if its online. Obviously, until you secure your oxygen mask, you should not attempt to rescue others, but lawyers have been found to gain “intense satisfaction” from doing service work, [x] and studies show it helps improve mental health and happiness.[xi]
For example, a researcher named Dr. Martin Seligman highlighted this theory in an experiment called “Philanthropy versus Fun,” Seligman divided up his psychology students into two groups. The first partook in pleasurable past times such as eating delicious food and going to the movies. The second group participated in philanthropic activities, volunteering in feeding the homeless or assisting the physically handicapped. What Seligman found was that the satisfaction and happiness that resulted from volunteering was far more lasting than the fleeting reward of food or entertainment.[xii] Even if you feel that it is being done for your own selfish gain, try it anyway and before long you will experience a heightened sense of peace, joy and satisfaction in life.
Service Work Suggestions: Try to do something kind for someone at least once a week. Try something small. If you have the time, volunteer your time to help another. Do not make the activity about you – it should be about giving to others. Whatever measure you take, large or small, remember that it will not only help others, but it will also serve to build your self-esteem, help put your life in perspective, and help to develop and maintain a vital connection with the community in which you live. [xiii]
8. Live in the Present. This cliché phrase may be one of the most under-appreciated tools for the legal profession of any listed here. How can this work? Try it. Consider during your day the things which you are able to do that day. Live it “only for today.” If nothing can be done about something on your mind in the day you are in, return your focus to the things you can do that day.
9. Expand your Spirituality or Consciousness. Whatever the variety, research has shown that expanding this area of life makes a major impact of the wellbeing of people, and particularly lawyers.[xiv]
10. Keep it Real. Recovering from a mental health or substance abuse problem requires honesty. If you begin to feel like you should be better than you are, but you are embarrassed to let others down by admitting your true condition, you are doing yourself a major disservice. Commit to “keeping it real.” Be honest with someone about how you are doing so that you do not lose touch with those who can help.
One way to develop or ensure honesty with ourselves is to do an inventory. We all know that any business that fails to take inventory is bound to fail. People are no different. Assessing your life by taking an inventory or snapshot of your daily life can give you an idea of where you are and — of equal importance — where you want to go. Small corrections in allocation of time today will help prevent an out-of-balance life tomorrow.
Chris Ritter, MEd, JD
Texas Lawyers’ Assistance Program
State Bar of Texas
Direct Phone: (512) 427-1458
Direct Fax: (512) 427-4346
TLAP: (512) 427-1453 email@example.com
 This is a type of anxiety disorder in which you fear and often avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed.
 See www.depression-screening.org for self-assessment screening tests for anxiety disorders.
 See G.A.H. Darling et al., The prevalence of depression, alcohol abuse, and cocaine abuse among United States lawyers, 13 International Journal of Law and Psychiatry 233-246 (1990).
 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, abbreviated as DSM-5, is the 2013 update to the American Psychiatric Association’s (APA) classification and diagnostic tool. In the United States, the DSM serves as a universal authority for psychiatric diagnosis. See Am. Psychiatric Ass’n, Diagnostic & Statistical Manual Of Mental Disorders (5th ed. text rev. 2013) (hereinafter “DSM-5”).
 See www.depression-screening.org for a self-assessment screening test for depression.
 See DSM-5.
 Barbara Lombardo & Carol Eyre, Compassion Fatigue: A Nurse’s Primer, 16 The Online Journal of Issues in Nursing 1 (2011).
 See Eric D. Caine, Suicide Prevention Is A Winnable Battle, 100 American Journal Of Public Health S1 (2012).
 If you or anyone you know is in need, the National Suicide Prevention Hotline is available 24/7 at 1(800)273-8255(TALK).
 The following are some of the many 12 Step Programs: AA – Alcoholics Anonymous; ACA – Adult Children of Alcoholics; Al-Anon/Alateen, for friends and families of alcoholics; CA – Cocaine Anonymous; Co-Anon, for friends and family of addicts; CoDA – Co-Dependents Anonymous, for people working to end patterns of dysfunctional relationships and develop functional and healthy relationships; DA – Debtors Anonymous; EA – Emotions Anonymous, for recovery from mental and emotional illness; FA – Food Addicts in Recovery Anonymous; FAA – Food Addicts Anonymous; GA – Gamblers Anonymous; Gam-Anon/Gam-A-Teen, for friends and family members of problem gamblers; MA – Marijuana Anonymous; NA – Narcotics Anonymous; NicA – Nicotine Anonymous; OA – Overeaters Anonymous; OLGA – Online Gamers Anonymous; PA – Pills Anonymous, for recovery from prescription pill addiction; SA – Smokers Anonymous; SAA – Sex Addicts Anonymous; and WA – Workaholics Anonymous.
 This section along with many resources herein were originally included in a paper written by Ann D. Foster, JD, LPC-Intern entitled Practicing Law and Wellness: Modern Strategies for the Lawyer Dealing with Anxiety, Addiction and Depression, which is available online at www.texasbar.com/AM/Template.cfm?Section=Wellness1&Template=/CM/ContentDisplay.cfm&ContentID=15158, and is inlcuded herein with her permission.
 See Matthew Lieberman, Social: Why Our Brains Are Wired to Connect (Crown Publishers 2013).
 See Brené Brown’s Ted Talk on “The price of invulnerability”: https://www.youtube.com/watch?v=_UoMXF73j0c&list=PLvzC42i6_rJJkyzWp1hyqUytxBBvNKgI6. Dr. Brown is a research professor at the University of Houston Graduate College of Social Work where she has spent the past 10 years studying courage, shame and authenticity.
 See Rhonda V. Magee, Making the Case for Mindfulness and the Law, 86 NW Lawyer 3 at p. 18 (2014)(available online at: http://nwlawyer.wsba.org/nwlawyer/april_may_2014/?pg=20#pg20).
 See e.g., STEVEN KEEVA, TRANSFORMING PRACTICES: FINDING JOY AND SATISFACTION IN THE LEGAL LIFE (1999); Leonard L. Riskin, The Contemplative Lawyer: On the Potential Contributions of Mindfulness Meditation to Law Students, Lawyers, and Clients, 7 HARV. NEGOT. L. REV. 1 (2002); Rhonda V. Magee, Educating Lawyers to Meditate?, 79 UMKC L. REV. 535 (2010).
Guided breathing exercises and meditations: http://marc.ucla.edu/body.cfm?id=22; Meditate at your desk: https://www.youtube.com/watch?v=nQjMJpQyj8E&feature=youtu.be;
 See http://www.ppc.sas.upenn.edu/publications.htm.
 See Steven Toepfer, Letters of Gratitude: Improving Well-Bring through Expressive Writing, J. of Writing Res. 1(3) (2009).
 See Lawrence S. Krieger and Kennon M. Sheldon, What Makes Lawyers Happy? Transcending the Anecdotes with Data from 6200 Lawyers . Geo. Wash. U. L. Rev. 83 (2015 Forthcoming), FSU College of Law, Public Law Research Paper No. 667(2014) (citing Bruno Frey & Alois Stutzer, HAPPINESS AND ECONOMICS: HOW THE ECONOMY AND INSTITUTIONS AFFECT HUMAN WELL-BEING at 105 (2002)).
 See also the following video of Dr. Charles Raison, the Assistant Professor of the Department of Psychiatry and the Director of the Mind/Body Program at Emory University, in which Dr. Raison talks about happiness and what causes it: http://www.youtube.com/watch?v=0orvsH07zeg
 See Karen Salmansohn, The Bounce Back Book (Workman Publ’g 2008), partially available online at http://www.psychologytoday.com/blog/bouncing-back/201003/the-world-taking-it-outta-you-seligman-study-shows-how-you-can-cheer-givin. See also Martin E. P. Seligman, Authentic Happiness (Simon & Schuster 2002).
 Ann D. Foster, JD, LPC-Intern entitled Practicing Law and Wellness: Modern Strategies for the Lawyer Dealing with Anxiety, Addiction and Depression, which is available online at www.texasbar.com/AM/Template.cfm?Section=Wellness1&Template=/CM/ContentDisplay.cfm&ContentID=15158.
 See Leonard L. Riskin, The Contemplative Lawyer: On the Potential Contributions of Mindfulness Meditation to Law Students, Lawyers, and Clients, 7 HARV. NEGOT. L. REV. 1 (2002).