|Oregon State Bar Bulletin AUGUST/SEPTEMBER 2006|
By Cliff Collins
Fifteen years ago, addiction referred primarily to dependence on substances: alcohol and other drugs. When the Bulletin last visited the subject, in a special August-September 1991 issue, "Drugs, Alcohol & Lawyers," recovery programs commonly saw the pure alcoholic.
"In 1991, I never saw a meth case," says Michael J. Sweeney, a veteran attorney counselor with the Oregon Attorney Assistance Program, or OAAP.
Today, much has changed: the number of addictions, how they are treated, science’s understanding of how addiction works, even the approach used for interventions — getting people to acknowledge that they need help and agree to enter treatment.
"We still see the pure alcoholic, and alcohol is still the No. 1 problem," says Sweeney. "In 1991, studies showed lawyers had twice the rate of addiction to alcohol than the general population. I think that still remains the same."
However, in 2006, lawyers and judges also are subject to the same broad range of addictions as the rest of society, including methamphetamine, cocaine, crack, heroin, marijuana, and prescription drugs such as OxyContin, but also compulsive disorders such as gambling, sex and computer games, addictions that have become more prevalent and accessible owing to the Internet and, in the case of gambling, also to state-sponsored lotteries.
The new addictions can be as costly as the old: Sweeney says some attorneys have lost their jobs because they could not stop playing computer games on the Internet.
Although a blanket definition is hard to come by, some researchers characterize addiction generally as a process whereby a behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by recurrent failure to control the behavior (powerlessness), and continuation of the behavior despite significant negative consequences.
Today, alcohol alone is rarely the addict’s problem. Dual or multiple addictions have become more commonly seen and acknowledged than in the past. The addictions besides, or in conjunction with, alcohol that send Oregon State Bar members to the OAAP most often are for meth and gambling. But the program also is seeing higher incidences of sex addiction, says Shari R. Gregory, OAAP assistant director and attorney counselor.
"Some addictions go hand in hand with each other." For example, she says, most sex addicts also are dependent on alcohol or drugs, and the same for gambling addicts.
Determining prevalence of alcoholism in the general population — and especially specifically among the legal profession — is difficult, partly because denial is one of the chief characteristics of addiction. Few studies have been done, and most are not recent. A 1994 study still cited by the U.S. Department of Health and Human Services found that approximately 14 million Americans — or 7.4 percent of the population — met the diagnostic criteria for alcohol abuse or alcoholism.
Meloney Crawford Chadwick, an attorney counselor with the OAAP, says the statistical estimates of individuals with substance use disorders are roughly 10 percent of the general population — but about 18 percent for those in the legal profession.
In his 1997 book Stress Management for Lawyers, Amiram Elwork reported that a survey of 801 Washington state lawyers "found alarming rates of reported depression and substance abuse," with 19 percent suffering from depression and 18 percent considered problem drinkers.
"These figures represented rates that are at least twice the national average for the general population," according to the author. "The researchers concluded that similar rates of depression and problem drinking would be found in most jurisdictions in the United States."
A Johns Hopkins study of 28 occupations measuring the prevalence of major depressive disorder found that lawyers were the most likely occupation to suffer depression, and also were 3.6 times more likely than the average to do so.
That mental health problems and addiction problems commonly are seen in the same individual is not surprising. "The neuroanatomy of addiction shares the same neurochemicals with the anxiety and mood disorders," says Shane P. Haydon, who holds a doctorate and has expertise in neuropsychology, and recently retired as regional vice president of Hazelden Springbrook, a residential treatment center in Newberg aimed at addicted professionals.
"Research is always way ahead of treatment," he explains. "We’ve learned about how various neurotransmitters attach in the limbic system. We know what the brain looks like while under the influence. The various (treatment) models remain relatively the same: cognitive-based, abstinence-based. But we’re getting more sophisticated insight about how we do some things better."
Haydon says that if the "psychological and emotional issues buried in the alcoholic’s life" are not recognized and dealt with during the person’s treatment for an addiction, "we are not totally preparing (the individual) for success in recovery." What Haydon refers to as "the chaotic lifestyles" and behavior of addicts require just as much attention as the addiction if the person is to undergo successful treatment, Haydon maintains. "Getting someone to stop is not that tough; getting them to stay stopped is real tough."
Much has been learned since 1991 about the brain and addictive behavior, agrees Dr. Donald E. Rosen, a psychiatrist and residency training director at Oregon Health & Science University. Scientists now recognize that susceptibility to addiction is due to a combination of biological and environmental factors.
"The debate changed, from nature (or) nurture to how one shapes another," he says. "We’ve made a lot of progress in our understanding, and we are on the cusp of understanding" even more. "The brain is not as much a static place as we were all taught 20 years ago."
Treatment options have expanded greatly, too. "One size doesn’t fit all," says Rosen. "In 2006, there are very different sizes of treatment to choose from than in 1991."
Medicines such as naltrexone, acamprosate or the antiseizure medication topiramate are sometimes used to help alcoholics recover. Afterward, if the individual abstains from drinking, he or she may never experience depression again. Drugs to reduce cravings also are used to treat the chemically dependent, says OAAP’s Sweeney. Haydon expects in coming years more "neuropharmacological strategies ... dealing with the craving issues."
According to Haydon, about 80 percent of addicted individuals who get treatment do so in an outpatient setting. However, he says the legal and medical professions lean more toward inpatient treatment, partly because people in those professions often carry a large amount of responsibility. The thought is, "That individual really does need to be separated from that pressure-cooker environment" in order to focus on recovery, Haydon says.
He adds, though, that residential is expensive: Depending on the type of facility, ranges are from $5,000-$7,000 a month up to $20,000-$40,000 a month. This hurdle can be particularly high for lawyers who, because of their addictions, have lost most or all their money or insurance coverage. Sweeney notes, "Back in 1991, there were a lot of hospital-based programs, but now there is very little residential" available. After insurers shrunk benefits, most of these options disappeared.
The best type of treatment depends on the problem and the person’s individual situation, he says. Sometimes, Alcoholics Anonymous and similar 12-step programs are sufficient to help the person recover; AA can work well, because the alcoholic is isolated and needs support, Sweeney explains. Others need more intensive outpatient treatment, and a few may qualify for immediate residential care if their environment dictates that approach, or if they would otherwise be homeless or have suffered a relapse, he says.
But residential treatment — being scarce and, if in a private setting, expensive — can be hard to obtain. Sometimes counselors refer addicts out of state, either because of lack of beds in Oregon or because the individual’s particular problem can be addressed best by a specialist who is located elsewhere.
The manner in which interventions are done has changed, as has law firms’ attitude toward treatment, observes Sweeney. In the early ’90s, the approach was to whisk the person away to treatment the same day the intervention occurred. Today, especially with the type of medications available, therapists may allow the addict a few days to get work and other matters in order first, he says.
Also, law firms no longer tell the addicted individual, "If you don’t get sober, you’re going to leave the firm," says Sweeney. "Today, the consequences are understood. You’re not setting someone up to fail." What used to be called "last-chance agreements" now are called "work agreements," he says, meaning that the recovering person agrees to follow certain steps to return to productive work.
After initial treatment, pairing up the recovering person with a monitor is important, both for support and to hold the individual accountable, says Haydon. "Monitoring works," he says. It is one of the keys to keeping the person on the program, and usually is done by someone in the same profession.
Haydon praises the medical profession for its success in spotting impairment among its members, educating physicians and their staffs about recognizing problems, and getting people into treatment. In addition, he says that health-related professions including dentistry and pharmacy have been supportive of their members who have addiction problems and go through recovery, whereas he has observed members of the legal profession return to work settings where they did not receive the same level of acceptance and support.
However, over the past decade, Haydon noticed a change: He has seen more law firms and settings show sensitivity toward individuals who tried to take care of themselves and went through treatment and are in recovery. He says this is in stark contrast to the former attitude: "the old-school concept of ‘damaged goods.’"
Cal Souther, chairman of the State Lawyer Assistance Committee, concurs that medicine has done a better job than law in helping and accepting its addicted members, and says medical professionals have experienced high rates of success in treating their members.
"We hope to move in that direction" he says of the legal profession. "(Physicians) have a much more serious attitude toward drinking in their profession. In law there is much greater tolerance of drinking, with a long history of this, and that makes it a little more difficult to intervene when necessary."
A particular problem for members of the legal profession who use drugs illicitly is that they realize "they are engaging in illegal conduct by using drugs," Souther says. "They carry that load; it weighs on them. It becomes an issue in recovery: They have to deal with (the fact) that their conduct has been breaking the law."
The stigma attached to alcohol and drug addictions is greater for women than men, and that fact is reflected in the numbers who seek treatment. The OAAP does not break down statistics by gender, but the percentage of female bar members who seek help from the OAAP with their addiction problems is much less than the proportion of female OSB members overall — which is 31 percent — and also much lower than the number of male bar members who seek help, says the OAAP’s Crawford Chadwick.
Alcohol dependence occurs at a faster rate in women than it does in men, she says. Women process alcohol differently than men, generally are built smaller and lighter, and experience health problems more rapidly.
Crawford Chadwick says the stereotypical "functional" alcoholic male — in his mid-50s, still holding down a job despite multiple-martini lunches — "does not have many female comparisons, partially because many women alcoholics don’t live to that age, or don’t reach that plateau stage in the same way that men do."
Many women become locked in a cycle of shame, believing "that they are bad and defective, instead of women with a chronic disease," she says. In addition, women who have experienced violence, trauma or sexual abuse have a higher likelihood of turning to chemical use in an attempt to numb painful feelings and unmanageable memories.
Another factor that keeps women from seeking treatment is child care. Many women are afraid or unwilling to leave their children for 30, 60 or 90 days of inpatient treatment, or they have no one to provide care for their children even if they are willing to go away. But female alcoholics frequently lose their spouses and children, whether they seek treatment or not, she adds.
The stigma may be magnified for drug use, given that alcohol is our most socially sanctioned legal drug. According to Crawford Chadwick, women also are more prone than are men to prescription drug dependency, such as benzodiazepines (including Valium and Librium) and opiate-related pain medications (Vicodin and OxyContin). Women are experimenting with and using meth in growing numbers because they believe it will help them lose or control weight and "get more done," she says.
The question of why lawyers and judges apparently may be more prone than the average person to becoming chemically or behaviorally addicted is an intriguing and perplexing one. A common explanation is that the legal profession comes with high pressure and stress, long hours, and often separation from family and friends.
In addition, conflict is a regular part of much of the law, and dealing with conflict is not easy for all attorneys, says OHSU’s Rosen. "I’m impressed with the number (of lawyers) I’ve met who don’t like conflict. They have a real discomfort with conflict. That’s part of the stress."
He says some litigators can take each other apart in oral argument, then go out together for coffee afterward. But "a lot of lawyers aren’t cut that way," Rosen says. "They can’t leave it at the office."
The OAAP’s Sweeney views the disproportionate numbers of addicted lawyers as being a result of a combination of genetics, stress and the personality characteristics of people who enter occupations or avocations that involve pressure or risk. He believes they can become addicted to the excitement, "the adrenaline rush," and if they become burned out with their work, they may turn to central-nervous system depressants such as alcohol.
"People who are attracted to the legal profession are very driven, with perfectionist tendencies sometimes," observes the OAAP’s Gregory. "And it’s a very stressful profession, so they are more prone to mental health issues. The profession is adversarial, where you are under scrutiny and (subjected to) negativity. You are trained to find what is wrong instead of what is right, which can lead people to problems. I think there are higher incidences of depression, because (these factors) bring it out in people."
The problems often show up well before individuals finish law school. Sweeney, who notes that some law students already are in recovery, cites a statistic that when students enter law school, their drinking rate is comparable to the average of the general population. But by the time they complete school, 19 percent are addicted.
Elkwork’s book points to a study showing that "the mental health of lawyers begins to deteriorate with their entrance into law school." Although entering students were found to be similar to the general population, by the spring semester they reported significantly higher-than-average rates of depression, anxiety, hostility and paranoia.
"The symptoms continued to increase into the end of the law school program, and did not return to pre-law school levels within the first two years of legal practice," Elwork writes.
OSB members who suffer from alcoholism, and who are not in recovery, have a higher rate of discipline complaints and more frequent malpractice claims. According to Barbara S. Fishleder, executive director of the OAAP, 80 percent of Oregon cases of theft from client security funds involve alcohol, drugs, gambling or mental health problems. Moreover, a study by the OAAP found that a lawyer who suffers from alcoholism (and who is not in recovery) is four times more likely, compared to the state’s average, to have a malpractice or discipline complaint filed against him or her. Conversely — and remarkably — lawyers in recovery from addiction experience malpractice and discipline rates that are significantly lower than the state’s average for all OSB members, the study found.
Such statistics demonstrate the dramatic professional turnaround experienced by lawyers in recovery, says Fishleder. "That and the expanded knowledge we now have of how to help people gives hope to those who are suffering and provides some motivation to accept the help that will lead to a better life."
ABOUT THE AUTHOR
Cliff Collins, a Portland-area freelance writer, is a frequent Bulletin contributor.
© 2006 Cliff Collins