Courage to Change

Well, suffice it to say that this issue was originally titled "Winter 1998". It's hard to believe that the last issue of Courage to Change came out over a year ago. I could chalk it up to how fast time flies, but it's probably more a function of procrastination than physics.

That said, welcome to the fourth issue of Courage to Change. Our theme for this issue, somewhat in keeping with the above, is depression and stress. Over the past several years, we at FLA have become more and more aware of a sizeable number of Bar members who are suffering from an impairment as painful and debilitating as chemical dependency, even though there are no drugs or alcohol involved. These are psychological conditions, including depression, bi-polar disorder, and other addictive or compulsive disorders like gambling, sex, and food. Many attorney assistance programs around the country are now learning (and struggling with) how to deal with these conditions, and hopefully this issue will bring you up to date on the situation in Florida.

FLORIDA LAWYERS ASSISTANCE MISSION STATEMENT

Florida Lawyers Assistance, Inc. (FLA) provides programs and services to assist attorneys, judges, law students, and other legal professionals who may be impaired in their ability to function in a legal setting. The backbone of FLA is a support network of recovering attorneys and judges who wish to carry the message to fellow members of their profession that recovery is possible.

FLA concentrates on assisting legal professionals with chemical dependency and/or psychological problems, providing evaluation, assessment and referral services, peer and facilitated support, aftercare programs, and monitoring services. In addition, FLA engages in preventative services through educational outreach programs, including mailings, literature distribution, and presentations to the judiciary, law schools, law firms, bar associations, bar seminars, and other professional entities. FLA's services are available for problems associated with drug, alcohol, gambling, food, and sexual addictions, as well as problems resulting from depression, stress, finances, and other areas that might affect an attorney's ability to competently function in a legal setting.

FLA is not a 12 Step program, although in cases of chemical dependency it relies on participation in the programs of Alcoholics Anonymous and Narcotics Anonymous as the primary resource in an attorney's recovery. Neither is FLA a treatment program, counseling center, employment agency, legal referral center, or employee assistance program, although all of these services can be accessed through FLA's resources. FLA works independently of, but cooperatively with The Florida Bar, the Florida Board of Bar Examiners, the Judicial Qualifications Committee, local bar associations, and the bar at large.

Expanding Our Horizons

The subject of this issue of Courage to Change is attorney depression, stress, and burnout. It's an area that, whenever raised, generates opinions and emotions from a number of directions. We thought it might be worth addressing this issue not as a means of putting it to rest, but to explain the position of the FLA staff and to promote an ongoing discussion.

About six or seven years ago, we at FLA began seeing attorneys who, although they displayed many of the signs and symptoms of chemical dependency, claimed they did not use substances and that their behavior was the result of psychological impairments. Initially, we had some trouble accepting this, believing instead that behavior such as abandonment of practice, trust violations, late or non-filings, and failure to communicate with clients was more likely the result of abuse of drugs or alcohol. What we realized very quickly was that many of these lawyers were being honest about their non-use of substances, and that depression and other psychological impairments could be just as devastating as chemical dependency.

Since that time, FLA has been working to develop a system as comprehensive and successful as that in place for addiction and alcoholism. As you probably know, the "guts" of the FLA program are 12 Step meetings, attorney support meetings, and a network of recovering attorneys, law students, doctors, and judges willing to contribute their experience, strength and hope. Unfortunately, this model doesn't easily translate over the mental health side for several reasons.

First, although self-help and 12 Step programs do exist for mental health disorders, they must usually be accompanied by professional therapy. That therapy can be expensive, especially if it's being provided by someone who understands the stress of practicing law and has the skill to really make a difference. While most times with substance abusing lawyers, Judy and I can at least say, "Come to the local FLA meeting and get yourself to AA", that "luxury" may not be available to an attorney suffering from a crippling bout of depression or heading into the manic phase of their bi-polar disorder.

Secondly, although we have tried referring mental health clients to the existing attorney support meetings, this has not been completely successful. There are some lawyers who have received tremendous help at the FLA meetings, but more often, it is difficult for them to identify with other attorneys who are focusing primarily on recovery from substances. Because of that, FLA has entered into a joint program with the PRN and IPN (the doctors' and nurses' support programs) to developed facilitated support groups for impaired professionals. These groups will be led by licensed and certified professionals, and will hopefully provide the same level of support and identification as the current groups do for chemically dependent lawyers. The first group will begin in Ft. Lauderdale in April 1999.

Finally, there is the issue of medication, a subject which probably generates more discussion than any other in this area. Much of this controversy, it seems, stems from a somewhat rigid definition of "abstinence". There seems to be a perception among some 12 Step and FLA members that taking any medication to "feel better" is akin to relapse, and that no one should need anything other than the program and the steps to recover. To my mind, this is like telling someone that they should be able to lick cancer through the power of positive thinking. Depression, bi-polar disorder, and other psychological conditions are illnesses, just like cancer or diabetes, and the advances that have been made over the past ten years in medications to treat these conditions are phenomenal. Telling someone who has been competently diagnosed as clinically depressed that there is something wrong with taking an anti-depressant is nothing short of cruel and negligent behavior. Anti-depressants are not mood altering or addictive drugs. They regulate brain chemistry to bring it back into balance, which can open a previously closed door and allow an individual to work and actually benefit from the steps and the program.

Don't get me wrong - I'm not saying that everyone who comes into recovery who's depressed should be immediately put on anti-depressants (although it appears that the number of addict/alcoholics with a co-existing mental health diagnosis is much higher than previously thought). Naturally, by the time most of us get here, we've pretty much trashed our lives and depression is generally appropriate. However, if after working the program for a while, the depression doesn't at least start to diminish and a diagnosis is made by a trained professional that a psychological condition is also present, then medication is likely called for and may be the difference between being able to sustain a recovery program or relapsing yet again.

OK - that's my soapbox for this issue. I would welcome your opinions, pro and con, on these issues, as well as your suggestions on how FLA could better serve the attorney who suffers from a psychological impairment. Believe me, Judy and I know we don't have all the answers, and this program (like the others) only works when you help us. -- Michael Cohen

Genius is eternal patience. - Michelangelo

ASSISTANT DIRECTOR'S COLUMN

For the past several years, FLA has been getting calls from attorneys-and about attorneys-who are suffering from depression. Many times, however, the caller doesn't identify the condition, but describes feelings or behaviors that they sometimes attribute to stress or burnout. On a professional level, the symptoms sound much like what we hear about the alcoholic or addict--missing hearings or appointments, not coming to the office for extended periods, showing up unprepared, not returning phone calls-the kinds of things that precipitate bar complaints. Personally, they complain of lethargy, sleeping problems (either too much or too little), inability to concentrate, and a myriad of physical and emotional discomforts lasting for a significant time. They sometimes express confusion about this condition and, all too often, guilt and shame about not being able to "pull it together."

Clearly, everyone experiences "down" days, and certainly it is not abnormal to have some of these reactions to significant losses or negative events in life. If this persists, however, both personal and professional consequences will occur. Bar complaints will be made, jobs will be lost and practices will fold. Financial difficulties will snowball and marriages and significant relationships may be strained or shattered. Suicide may or may not be considered but a profound sense of hopelessness and isolation almost always occurs.

If this sounds familiar to the alcoholic or addict, it's because the common denominator is impairment. Whether the impairment comes from ingesting chemicals or chemical disorders in the brain, the feelings, behaviors and resulting unmanagability is strikingly similar. Additionally, depression is often either a cause or effect of chemical abuse; and, though it's tempting to debate 'chicken or egg', it doesn't matter very much. If both conditions exist, we have a "dual diagnosis." Although many alcoholics and addicts cease to be depressed after entering recovery, many will need to be treated for depression as well. Sometimes treatment is short-term; sometimes it is a long-term or lifetime necessity.

Some of the "single diagnosis" depressed clients have enjoyed attending FLA support groups, and some have actively embraced the 12-step program in their lives. Most have expressed relief to have a group in which they can share their feelings and receive feedback from others who have been through similar circumstances, both personal and professional. There are others, however, who have felt unique and uncomfortable in the groups because they were not affected by chemicals, and some groups have expressed their discomfort in including these attorneys in their group.

As someone who has struggled to gain sobriety only to hit another bottom with depression a few years later, I can say that there are great similarities as well as great differences. Both tend to foster overwhelming fear, isolation, decreased levels of functioning and, for me at least, loss of self-esteem and shame. Obviously, sobriety demands abstinence from mood altering chemicals, and treatment for depression generally requires medication, at least for a time, to alter brain chemistry. The 12-step programs have proven extremely effective in helping alcoholics and addicts, but professional help is usually necessary for the treatment of depression.

For me, the AA fellowship and principles that were essential in getting sober were something of a mixed blessing in dealing with depression. It was painful to hear that I must not be going to enough meetings or working the program properly, and frightening to think that maybe AA had stopped working. I didn't feel like drinking, but some people told me that it was only a matter of time. The truth was I didn't feel like going to meetings-I didn't really feel like doing much of anything-and did stop for a while even though I always believed that when that occurred, relapse would not be far behind. Everything that had worked - prayer, meditation, service - seemingly lost its power.

Fortunately, I got help. For me it came from my AA sponsor who suggested therapy, and a therapist who sent me to a psychiatrist. I took medication, reluctantly at first, and went to bi-weekly individual therapy and group sessions for a long time. But relief came in fairly short order; everything seemed to come into focus and I was able to get on with life. Eventually I was able to stop the medication, with my doctor's approval, but with the understanding that I might need to take it again. I no longer see a therapist, but I have learned to monitor myself and would get help if symptoms persist. AA is my only treatment now and I continue to rely on it to keep me in balance.

Unlike many others, my depression was arrested before it became severe enough to cause serious problems. Even though it was at times an enormous effort, I always managed to show up and do an acceptable job, despite the fact I don't think I've ever worked harder or been less productive. Obviously my practice suffered and my income declined, but the damage was minimal.

When I listen to attorneys who have called about depression, I try to share my experience, strength and hope. Almost without exception, they tell me that they haven't been able to talk about it to friends and family and that it is such a relief to do so. Most are open to suggestions and willing to get treatment. It has become clear that FLA will be called upon to assist more and more attorneys with depression and related disorders. Some studies suggest that around 30% of attorneys will suffer from depression at some time during their careers. Our hope is that more awareness of the dangers of depression and improved treatment options will encourage more of them to seek help from FLA, or other sources, earlier.

It should be said, in closing, that even though the majority of our mental health cases are depression and respond well to treatment, there are those whose treatment and recovery are complex and sometimes difficult. FLA will continue to rely on physicians and mental health professionals for evaluation, treatment and monitoring in these cases, and concentrate on providing better methods of peer support for these lawyers where appropriate. This, along with some other new programs, will be our challenge for the coming year. As always, we need your help. Let's hope 1999 is the best year ever for FLA and all of you! - Judy Rushlow

LAWYER BURNOUT

by Keman Manion