International Journal of Law end Psychiatry, Vol. 13,233-246. Printed in the U.S.A. All rights resewed.

1990

0160-2527190 $3.00 + .oo Copyright 0 1990 Pergamon Press plc

The Prevalence of Depression, Alcohol Abuse, and Cocaine Abuse Among United States Lawyers G. Andrew H. Benjamin,* Elaine J. Darling,** Bruce Sales***

Introduction In recent years, the American Bar Association has begun to address the problems created by physical and psychological impairment of practicing lawyers. Among the presumed causes for this impairment are depression, alcoholism, and cocaine abuse. Depression When a person experiences a series of disappointments in a career or relationships, each loss is usually followed by a few days of sadness, withdrawal, sleep disturbance and anxiety; soon afterwards, the normal mood is re-established, and the person regroups and continues with life. When, however, the depressed mood persists, isolation from others increases, the individual loses a sense of pleasure and meaning in life, and begins to develop physical symptoms such as loss of appetite, a marked interruption in the regular sleep cycle, and a marked decrease in the ordinary level of activity; these signs signal the onset of a “clinical depression”. Periods of depression are characterized by at least five of the following symptoms, in addition to either a depressed mood or loss of interest or pleasure in usual activities and relationships:’ l

Poor appetite and weight loss, or the opposite, weight gain;

increased appetite and

*Department of Psychiatry and Behavioral Science, School of Medicine, University of Washington, XD45, Seattle, WA 95195. **Employee Assistance Specialist. ***Law, Psychology and Policy Program; University of Arizona, Department of Psychology, Tucson, AZ 85721. Acknowledgement: This study would not have been possible to conduct a few years ago. The leadership of the Washington State Bar Association (WSBA) recognized that unless the extent of lawyer pathology was documented and discussed openly, WSBA only would continue the pattern of institutional denial that pervades other professional associations. IAmerican Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 222-23 (3rd ed. revised 1980).

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Sleep disturbance: sleeping too little, or sleeping too much in an irregular pattern, for instance early morning awakenings; Loss of energy; Change in activity level, either increased or decreased; Decreased sexual drive; Diminished ability to think or concentrate; Feelings of worthlessness or excessive guilt that may reach grossly unreasonable or delusional proportions; Recurrent thoughts of death or self-harm, wishing to be dead or contemplating suicide. Our earlier research2 documented in one state law school in Arizona that the percentage of prospective law students suffering from statistically significant levels of depression, before entering law school, approximated what would be expected in the general population. Thereafter, depression far exceeded that norm. Whereas only 3 to 9 percent of individuals in Western industrialized countries suffer from depression3 by late spring of the first year of law school, 32 percent of the students were depressed. The percentage increased again by late spring of the third year when 40 percent of the class reported significantly elevated depression levels. Two years after law school, 17 percent of the same subjects were still reporting that they were depressed. Thus for the limited sample studied, law students and lawyers suffered from depression at a rate twice to four times what would be expected in the general population. Alcoholism As early as 1957, the AMA officially endorsed the concept that alcoholism is a disease.4 Alcoholism is a chronic, progressive and fatal disease that will cause problems in the major areas of ones’ life such as health, employment and relationships. Despite a long history of medical concern about the disease, physicians still do not diagnose alcoholism with much accuracy.5 Alcohol’s effert on the nervous system is insidious and progressive, with alcoholism being characterized by a loss of control over drinking and habituation or addiction to the alcohol.6 As alcohol intoxication becomes abusive or dependent, maladaptive behavioral changes due to recent ingestion of alcohol arise in increasing frequency and intensity.’ These changes may include aggres2G. A. H. Benjamin, A. Kaszniak, B. Sales and S. B. Shanfield. “The role of legal education in producing psychological distress among law students and lawyers,” American Rar Foundation Research Journal 225252, (1986). 35. H. Boyd & M. M. Weisman, “Epidemiology of affective disorders,” 38 Archives of General Psychiatry 1039-1044 (1981). “American Medical Association Manual on Alcoholism (Chicago, 1957). Ohio State Medical .Journal 78-79 (1985). SW. Kennedy, “Chemical dependence,” 6N. J. Ester, E. Heineman, Alcoholism-Development, Consequences and Interventions (St. Louis: C. V. Mosby Co., 1977). 7J. Royce, Alcohol Problems and Alcoholism-A Comprehensive Survey, (New York: The Free Press, 1981); The hallmark symptom of alcoholism is denial of the disease itself despite clear and convincing evidence to the contrary. This particular symptom often prevents the early identification of the problem drinker or drug addict. Prognosis for treatment is dependent upon how chronic the problem drinking or drugging has become.

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siveness, impaired judgement, impaired attentional abilities, irritability, depression, emotional lability, and other manifestations of impaired social or occupational functioning. Characteristic physiologic signs include slurred speech, lack of coordination, unsteady gait, nystagmus, and flushed features.8 Studies of intoxicated individuals have indicated that the presence of alcohol in the blood stream interferes significantly with the acquisition and recall of new information, both critical cognitive capabilities for practicing lawyers. If alcohol dependence develops, neuropathological changes can lead to Korsakoff’s syndrome as the neurotoxic effects of alcohol and the nutritional deficiencies take their toll on the body. At that point, significant deficits in shortterm retention, new learning and memory, and visioperceptual abilities remain permanently present even in detoxified alcoholics. These defects are likely the results of both cortical and limbic/diencephalic destruction and are seen in alcoholics regardless of age.9 The presence of at least one of the following diagnostic criteria will determine alcohol abuse: 1) continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem that is caused or exacerbated by use of the psychoactive substance, or 2) recurrent use in situations in which use is physically hazardous (e.g., driving while intoxicated) with the symptoms of the disturbance persisting for at least one month, or occurring rapidly over a longer period of time; in addition, when central nervous system tolerance causes a withdrawal syndrome to occur on the cessation or diminution of intake, alcoholism with physiological dependence is present.lO Based upon anecdotal evidence, a number of articles have raised concerns about larger than expected percentages of lawyers abusing alcohol.11 If these estimates are true they are troubling since epidemiological data suggest that approximately 10 percent of all employed persons in the U. S. abuse or are dependent on alcohol, with the direct cost of such abuse approximating $66 billion annually. I2 Cocaine Abuse Cocaine abuse, regardless of its use pattern, is associated with a variety of potentially severe psychiatric and neurologic complications: including depression, agitation, assaultiveness, paranoia, psychosis and hallucinations.13 The

sJ. Brandt, N. Butters, C. Ryan, R. Bayog, “Cognitive Loss and Recovery in Long Term Alcohol Abusers,” 40 Archives of General Psychiatry 435-441 (1983). 9Id. Wupra, note 1. ttB. A. Goodfield, “Do lawyers have problems being people?” 5 Barrister, I3-I5 (1978); R. L. Hirsch, “Are you on target?” I2 Barrister 17-20, 49-50 (1985); C. Maslach & S. E. Jackson, “Lawyer burnout,” 8 Barrister 52-58 (1978); “Helping alcoholic lawyers,” ABA Journal, 22 (Nov. 1986); “Cocaine in the legal profession,” Illinois Bar Journal, SO-56 (September, 1984). t2J. E. Keller, “Drinking, drunkenness and alcoholism: A definition,” The Bar Examiner 5-10 (August, 1987). Wince mere possession of cocaine is a felony, conviction of which mandates disbarment for violating the rules of professional responsibility in most jurisdictions (ABA Fifteenth National Conference on Lawyers’ Professional Responsibility, Impaired lawyers discipline or rehabilitation, May, 1989). occasional cocaine use represents a legal abuse problem for the profession, even if it does not rise to a clinical abuse problem. Indeed,

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most frequent neurological complications fall into four categories: seizures, focal neurologic deficits, headaches and transient loss of consciousness.lJ The essential features of this disorder are maladaptive behavioral changes (i.e. , euphoria, fighting, grandiosity, hypervigilance, psychomotor agitation, impaired judgement, and impaired social or occupational functioning), and other specific physical signs (i.e., tachycardia, pupillary dilation, elevated blood pressure, perspiration or chills, nausea and vomiting, and visual or tactile hallucinations) due to the recent use of cocaine. The onset of these symptoms begin no later than one hour after administration, and may occur within a few seconds.1s The fear that cocaine abuse exists among a significant percentage of lawyers is growing among the bar association leadership.16 Indeed, this concern may be legitimate since as many as 3 percent of the U. S. adult population may be cocaine abusers.” Present Study In light of the concern about alcoholism and cocaine abuse based on the anecdotal evidence, and the fact that our prior study only focused on law students from one state school and graduates of that law school with two years of post-degree experience, we decided to extend our work by focusing on the clinical epidemiology of these problems for lawyers in another jurisdiction. The purpose of this article is to present empirical results about Washington lawyers who were surveyed to determine how many suffered from depression, alcoholism, and cocaine abuse. METHODOLOGY

Subjects A random sample of 10 percent (1184 lawyers) of Washington lawyers, stratified by years of practice, was cross-sectionally measured. There were five stratifications, which provided control for differences in length of practice:

there is reason for concern if lawyers’ use of cocaine even matches that found in the general population. Epidemiological data indicate that 6.1 percent of the population between 26 and 34 years old are currently using cocaine. For purposes of this article, however, we will focus on the clinical threshold for cocaine abuse. 14D. Lowenstein, M. Massa, M. C. Rowbotham, S. D. Collins, H. E. McKinney, R. Simon, “Acute Neurologic and Psychiatric Complications Associated with Cocaine Abuse,” 83 The American Journal of Medicine 841-6 (1987). tsD. E. Smith, “Diagnostic, Treatment and Aftercare Approaches to Cocaine Abuse,” I Journal of Substance Abuse Treatment 5-9 (1984).

I6ABA ISth National Conference on Lawyers’ Professional Responsibility, Impaired Lawyers: Interactive roles of rreatmenf programs and discipline systems (May, 1989). “Drug Use in the U. S. -Household Survey, National Institute of Drug Abuse (1985); National Clearinghouse for Alcohol and Drug Information, “Alcohol and other drug abuse affects the lives of millions of Americans,” The Fact Is . . . I (October, 1988): The 3 percent estimate is taken from this publication that indicated

that of the 180 million adult U. S. citizens,

6 million people used cocaine

at least once a month.

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1. 2. 3. 4. 5.

lawyers lawyers lawyers lawyers lawyers

in in in in in

practice practice practice practice practice

237

for two years; more than two years but less than five years; more than five years but less then 10 years; more than 10 years but less than 20 years; 20 years or more.

In addition, the first stratification of the Washington random sample (184 lawyers) was compared with the 96 Arizona alumni of the earlier longitudinal research who had similarly practiced for only two years. Instruments Both the Arizona and Washington studies, used well standardized and validated self-report instruments that would assess similar symptom dimensions.18 Both studies shared the most important instrument, the Brief Symptom Inventory (BSI), a shortened form of the Hopkins Symptom Checklist-90, that measures depression. I9 It can be scored by using either mean raw scores or gender adjusted standard scores. A significant elevation of the BSI depression symptom (a score that exceeds two standard deviations above the normal population mean) is strongly correlated with clinical impairment, and suggests the need for specific treatment. Neither the possibility of alcoholism nor cocaine abuse was directly measured in our earlier longitudinal research, although one question about the respondents’ concern over their use of alcohol was included. Since the results of that question have not been previously reported, it will be presented below. The level of alcoholism present in Washington subjects was assessed with the Michigan Alcoholism Screening Test-Revised (MAST).2o The MAST is a widely used assessment device whose reliability and validity as a screening instrument has been demonstrated in clinical and non-clinical settings.21 If an individual endorses five or more of the MAST’s 24 true-false statements, it is very likely that the individual is abusive of or dependent on alcohol.22 Cocaine abuse was measured by identifying all Washington respondents who used cocaine at least once a month and who exceeded the Drug Abuse Screening

IsAlthough this article presents only the results from four of the many measures employed in both studies, the battery of instruments for each study included several hundred questions. Later papers will publish the results about psychopathological symptoms other than depression, drug abuse other than alcohol and cocaine, marital discord, and cardiovascular risks. t9L. R. Derogatis & N. Melisaratos, “The Brief Symptom Inventory: An Introductory Report,” 13 Psychological Medicine 595-605 (1983). The BSI depression scale scores were strongly correlated with the Beck Depression Inventory scores and the MMPI depression scale. The Beck is a commonly used self-report measure. The BSI is discussed fully in Benjamin ef al., supra, note 2. 2eG. R. Jacobson, The Alcoholisms: Direction, Assessment and Diagnosis. (New York: Human Sciences Press, 1978); H. A. Skinner, “A multivariate evaluation of the MAST,” 40 Journal ofstudies in AIcohol83L

844 ( 1979). 21D. M. Gallant: Company,

Alcoholism: A guide to diagnosis, intervention and treatment, (New York: W. W. Norton

1987); L. E. Gibbs, “Validity

and reliability

Drug [Alcohol Dependence 279-285 (1983). =Id.

of the michigan

alcoholism

screening

test: a review.” 12

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and B. SALES

Test’s (DAST)23 cut-off for abusive or dependent drug use. The DAST is quite similar to the MAST in construction; it identifies abusive or dependent behavior. The reliability and validity of the DAST as a screening instrument also has been demonstrated in clinical and non-clinical settings.24 Sampling and Mailing Procedures The Arizona study used a cohort-sequential design that permitted us to collect data from 310 subjects during 706 testings. Subjects included pre-law students, first year law students, third year law students, and alumni who had practiced for two years. Each independent cohort overlapped in either the first or third year of legal studies. Had we collected data from all possible subjects for each testing, it would have yielded 912 sets of data. The 706 sets of data represent a 77 percent total response rate for the complete subject population, with no particular cohort response rate dropping below 70 percent. Of the subjects we initially assessed, 93 percent of the subjects in the cohorts were reassessed at each subsequent assessment intervals. Furthermore, 79 percent of all Arizona alumni responded to the survey. This group is the one that overlapped with the first stratification of the Washington Lawyers. The stratified random sample of the Washington lawyers received a questionnaire, a stamped return envelope, and a cover letter. The cover letter contained an explanation of the purpose of the questionnaire and an assurance of confidentiality. These procedures did not differ from those used during the mailing that was sent to Arizona alumni. Although we were not able to pursue rigorously the same follow-up procedures used in the Arizona study, 801 of the 1186 Washington lawyers returned their questionnaire, a 68 percent response rate. Of the Washington lawyers with two years of practice, 184 or 77 percent returned their questionnaires. Results

Quality of the Survey Data Before conducting the Arizona study, we pre-tested the measures on a separate group of law students and lawyers to determine how best to collect the data. At that time identifying information about the pre-test subjects was requested, so that we could compare respondents with non-respondents. So many of these subjects proved unwilling to respond unless their anonymity was guaranteed that collecting identifying information was abandoned because it appeared too many subjects would refuse to participate in the study.2s During both of the Arizona and Washington studies anonymity was pursued rigorously.

*3H. A. Skinner,

“The drug abuse screening

test,” 7 Addicfive Behaviors 363-371 (1982).

*4/d. 2sAn earlier researcher found a similar pattern of extreme concern among law students and lawyers about injuring their reputations which precluded collecting any data unless it was anonymously provided: G. A. Gluck, “Interpersonal Traits in the Socialization of Law Students in a University Law School,” Dissertation Abstracts International (1979).

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There are a number of reasons to have a high degree of confidence in both the Arizona and the Washington data: (1) unlike earlier studies involving lawyers, most of the survey recipients completed the questionnaires, thus decreasing the chance that the results are seriously biased by the lack of response from a substantial portion of potential subjects; (2) no differences arose among any of the cohorts within the Arizona-cohort-sequential designz6 permitting the linking up of the cohorts to form longitudinal analyses between cohorts; (3) readers may argue that the Arizona results would not generalize to other lawyer populations because of the idiosyncratic aspects of the students or the law school program under study. In an earlier publication, we addressed this possibility by documenting the following findings:*’ (a) the demographic characteristics, undergraduate gradepoint averages, and LSAT scores appeared similar to those of law students at other law schools; (b) Arizona’s admission process differed little from other law schools, it being highly competitive; (c) the vast majority of Arizona’s law professors acquired their legal training from a handful of prestigious law schools, which led to Arizona’s curricula being quite typical of what is found in most other law schools; and (d) independent evidence as to similarities between student bodies and law schools was provided by earlier research, which showed that regardless of the institutions involved, very few law students felt good about their schools in general.28 We addressed the generalization issue more directly in the current study by compiling data collected from another population, Washington lawyers. If the new lawyers in both populations suffered from similar levels of depression, it would suggest that the data generalized from one lawyer population to another. Such concordance would also increase a.ur confidence in the reliability of the Washington data that was collected from a lower percentage of possible subjects. In addition, within the Washington battery of instruments, we embedded the L scale from the Minnesota Multiphasic Personality Inventory (MMPI) to provide protection against response sets, in particular whether subjects would respond to questions in a socially desirable manner. This technique permitted us to assess the under-reporting of symptoms, and to determine whether respondents were being open and honest when answering the questions.29 Less than two percent of the Washington lawyers attempted to present themselves in a favorable light. Comparison

of Arizona and Washington

Lawyers

Demographic Differences Approximately two-thirds of both the Arizona and Washington new practicing lawyers were male. No statistical differences arose as to gender between the two groups. Age did result in differences (female-t(105) = 10.5, p < .005;

Wupra, note 2. *%pra, note 2. Xl. A. Auerbach, “Legal Education and Some of its Discontents,” *9J. D. Graham, The MMPI: A Practical Guide (New York Oxford:

34 J. Legal Educalion 43 (1984). University Press, 1977).

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male-t(156) = 7.7,~ < .Ol), with Arizona female (X = 29.0; SD. = 3.5) and male lawyers (X = 28.6; SD. = 3.8) being younger than their Washington counterparts (females-X = 32.7; SD. = 6.5 and males X = 31.5; SD. = 6.6).30The implications of the age difference will be discussed later. Depression Statistically, if attorney depression scores exceed the 98.8th percentile (the two standard deviation level) of non-patient normative scores, we would be confident that the scores accurately reflect subjects as being very depressed. No statistically significant differences in the number of subjects with elevated levels of depression existed between Arizona and Washington lawyers. One fifth of both states’ young lawyers developed depression levels that exceeded two standard deviations above the normal population mean.31 Alcohol Problems Self-concern about recent alcohol use among Arizona subjects significantly increased during the course of law school and the early career years (pre-law8%, first year-15%, third year-24%, and alumni-26%; X2(3) = 12.9, p c .004). Concern about alcohol use may not be the same as having a clinical alcohol problem though. Thirteen percent of the young matching Washington lawyers exceeded the MAST score, which indicates that an alcohol problem is likely. Since the same percentage of male subjects from Arizona expressed concern about their alcohol use as did Washington lawyers who scored above the clinical cut-off on the MAST, it appears that alcoholism among the male attorneys is likely to be occurring at the same rate in the two states. Differences arose between the females, however. More Arizona female lawyers expressed concern about their alcohol use than Washington females who scored above the clinical cut-off for the MAST (X2(1) = 10.4, p < .005). These gender differences will be discussed later. The Prevalence of Distress in Washington

Lawyers

Prevalence of Distress Symptoms Compared with the 3 to 9 percent of individuals in Western industrialized countries who suffer from depression, 3219 percent of the Washington lawyers suffered from statistically significant elevated levels of depression. Of these

soReaders without C/iniculBios~ufisrics stone tenth of the finding approximates of depression affected 2. 3zBoyd & Weisman,

developed statistical skills will find clear (St. Louis: C. V. Mosby Co., 1977). pre-law students were depressed before they the level of depression found among Western 32 to 40 percent of first year and third year

Supra, note 3.

detailed

explanations

matriculated. industrialized law students:

in A. R. Feinstein,

As previously reported, this populations. Elevated levels Benjamin, et al., supra, note

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individuals, most were experiencing suicidal ideation. In addition, they typically isolated themselves (r = .64, p < .OOOl),which greatly exacerbates the risk of their acting upon suicidal ideation. Although we were unable to collect empirical data about the frequency of lawyers attempting to commit or committing suicide, and how these rates contrast to the general population, it is our clinical impression that, unless lawyers enter treatment and end their isolation, they are at much greater risk of not only acting upon their suicidal ideation but of also being lethal during an attempt. Eighteen percent of the lawyers were problem drinkers. This percentage is almost twice the approximately 10 percent alcohol abuse and/or dependency prevalence rates estimated for adults in the United States.33 Alcoholism and depression are independent disorders, and alcoholism is generally not a masked form of depression. Yet five percent of the Washington lawyers suffered from both alcoholism and depression. This result is of particular concern because depression that follows the onset of alcoholism is associated with poor social consequences and undesirable life events, such as marital breakdown, and has been shown to be highly predictive of suicide attempts and relapses.34 Less than one percent of the lawyers exceeded the clinical cut off established to determine cocaine abuse. This figure is significantly below the national average of 3 percent of the adult population. On the other hand, 26 percent of our sample have used cocaine at some point in their lives, compared to 12 percent for the general population. 35Unfortunately, we lack the data to predict how many of these individuals will later develop clinically abusive patterns. Length of Practice The number of years that lawyers practice did not affect the percentages of subjects who suffered from depression or cocaine abuse.36 This result did not occur for problem drinking. While approximately 18 percent of the lawyers who practiced 2 to 20 years had developed problem drinking, 25 percent of those lawyers who practiced 20 years or more were problem drinkers (X2(4) = 9.6; p = .0476). Al co h o 1 a b use and dependency is a chronic and progressive disease. It can take many years to become evident in some cases. As a result, those who have practiced longer appear to be more susceptible to developing problem drinking.

33National Clearinghouse for Alcohol and Drug Information, supra, note 17. 34K. Merikaugasm, J. F. Leckman, B. Prusoff, D. L. Pauls, M. M. Weisman “Familial transmission of depression and alcoholism,” 42 Archives of General Psychiatry 368-374 (1985); J. G. MacDonald, “Predictors of treatment outcome of alcoholic women,” 22(3) International Journal of the Addictions 235-248 (1987), J. Wallace, D. McNeil, D. Gilfillan, K. MacLean, F. Fanella, “Six-month treatment outcomes in socially stable alcoholics’ abstinence rates,” 5 Journal of Substance 7keafment 247-252 (1988). Wupra, note 17. shAddiction is a progressive disease that takes time to develop. Since young lawyers who grew up in the 1960s and 1970s may develop abuse patterns differently than lawyers who grew up 40 or more years ago, these data may be non-predictive of the likelihood of current young cocaine users developing into abusers.

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Demographic Differences A multivariate analysis of variance (MANOVA), using Hotelling’s T2 and a gender-adjusted standardized depression score, was performed to control for familywise error and to determine whether the three symptom measures and age differed between genders; significance within this global test was followed by univariate t-tests to determine which symptom measure contributed to the overall effect.37 A significant MANOVA was obtained for the three symptom measures and age, (F(4,788) = 16.8, p < .OOl). Table 1 presents the means, standard deviations, t-test values and significance level findings by gender for the different symptoms. Significant t values were obtained for the BSI depression scale (t(788) = 10.5, p < .OOl) and the MAST (t(788) = 11.85, p < .OOl). Men were more likely than women to develop into problem drinkers, while women were more likely than men to experience depression. Additionally, men of the sample were significantly older than women (X = 40.74 versus 34.36, t(788) = 48.6, p < .OOl). The proportion of females experiencing elevated levels of at least one of the three symptoms under study differed from males (females = 24% and males = 35 %, X2 = 6.79, p = .009) with a greater number of males suffering from a pathology. Discussion It appears from comparing the new Arizona alumni with the similar group of Washington lawyers that the presence of depression, problem drinking, and cocaine abuse is likely to affect lawyers at similar rates, regardless of jurisdiction within the United States. Thus, the Washington data become even more significant. Thirty-three percent of the Washington respondents suffered from either depression, problem drinking, or cocaine.abuse. Clinical depression was likely to be experienced by lawyers at the same proportions regardless of the TABLE 1 Manova With Depression’, Mast, Dast Scores by Gender

Females (N = 186) Scale Depressiona XMAST XDAST Age

M 1.52 .lOl 0.00 34.36

SD 2.20 .30 0.00 7.3

Males (N = 607) M

SD

t(788)

.97 .21 .003 40.74

1.97 .41 .06 11.8

10.4’ 11.9* .61 48.6’

aGender adjusted standard score. bXMAST and XDAST are variables that indicate whether individual scores equaled or exceeded the clinical significant cut-off level of 5. ‘P .OOl. 37Feinstein. supru, note 29.

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number of years that they practiced. Only one percent of the sample suffered from cocaine abuse,3* with the years of practice seemingly not affecting the prevalence rates. 39This result did not occur for lawyers suffering from alcohol problems; those with twenty or more years of practice were much more likely to suffer from alcohol abuse. One set of findings deserves special attention. Statistically fewer of new Washington female attorneys reported alcohol problems than did the Washington men. This finding probably reflects the fact that the Washington females were significantly younger than the men in this sample, and because of their gender, developed alcohol problems later in their lives. The logic for this hypothesis is as follows: We know from the empirical literature that problem drinking develops much later for people who experience depression, but particularly for females rather than the men in our culture.40 Severe depression often predates the development of problem drinking and treatment-seeking for alcoholism in many women.41 In addition, it is estimated that between one-fourth and two-thirds of alcoholics experience symptoms of depression that are severe enough to interfere with functioning, and that women are more likely to report depressive symptoms than men. 42Since the Arizona females were older than the Washington females in our samples, this hypothesis also may explain why a greater proportion of Arizona female lawyers were concerned about their alcohol use. Future Research Clearly these results demonstrate the need for further research in the United States about the prevalence of depression and alcoholism in practicing lawyers. Although cocaine abuse was found to be low in the Washington sample, the fact that cocaine use exceeded twice the national average, is noteworthy-particularly since the users tended to be younger; we do not know how many will develop into cocaine abusers.43 Thus, the findings relating to cocaine use and abuse also should be replicated in other states. Moreover, a longitudinal replication should be conducted to determine the course of suffering experienced by one third of the actively practicing bar who are experiencing statistically significant elevations of pathological symptoms. This research is critical since professionals generally agree that substance abuse is a contributing factor in a substantial portion of lawyer disciplinary cases. For example, in 1988, the American Bar Association determined that 27 percent of the discipline cases in the United States involved alcohol abuse.44 3sOn the other hand, it is troubling to note that 26% of the Washington sample have used cocaine even though such use is a felony, supru, note 13. 3sBut see, supru, note 36. 405. E. Turnball, E. S. L. Gomberg, “Impact of Depressive Symptomatology on Alcohol Problems in Women,” 12(3) Alcoholism: Clinical and Experimental Research 374-81 (1988). 41B. Thorn, “Sex differences in help-seeking for alcohol problems-the barriers to help seeking,” 81(6) British Journal of Addictions, 777-88 (1986). 4aTurnbal1, supra, note 39. 43See supra, note 36. MR. Theis, Center for Professional Responsibility, American Bar Association, (personal communication, January, 1989).

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This figure may actually be much higher, however, because not all state and county bar associations report their disciplinary cases. In addition, underreporting has occurred because state bar associations were unable to identify alcohol abusing lawyers who became part of the disciplinary process. Indeed, until recently, very few bar associations considered the causes for the lawyers’ infractions. For instance, neglect cases tend to arise among lawyers who are procrastinating because they are clinically depressed. Finally, lawyers who go untreated often become defendants in malpractice suits.45 A study conducted in 1986, by the Oregon State Bar Professional Liability Fund (OSBPLF), showed the relationship of alcohol and drug problems with malpractice claims.46 OSBPLF reviewed the records of 100 consecutive lawyers who entered its lawyer assistance program. Sixty percent of the lawyers had malpractice suits filed against them while suffering from substance abuse. Although we have some information to link directly substance abuse to impaired performance, we need to understand the relationship between other types of psychological distress (e.g., depression)47 and the evolution and prevalence of practice impairment, and the costs of that impairment. Such information is important in identifying warning signs of future impaired performance that may ultimately lead to malpractice, and in appropriately structuring remediation and rehabilition programs. Such research should include other types of psychological distress beyond that studied here-depression. For example, although not discussed in this article, in the Arizona study, there were data to show that law students and lawyers suffered from significantly elevated levels of paranoid ideation and hostility.48 Although these symptoms would be considered significant problems for sufferers in the general population, perhaps these behaviors are adaptive for many lawyers in the adversarial legal system of the United States. Future research needs to replicate the existence and prevalence of these and other forms of distress, and determine what if any consequences they have on practice.4g Such research will have to be particularly sensitive to the different types of legal practice. Perhaps a pathological level of hostility does not negatively affect more traditional forms of practice, but does impair a lawyer’s ability to successfully mediate disputes. Such information will aid attorneys in better understanding themselves and their fit with particular forms of practice. In addition, this information could also suggest the need for research into the relationship of legal advice, strategy and tactics with client needs versus lawyer psychologiWupra, note 16. 4sC. Greene, Half of Lawyer Malpractice and Discipline Stems from Substance Abuse-Annual Meeting of the National Conference of Bar Presidents- (August 6, 1988); D. Muchogrosso, Profile of Legal Malpractice- A Statistical Study of Determinative Characteristics on Lawyers’ Professional Liability Fund- Oregon, State Bar Association, internal program memorandum - (May 1986). “‘Bar association discipline counsel are just beginning to realize that the procrastination that causes neglect of cases is a common symptom of a depressed lawyer: supra, note 16. Wupra, note 2; A particular subset of lawyers continue to smoke: See, J. A. Chiles, G. A. W. Benjamin and T. S. Cahn, “Who Smokes? Why? Psychiatric aspects of continued cigarette usage among lawyers in Washington State,” 3 l(2) Comprehensive Psychiatry 176- 184 (1990). 4sSuch work also should investigate the impact that the distress has on family life. Protecting clients should not overshadow the additional need of improving the quality of life for members of the legal profession.

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cal distress. To the extent the latter significantly influences legal advice, strategy and tactics, it raises the need for thoughtful discussion about its implications for jurisprudence of the United States, and litigiousness in that society. Finally, future research must explore the causes of the pathological distress. This investigation should focus on at least three lines of potential etiologic agents: pathological history prior to entering law school; legal education; and practice experience. Specifically, we need to answer the following questions: Are those interested in practicing law more likely to develop pathological symptoms and self-select for this profession because of a pathological history?50 How does the acculturation process of becoming a lawyer affect the development of pathology?51 Are there fundamental aspects of the practice of law that exacerbate the development of pathology such as: the adversarial nature of the business; the fact that lawyers are forced into being businessmen rather than advocates; the problem of chronic overcommitment because of lack of control over time deadlines (due to court imposed trial/calenders and the needs of maintaining a cash flow); the fact that the outcomes in our business rarely are greeted with gratitude by our clients, or by recognition of family members and colleagues; the demands that the practice of law places upon our families, that may result in higher rates of marital discord and divorce? Societal and Professional Responses But even without this research, given the similarity in findings in our Arizona and Washington samples, the profession must respond to so many lawyers suffering from elevated symptom levels. The national United States and the regional state Bar Associations should avoid the phenomenon of institutional denial and attempt to reach their members before symptoms lead to malpractice or unethical practice. 52 The profession bears a special responsibility in this regard because lawyers are gifted at rationalization and intellectualization, and appear to be underdiagnosed frequently by physicians and mental health professionals. This result should not be surprising. With the general population, 71 percent of physicians feel either incompetent or ambivalent about treating alcoholism; only 21 percent recognize alcoholism as a primary disease.53 In addiseAlthough our Arizona study, supru, note 2, demonstrated that pre-law students did not differ from the normal population in the prevalence of depression and concern about alcohol use, it is possible that this finding is spurious because we failed to ask the right question. It now appears to us because of our clinical experiences that many of our lawyer clients are victims of child abuse, neglect, and exploitation. In theory, people would compensate for these earlier narcissistic injuries inflicted upon them by their parents by becoming overachievers. This behavior works well in maintaining balance in one’s life as long as the challenges are not too difficult. Indeed, until law school or the practice of law, many lawyers have not had to face the tough challenges that are replete within our profession, and which to some extent are comparable to being abused. stSee Benjamin et ol., supru, note 2. s2Many state bar associations spend less than one dollar of each lawyer’s membership dues each year on lawyers assistance program services versus $60-90 per lawyer on discipline services. Yet lawyer depression and alcohol abuse can often be prevented from developing into discipline consequences. ssJ. L. Coulehan, S. M. Zettler, M. Block, M. McClellan, N. Schulberg, Recognition of alcoholism and substance abuse in primary care patients, 147, Archives of Internal Medicine, 349-52, (1987); J. H. Mendelson, T. F. Babor, N. K. Mello, and H. Pratt, Alcoholism and prevalence of Medical and Psychiatric

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tion, physicians are not trained to recognize other forms of psychological distress. As well, lawyers suffering from depression or substance abuse may try to avoid psychiatrist or psychologist contact. Because they are bright, articulate, and careful to look “normal”, they may fool others into not identifying their need for such contact. It is only when the impairment becomes chronic and late stage in nature that others will see through the deception. Avoidance of treatment is particularly unfortunate because lawyers who go untreated damage clients and often become defendants in malpractice suits-results which could be avoided if treatment were pursued earlier.54 International Implications Our data also raise significant questions internationally. To what extent do attorneys in other countries experience psychological distress, and/or abuse alcohol and other drugs? What causes these problems in other cultures? How do the legal profession and lay public in these countries respond? Are the prevalence rates, etiologic agents, and professional/societal responses similar cross-culturally? Should they be? Unfortunately, we have not been able to find any literature addressing these or related questions. Perhaps then, this study will provide the impetus for such cross-cultural research and writings. Clearly people in all nations would benefit from the products of such work.

disorders, 47, Journal of Studies on Alcohol, 361-6, (1986); M. L. Willenbring, Measurement in alcoholics, 47, Journal of Studies on Alcohol, 367-372 (1986). s40ne year after the Oregon State Bar Professional Liability Fund developed a program stance abuse, members of the Oregon State Bar have a lower ratio of malpractice claims than members across the nation. While one in ten lawyers nationwide face malpractice claims, the is experiencing one in fourteen: supra, note 45. Unfortunately, this conclusion may be suspect know what the ratio in Oregon was before the program’s inception.

of depression to combat subother State Bar state of Oregon since we do not