Wellness and the Legal Profession: Implications of the 2016 Landmark Study on the Prevalence of Substance Use and Mental Health Concerns among U.S. Attorneys

This article originally appeared in The Bar Examiner print edition, March 2016 (Vol. 85, No. 1), pp 50–57.

By Linda Albert and Patrick R. KrillThe U.S. legal profession is vital to our society, economy, and government—and the behavioral health of attorneys is therefore of great importance. It has long been suspected that attorneys experience considerable levels of substance use disorders and mental health concerns, yet empirical and statistical information has been lacking—information that is critical in order to provide attorneys with the resources and support they need so that they can effectively serve our society. Previously available data, which indicated significantly higher levels of alcohol abuse and depression among attorneys than in the general population, were over 25 years old and drawn from a much smaller sample in only one state.1 The need for a study collecting current data on a national level in order to define the scope of the problem was imperative.

This article summarizes the results of such a study, conducted collaboratively in 2014–2015 by the Hazelden Betty Ford Foundation2 and the American Bar Association’s Commission on Lawyer Assistance Programs (CoLAP).3 The results confirm a substantial level of behavioral health problems among attorneys that are a cause for great concern—in particular, very high rates of alcohol abuse and of depression, anxiety, and stress. Most notably, the results indicate a reversal of previous data that had indicated a positive correlation between levels of alcohol abuse and number of years in the profession—that is, the latest data show that younger lawyers newer to the profession are now the ones experiencing the highest rates of alcohol abuse. Additionally, the study sought to gain information about the help-seeking behaviors of attorneys and barriers to treatment. It is hoped that the data brought to light by this groundbreaking study will inform all members of the legal profession and inspire action to address what is clearly an unsustainable situation in the legal profession.

History and Scope of the Project

In the late fall of 2013, Patrick R. Krill, the director of the Legal Professionals Program at the Hazelden Betty Ford Foundation, approached CoLAP about the potential for this innovative collaboration. The intent was to join resources and conduct the first-ever national study of attorney behavioral health. It wasn’t long before CoLAP approved a motion to pursue this collaboration, and Linda Albert, a CoLAP commissioner, volunteered to be the representative from CoLAP to work with Krill. The ABA soon followed CoLAP’s lead by officially approving the collaboration between the two entities.

In 2014 the collaborative team designed the study to include instruments to measure problematic substance use, mental health issues, and barriers to seeking help. Data collection began in 19 states. By February 2015, data collection had concluded and the results were being analyzed.4 The results were then summarized and reported in an article that was published in the February 2016 edition of the Journal of Addiction Medicine.5

21% of respondents scored at a level consistent with problematic drinking…with 32% of those 30 or younger having levels of problematic drinking and 28% of those with 10 or fewer years in the field having levels of problematic drinking.

The collaborative nature of the effort is important, as it led to the completion of a study that neither entity could have easily, if at all, accomplished in such a comprehensive way on its own. Both the Hazelden Betty Ford Foundation and CoLAP play important roles in addressing the behavioral health needs of the legal profession and are situated as national thought leaders and resources in that regard. Through the pooling of complementary talents, resources, and relationships, the project had a broader scope and greater success than it would have had it been undertaken by either entity alone. This project demonstrates how stakeholder collaboration can be significant in tackling the behavioral health challenges of the legal profession. The hope of the project coordinators is that this model will inspire additional partnerships within the profession in order to effect much-needed change.

Participants in the Study

Nineteen states6 representing all regions of the country were solicited and participated in the study, resulting in a total of 14,895 individuals completing the survey. The inclusion criteria for the final analysis required respondents to be currently licensed and employed in a legal position, a criterion met by 12,825 respondents, thereby resulting in a sample of 12,825 participants.

The gender breakdown of respondents was males 53.4%, females 46.5%, and transgender .1%. Diversity of race was Caucasian/White 91.3%, Latino/Hispanic 2.6%, Black/African American 2.5%, Multiracial 1.5%, Asian 1.2%, Other .7%, and Native American .3%.

Age was measured in six categories, beginning with 30 years or younger and increasing in 10-year increments to 71 years or older, with the most commonly reported age group being 31 to 40 years old (25.2%). Length of career in the legal profession was measured in five categories, beginning with 10 years or fewer, and increasing in 10-year increments to 41 or more years, with the most commonly reported career length being 10 years or fewer (34.8%). Other professional data collected were work environment, firm position, and hours worked per week.

Substance Use Findings

Alcohol Use

The Alcohol Use Disorders Identification Test (AUDIT) was used to gather data on alcohol use. This 10-item instrument was developed by the World Health Organization and is widely used by health workers and alcohol researchers throughout the world due to its well-established validity and reliability.7 It screens for hazardous and harmful alcohol use as well as possible alcohol dependence.

Younger, less experienced lawyers working in lower positions had higher levels of problematic drinking.The AUDIT results showed that of the 88% of respondents who completed all 10 questions on the AUDIT, 21% of respondents scored at a level consistent with problematic drinking (i.e., demonstrating drinking patterns that are hazardous, harmful, and possibly indicative of alcohol dependence). Males had higher levels of problematic drinking (25%) than females (16%). Younger participants had much higher levels of problematic drinking than older participants, as did those working in the field for a shorter duration, with 32% of those 30 or younger having levels of problematic drinking and 28% of those with 10 or fewer years in the field having levels of problematic drinking. Those working in a private firm or in bar administration and lawyer assistance programs had higher levels of problematic drinking, 23% and 24% respectively, than those in other work environments. Within firms, junior associates had higher levels of problematic drinking (31%) compared to senior associates (26%).

As the data show, a reverse relationship was found between age, years in the field, position within the firm, and problematic drinking. Younger, less experienced lawyers working in lower positions had higher levels of problematic drinking. This is an important finding that should be underscored, as previously available data demonstrated a positive association between the increased prevalence of problematic drinking and an increased amount of years spent in the profession.8 The study found a direct reversal of that association.

Another interesting finding related to the comparison between the amount of problematic drinking among lawyers and among physicians. This comparison was made using the AUDIT-C, a subscale within the AUDIT that is often used as an abbreviated version of the instrument. The AUDIT-C is composed of the first three questions of the AUDIT and focuses exclusively on the quantity and frequency of alcohol consumption. Based on that measure, a staggering 36% of the sample screened positive for problematic drinking, whereas 15% of physicians screened positive in a 2012 study.9

Drug Abuse

Drug abuse was measured using the Drug Abuse Screening Test-10 (DAST-10), based on the use of various classes of substances in the past 12 months. The DAST-10 is a 10-item instrument used in both clinical and research settings to screen and quantify consequences of drug use, and its reliability and validity have been demonstrated.10

A smaller percentage of respondents, only 27%, completed the DAST-10, compared with the response rate for the other screens used. Lower response rates on this instrument are difficult to interpret. It isn’t known whether fewer participants were willing to complete the DAST due to fear of repercussions from disclosure of the use of illegal substances or whether the large number of participants who did not complete the DAST didn’t do so because they in fact did not use drugs. However, considering that this test measures the nonmedical use of illegal substances or prescription drugs, the fact that 25% of respondents fell into the severe (1%), substantial (3%), and intermediate (21%) range of drug abuse warrants attention. Illegal use of drugs, at any level, places an attorney or judge at risk for legal problems along with regulation problems and potentially serious health problems.

Additional Self-Report Data Regarding Alcohol Use and Drug Abuse

Participants were asked to self-report their concerns about their alcohol or substance use in a section separate from the instruments utilized to measure their use. For example, the following question was asked: “Have you ever thought your use of alcohol or other substances was causing problems in your life?” 23% reported that their alcohol or substance use had been a problem for them sometime during their lives; of those who so reported, 28% reported problematic use prior to law school, 14% reported problematic use started during law school, 44% reported problematic use started within the first 15 years following law school, and 15% reported problematic use started more than 15 years after law school. The self-report data was a close match to the results from instruments utilized, demonstrating higher levels of problematic use with the younger, less experienced practitioners. Similarly, a recent study on law student well-being showed that 22% reported binge drinking two or more times in the prior two weeks, with male students engaging more in binge drinking than female students.11 Problematic drinking appears to continue from law school into the practice of law and then escalate within the first 15 years of practice.

Mental Health Findings

28%, 19%, and 23% of respondents reported experiencing mild or higher levels of depression, anxiety, and stress, respectively.Data pertaining to mental health were gathered by using the Depression Anxiety Stress Scales-21 (DASS-21). The DASS-21 is an instrument composed of three 7-item subscales that assess symptoms of depression, anxiety, and stress, and whose validity and reliability have been established by several studies.12 Of the 90% of participants who completed all questions on the DASS-21, 28%, 19%, and 23% of respondents reported experiencing mild or higher levels of depression, anxiety, and stress, respectively. When asked to self-report those same issues separate from the instruments utilized to measure their presence, 61% reported that they had experienced anxiety at some time during their legal career, followed by 46% reporting concerns with depression; 11.5% reported suicidal thoughts during their career, with 2.9% reporting self-injurious behaviors and .7% reporting at least one suicide attempt.

The mental health scores followed a similar pattern and trajectory as the alcohol use scores: younger participants (those in the 31–40 age group) with fewer years of practice (10 years or fewer in the field) had higher scores, indicating higher levels of mental health concerns. There was also a positive association between higher scores on the DASS-21 mental health instrument and higher scores on the AUDIT alcohol use instrument. This showed that those who were struggling with problematic drinking were also struggling with depression, anxiety, and/or stress.

Help-Seeking Behaviors

Seeking help was thwarted by the following concerns, listed in descending order of prevalence: not wanting others to find out, confidentiality, concerns about impact on license, not knowing who to ask, and not having insurance or the money to pay for help. Although the rate of problematic drinking was 21%, only 7% of respondents had sought help of any type for alcohol or substance use, including multiple treatment formats, self-help groups, and the services of a lawyer assistance program. By contrast, 37% of respondents had sought help for mental health concerns.

Although the rate of problematic drinking was 21%, only 7% of respondents had sought help of any type for alcohol or substance use… By contrast, 37% of respondents had sought help for mental health concerns.From looking at this data, one could speculate that there may be less stigma or fewer barriers in seeking help for mental health concerns than for substance use problems. For whatever reason, over five times the number of participants had sought help for mental health concerns than for substance use problems. This limited help-seeking behavior was also found in law students, where only 4% of respondents answered affirmatively that they had sought help from a health professional for alcohol or drug problems, whereas approximately 20% had sought help from a health professional for a mental health concern.13

What Have We Learned?

• Attorneys in the United States have significantly higher rates of problematic drinking and mental health problems than the general population. According to the Substance Abuse and Mental Health Services Administration, 6.6% of adult Americans experienced a major depressive episode in 2014 and 6.4% had an alcohol use disorder,14 whereas 28% of attorneys reported mild or higher levels of depression and 21% scored at a level consistent with problematic drinking.
• Younger, less experienced lawyers working in small firms have higher levels of distress symptoms than their older, more experienced peers.
• Lawyers don’t seek help for their behavioral health problems because they fear someone will find out and it will discredit them and possibly affect their license.
• Law student research seems to demonstrate similar themes, with law students experiencing higher levels of distress symptoms than the general population and limited help-seeking behaviors.15

This research is a call for action. The numbers we uncovered are incompatible with a sustainable professional culture. Too many individuals are struggling and suffering, and the impact on the public is too great for the profession to ignore.

What Are the Implications for the Legal Community?

The results are compelling. The implications for the legal community are multifaceted and far-reaching. This study, along with the study on law student well-being,16 is a call for action—a call for every part of the legal community to contribute toward addressing this crisis. From law schools, to bar admission agencies, bar associations, legal regulators, lawyer assistance programs, and private firms and beyond, it is time for all stakeholders to get actively involved. It is the duty of each entity to evaluate what it can do within its respective role—to coordinate with others to promote early referral to behavioral health services, encourage help-seeking behavior, support and establish policies and procedures that demote the use of alcohol within work settings and at work events, and promote wellness and balance.

A Focus on Wellness Is Needed

Many lawyers find themselves working long hours; getting minimal sleep; not eating well; and distancing themselves from family, friends, and colleagues as they attempt to keep up with the demands of the profession. These patterns are reinforced by organizations that impose heavy workloads on their employees without consideration for the impact upon those employees. Young lawyers are having difficulties finding jobs and paying off student loans and often struggle to maintain adequate social support, while also postponing life events such as marriage and starting a family. It is possible, if not probable, that these circumstances contribute to the higher level of distress symptoms we see among lawyers during their first 15 years of practice.

Wellness concepts include teaching law students and legal professionals about stress management as well as building hardiness and resiliency skills; the importance of physical exercise, good sleep, and quality nutrition; minimizing alcohol use; and incorporating interpersonal connectedness into their lives. Wellness is connected to life satisfaction and happiness. A 2014 study on lawyers and ­happiness found that those who engage in work that is interesting, engaging, and personally meaningful are happier than those who seek good grades, prestige, and affluence.17 The study’s authors also state that “the tendency of law students and young ­lawyers to place prestige or financial concerns before their desires to ‘make a difference’ or serve the good of others will undermine their ongoing happiness in life”; accordingly, they state that “one powerful approach to raise the level of professional behavior among lawyers is to teach law students and lawyers to maximize their own happiness.”18 We have to ask what lawyers are being taught about maintaining wellness during law school and throughout their careers. What messages are they receiving about seeking help if needed; maintaining quality ­connections with family, friends, and colleagues; or finding work that is personally meaningful and interesting?

Key Recommendations

It is possible that teaching law students and lawyers to maximize their own happiness while improving their health and well-being can be accomplished at multiple levels. Bar associations and lawyer assistance programs have developed many programs and resources toward that end. If not already in place, the following are recommended:

1. Law schools should require students to take classes on the importance of maintaining personal well-being, happiness, and life satisfaction to ensure fitness to practice, similar to classes on other areas of professional responsibility.
2. Legal employers should offer comprehensive mentoring programs for new lawyers. It is imperative that these programs do not center on happy hours or other alcohol-related events to generate participation or facilitate networking.
3. Bar examiners should make automatic referrals to local lawyer assistance programs when they receive applications from at-risk individuals or have concerns about applicants.
4. All states should have conditional admission, which allows lawyers who are currently fit to practice (but otherwise have conduct in their past that might impair their ability to practice law if it should recur) to be admitted to practice while being monitored by a lawyer assistance program.19
5. All regulatory agencies should evaluate the rules in their jurisdiction to ensure that they have the means to refer to the lawyer assistance program when concerned about a lawyer prior to, during, or after discipline.
6. The continuing legal education requirements of each jurisdiction should mandate a certain number of hours each reporting period on prevention, detection, and treatment of substance abuse and mental illness.
7. State and local bar associations should form partnerships with local health organizations to learn about the best practices for increasing the health and well-being of their members.
8. Lawyer assistance programs must be funded at a level that allows them to increase their services to provide more outreach, screenings, counseling, peer assistance, monitoring, and preventive education.
9. Profession-wide health and wellness summits should be organized to develop and implement comprehensive strategies and plans for improving the health and well-being of the legal profession. These summits should include key stakeholders from all sectors of the profession.

Conclusions

The U.S. legal profession—a distinguished, bedrock component of our society, economy, and government—is under direct threat from unacceptably high rates of problematic substance use and mental health concerns. As this study demonstrates, the problems are pervasive, and no sector or pocket of the profession is immune to their grip. These problems often have their beginnings in law school and then continue to grow and worsen with admission to the bar and the inculcation of cultural norms within the profession.

For a systemic problem, a systemic response is indicated. All members of the profession have a part to play in redressing the prevailing attitudes and behaviors that simultaneously encourage unhealthy lifestyles while discouraging help-seeking. Greater investment of resources and attention by law firms, law schools, and in-house legal departments—the “private sector” of the profession—will be necessary to effect a long-overdue sea change in regard to behavioral health in the legal profession. With the publication of this new research, the authors and their sponsoring entities hope to reinvigorate the discussion about finding—and aggressively pursuing—new solutions to a lingering and debilitating problem.

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