Alcoholism and Depression Among Practicing Attorneys

Alcoholism exacts an exorbitant toll on lawyers, the legal system, and consumers of legal services. In a 1990 study conducted by the North Carolina Bar Association, a staggering 17% of the 2,600 attorneys surveyed admitted to drinking 3-5 alcoholic beverages per day. In the state of Washington, another study found that 18% of the 801 lawyers surveyed were problem drinkers. It is estimated that the number of lawyers in the United States actively abusing alcohol and drugs is twice that of the general population. Approximately 40% to 70% of attorney disciplinary proceedings and malpractice actions are linked to alcohol abuse or a mental illness.

Yet, despite this high incidence, lawyers suffering from alcoholism often feel painfully alone. Fearing discovery or retribution, they are reticent to ask questions or to attempt to learn more about their problem. Very often, they fail to seek help before the problem has escalated to serious proportions. The purpose of this article is to introduce the impaired lawyer to the symptoms and causes of alcohol dependence and to the large menu of treatment options that now exist. This information also should be of help to colleagues, friends and family members of alcohol dependent attorneys.


THE SYMPTOMS

"Denial" is a common feature of alcoholism. There are widely differing opinions about whether denial is an unconscious psychological defense mechanism, a misguided effort to conceal the shame of addiction, or simply a reaction to accusations or punitive actions by other people. Regardless, it is clear that those who are addicted to alcohol are often the last ones to recognize or acknowledge the existence of a problem. As a result, they unfortunately may not seek help until they are faced with serious medical, legal, financial, or social repercussions.

Official diagnostic criteria for "alcoholism" or "alcohol dependence" focus on the compulsive use of alcohol despite the significant negative consequences of that use.Some alcoholics will exhibit symptoms of physical dependence, including a need for significantly increasing amounts of alcohol to achieve the desired effect ("tolerance"), or withdrawal symptoms (e.g., nausea, tremor, insomnia) when levels of alcohol in the blood decline.

For a substantial proportion of alcoholics, however, dependence is manifested solely by a behavioral or psychological compulsion to use alcohol, without any noticeable accompanying physical symptoms. This may include recurrent episodes of binge drinking; frequent intoxication under dangerous or inappropriate circumstances (e.g., while driving); multiple, unsuccessful efforts to quit or to reduce the use of alcohol; excessive involvement in alcohol-related activities; reduced involvement in adaptive or productive social and occupational activities; or the continued use of alcohol despite significant physical or psychological ill-effects.

Rather than focusing on these direct symptoms of addiction, however, it is often more instructive or productive to focus on the loss of functions or competencies that typically accompany the addiction. Efforts to confront an alcoholic with positive evidence of his or her addiction (e.g., black-outs, binges, or the smell of liquor on the breath) typically invoke excuses, manipulations, or angry counter-attacks. It is much harder, however, to deny the existence of a problem when one's accomplishments have fallen far short of one's goals and abilities.

THEORIES OF CAUSATION

Theories about the causes and treatment of alcoholism are generally more reflective of personal philosophies and belief systems than of scientific or clinical evidence. Historically, the "Moral Model" of addiction viewed alcoholism as a sign of characterological weakness or moral turpitude. As such, treatment, if any, was designed to confront the alcoholic with the consequences of his or her behaviors and to force or shame him or her into making improvements.

The "Disease Model" of addiction assumed prominence in the middle part of this century. This model, which views alcoholism as fundamentally a medical illness, has found some support from recent discoveries about the genetic, biochemical, and pharmacological aspects of addiction. Treatments based upon the Disease Model sometimes emphasize the individual's relative powerlessness over the illness. This philosophy has attracted a great deal of support from the "self-help" movement because of its deemphasis on issues of blame and morality.

Most recently, a "Habit Model" or "Behavioral Model" of addiction has achieved relative prominence, particularly in the fields of psychology and education. This model views addiction as essentially a learned behavior, resulting from faulty problem solving, ineffective role modeling, or a complicated system of rewards and punishments which sustains the alcohol usage. Rather than viewing the individual as powerless in the face of a disease process, the Behavioral Model seeks to increase the individual's sense of efficacy and potential control over the problem. A distinction is made between moral blameworthiness regarding the past and behavioral accountability in the future. People may not "choose" to be addicted, but it is assumed that they have ultimate control over changing their behavioral patterns.

Philosophies aside, no one really knows for certain what causes alcoholism and it is highly unlikely that any single causal agent will ever be identified. Alcoholism appears to be a result of many different processes. For any particular individual, it may stem from a genetic predisposition, from environmental stress or trauma, from learning history, or from a complex combination of any of these.

It is useful to think about alcoholism in light of the "diathesis-stress" model of illness. Some individuals have a strong genetic loading ("diathesis") for a particular disease, which may be activated with minimal environmental influence. For example, some people are genetically predisposed to develop cancer, which may manifest itself almost irrespective of diet, exercise, or other habits. Other individuals, in contrast, are genetically heartier and do not develop the disease unless they are exposed to potent environmental carcinogens. In a similar vein, individuals appear to vary in their genetic vulnerability to alcoholism. Some people can apparently drink steadily without developing dependence or becoming socially maladapted. Others are less fortunate.

Given the current state of medical science, it is difficult to know in advance who is or is not vulnerable to developing alcoholism. However, a look at your family tree may shed light on your own risk liability. Rates of alcoholism are significantly higher within some families than in the general population. It is uncertain whether this is due to an inherited familial vulnerability to alcoholism, or whether it results from role modeling or social learning. Children of alcoholics may simply be exposed to alcohol at a younger age, or they may be negatively affected by concomitant family dysfunction. Most likely, a positive family history reflects both learned and genetic factors, in which biological and environmental forces combine to increase one's risk exponentially.

Compared to the general population, alcoholics suffer from significantly higher rates of psychiatric disorders such as depression and anxiety. This has led to some speculation that alcoholics might be "self-medicating" some uncomfortable emotional state. In fact, part of the chemical effect of alcohol is to dull the emotions. It is difficult, however, to disentangle cause and effect because of alcohol's depressant influence on the central nervous system. Chronic alcohol use may bring about long-term brain changes, leading to the development of depressive or anxiety states. It is also possible that some individuals have a generalized vulnerability to stress which, depending on the specific circumstances, may manifest itself as alcoholism, depression, anxiety, or some other emotional disturbance.

TREATMENT OPTIONS

Regardless of the counseling option one chooses, it is always highly advisable to first undergo a thorough physical evaluation by a physician. A number of complicating medical conditions often accompany chronic alcohol abuse which, paradoxically, may be exacerbated by withdrawal from or sudden reduction in alcohol use. In addition, a physician can address other related difficulties such as vitamin deficiencies that may contribute to a more difficult recovery.

A dizzying array of specific treatment options are available for alcohol dependence. Many practitioners tout their particular program as being most effective for most clients under most circumstances. Unfortunately, these superlatives tend to confuse consumers and to cause needless dissension within the addictions field. The consumer of addiction services should attempt to find the best match for his or her needs and comfort level. Just like shopping for a suit, not all styles are an appropriate fit. If you are uncomfortable with or disillusioned by one treatment choice, do some additional research and consider other options. Several books are available which provide fairly balanced appraisals of different treatment options, including synopses of empirical evidence (if any) supporting the efficacy of these programs.

Treatment programs differ along many dimensions, including: their causal and treatment philosophies (i.e., Moral Model, Disease Model, or Behavioral Model); whether they are conducted in an inpatient, outpatient or residential setting; whether they are administered by licensed professionals or by peers who are themselves in recovery; and whether they are performed in an individual, group, or family therapy format.

Traditionally, alcoholism was treated in an inpatient or residential setting. The first week or so was generally dedicated to "detoxifying" the individual or reducing withdrawal symptoms (if any), followed by a structured routine of group and recreational therapies. The emphasis was generally placed on preventing the individual's contact with alcohol or alcohol-related stimuli.

Although this may be an effective mode of intervention in the very short term, it also may not adequately prepare an individual for returning to life in the "real world," with all of its associated stressors and triggers for relapse. Being away from the familiarity of family, friends, and job may itself cause additional stress and feelings of loneliness. Social and occupational demands continue to pile up during this absence, and family tensions may be intensified. These and other considerations have led to a greater reliance on outpatient treatment for those individuals who do not have severe medical or psychiatric complications accompanying their alcohol use.

Outpatient treatment enables the individual to practice strategies and skills learned in therapy in the "real world" and to bring new material and actual experiences into the therapy sessions. For individuals with more severe addictions, this may be accomplished in a day or partial hospital program in which therapeutic services are provided for several hours during the day or evening, after which the individual returns home for the night.

In either an inpatient or outpatient setting, the medications Disulfiram (antabuse) or Naltrexone may be prescribed as one part of the treatment regimen. When combined with alcohol, antabuse produces unpleasant physical effects, including headache, nausea, and anxiety. To ensure compliance with this aversive regimen, it is sometimes necessary to have a family member or significant other of the individual monitor daily ingestion. Naltrexone has effects very different from that of antabuse. Rather than induce illness, it blocks the pleasurable effects of alcohol by binding to relevant receptor sites in the central nervous system.

Some patients and treatment providers are very resistant to pharmacological treatment because they fear that it merely replaces one drug with another. It is important to recognize, however, that antabuse and Naltrexone do not have the same intoxicating effects as alcohol or other addictive drugs. Particularly in cases involving severe addiction, or those with severe psychosocial or medical complications, adjunctive pharmacotherapy may be very helpful, at least in the short run.

It is therefore advisable to seek consultation with a physician during the course of addiction treatment.

Historically, the content of addiction counseling focused on early life experiences and intrapsychic conflicts which were hypothesized to later result in addiction. However, empirical evidence has failed to identify common psychological conflicts or personality structures among alcoholics. Therefore, more modern approaches focus to a greater extent on alcohol-specific cognitions rather than unconscious psychological forces. For example, the goal may be to correct illogical or maladaptive thoughts related to alcohol (e.g., "Whisky is my best friend.") or to correct dysfunctional attitudes about oneself in relation to drinking (e.g., "I'm a worthless person, so I might as well get drunk.").

Behavioral strategies utilized in the treatment of alcoholism typically involve identifying "triggers" or "risk factors" for alcohol use and helping the person avoid these triggers. Therapy sessions may be spent practicing alcohol-refusal strategies and planning ways to minimize exposure to alcohol or alcohol-related stimuli. Group or family interventions may be particularly well-suited to developing and practicing these strategies. 15 Significant others, for example, are frequently reliable reporters about alcohol-related triggers and events. Similarly, in a group setting, the individual may learn about common triggers and coping strategies that have been identified or employed by other people.

By far the most common intervention for alcoholism is involvement in a self-help, "twelve-step" group such as Alcoholics Anonymous (AA). These programs generally focus on the goal of abstinence as opposed to reduced or controlled drinking. Participants receive group support, repeated reminders about the consequences of alcohol use, and
straightforward advice about methods for maintaining abstinence. AA is a spiritual (not necessarily religious) program that requires some belief in a power beyond oneself, and an acknowledgment of one's relative powerlessness over addiction in the absence of spiritual or communal support.

Although anecdotal testimonials to its effectiveness abound, the scientific evidence for the superiority of AA over other treatment approaches is largely lacking or contradictory. Nevertheless, one of the most effective components of AA is the appointment of a "sponsor" for each participant, who is available to provide guidance and assistance 24 hours a day. Another advantage of AA is that, in many geographic regions, open group sessions are available without prior appointment most evenings of the week. Finally, AA uses a peer group approach to instill a number of psychologically healthy values, such as sincerity, forgiveness, tolerance, gratitude, humility, self-care, and affiliation.

Not all people find the philosophy and structure of AA to be palatable. A common area of discomfort is the method for handling denial. At some point, AA participants are expected to publicly acknowledge their status as an alcoholic as well as their powerlessness over alcoholism as a necessary step towards recovery. Programs that are based more upon the Behavioral Model of addiction, in contrast, believe that such labeling is unnecessary and may even be counterproductive. Behavioral programs view alcoholism as a learned pattern, as opposed to a disease state to which one has unavoidably succumbed. Therefore, it is believed that acknowledging powerlessness over the disease may have the unintended consequence of making the person feel helpless about the future.

Some people find the group atmosphere of AA to be anxiety-provoking or discomforting.

Causes and Symptoms of Depression in Lawyers

If you are a lawyer who is suffering from depression, you are not alone. Several studies since the early 1990s have demonstrated that lawyers have among the highest rates of depression in the nation. For example, the North Carolina Bar Association surveyed close to 2,600 attorneys and found that about 37% of them admitted to feeling depressed, approximately 25% reported physical symptoms of depression (e.g., appetite loss, lethargy), and over 11% reported suicidal ideation at least 1-2 times per month in the past year. A study in the state of Washington surveyed 801 lawyers and found that 19% of them reported symptoms of clinical depression, a rate that was twice the national average for the general population. Finally, a Johns Hopkins University study found that of 28 occupational groups across the country, lawyers were the most likely to suffer from depression and 3.6 times more likely than average.

THE SYMPTOMS

Depression is commonly felt across several experiential domains. The most characteristic emotional symptoms include sadness, fear of rejection and failure, guilt and anger. Mentally, a depressed person is likely to express a sense of pessimism and hopelessness, low self-esteem and helplessness; in more severe cases, depression is also characterized by suicidal ideation.

These thoughts and emotions often accompany some degree of cognitive impairment, such as an inability to think and concentrate, loss of memory, and an inability to "find the right words." Such symptoms can have a devastating effect on a
speaking in front of other people, or they may not trust peers to exercise the same degree of discretion and confidentiality as licensed professionals. In contrast, others find group therapy to be the essential ingredient of successful treatment. In particular, it may be much more difficult to "con" or mislead other people who have "been there" themselves, and one might also expect to receive greater empathy and understanding from such persons.

Not all treatments are appropriate for all people. It is essential to find a good match between your own personal needs and the functional components of a particular program. Importantly, most programs share common core ingredients that appear to be essential for recovery. These include an opportunity to share feelings with others, to be heard, to be reinforced for abstinence, to reduce resistance in an atmosphere of trust, and to realize that you are not alone with the problem of alcoholism. Regardless of the specific program you choose, you are highly likely to receive some symptom relief simply by taking a measurable first step.

Lawyer's ability to work. Where attention to detail and logical analysis are crucial, mental impairment will usually reduce the speed and quality of the lawyer's work. There will be a greater likelihood of both administrative and substantive errors (e.g., failure to calendar, inadequate research), and that can lead to malpractice.

Depression is also characterized by a number of behavioral or physical symptoms, such as a sad facial appearance, crying, slowness of speech and movement, agitation, loss of appetite, sleep disorders, lowered interest in sexual activities, and various bodily complaints (e.g., stomach ache).

Current professional diagnostic methods presume that there are different types of depression, each of which have some distinctive features (e.g., intensity, duration). Many theorists also believe that the various depressions have distinct causes and require distinct treatments. Some symptoms of depression are symptoms of other ailments as well, both physical and psychological. For example, many of the behavioral/physical signs listed above can be indicative of alcoholism as well as depression. Indeed, alcoholism and depression often accompany each other.

Thus, especially in the more serious cases, it is recommended that proper diagnosis be sought from a qualified mental health professional. Oftentimes, a complete medical examination is recommended to rule out purely physical causes, such as viral infections, cerebral tumors, postpartum endocrine changes, or even medicinal side effects.

THE CAUSES

After many years of research, mental health professionals have reached a consensus on the symptoms of various types of depression, but not on their causes. There are those who believe depression is caused by genes or malfunctioning brain chemistry. Others think that environmental stressors and psychological habits are what cause depression.

As with all controversies of this type, there is a "chicken-or-egg" problem. Undoubtedly, depression involves both the mind and the body, but either one can cause the other. For example, it has been demonstrated that depression is both predictive of (cause) the onset of cardiovascular disease, as well as a common reaction to (effect) the onset of cardiovascular
disease. Thus, more and more experts are coming to the conclusion that there are various types of depression and that none of them can be explained by a single biological, biochemical, social, environmental or psychological factor.

Obviously, some of the mental health problems lawyers experience have little to do with their vocation. On the other hand, the fact that lawyers experience higher rates of depression than average indicates that certain aspects of being an attorney must contribute to the problem. The most likely agent to explain the higher rates of depression among lawyers is "occupational stress," which is caused by the discrepancy between the "demands" of being a lawyer and the "capacity" of lawyers to manage such demands. This is magnified by the high level of perfectionism among lawyers.

TREATMENT CHOICES

The majority of people with a depressive disorder do not seek professional help. This is sad in itself because depression happens to be a disorder that responds well to treatment in most cases. In severe instances of depression, such as when there is a high risk of suicide, hospitalization may be necessary. Generally, however, depressed patients are treated on an outpatient basis. Typically, treatment involves either psychotherapy, medications, or a combination of the two.

There are numerous schools of thought about how psychotherapy should be conducted with depressed patients. Some proponents of each approach claim that theirs is the best one. The truth is, that of the reputable psychotherapies, each has something valuable to offer, but none represents the ultimate answer. Here is a list of several types of psychotherapy:

Psychodynamic Psychotherapy - Sometimes referred to as "psychoanalytically oriented psychotherapy," the primary focus of this type of treatment is the examination of key relationships and experiences in a person's past and present, and how these are related to current problems. Change occurs through insight into previously unresolved conflicts and unconscious motives, which frees the person to make new choices.

Humanistic Psychotherapy - This type of treatment emphasizes the creation of a warm, supportive and non-judgmental therapeutic environment, in which the client feels free to engage in self-exploration and self-expression. It focuses on conscious thoughts and feelings, and current experiences. Change occurs because the positive therapeutic relationship encourages the client to experiment and grow.

Behavioral Therapy - This type of treatment applies learning principles to systematically transform a person's current self-destructive behaviors into adaptive behaviors. For example, a person who is prone to procrastination is taught concrete behavioral techniques to overcome this destructive habit. This brings about more positive or reinforcing real life
experiences, which in turn leads to more optimistic thoughts and feelings.

Cognitive Psychotherapy - The aim of cognitive therapy is to correct dysfunctional thinking patterns. For example, people who are depressed tend to anticipate the worst and react to negative events by overgenerahzing and personalizing their effects. A cognitive therapist will attempt to make a client aware of and question the validity of these thought patterns, and consider alternative points of view.

Couple, Family and Group Psychotherapies - There are a variety of approaches that involve more than just one person in treatment. These approaches will differ somewhat as a function of the therapist's underlying theoretical points of view. What they share in common, however, is the idea that people grow through relating, learning from, getting support from and giving support to others.

Which type of psychotherapy should you choose? In numerous scientific studies, cognitive therapy has been shown to be particularly effective with depression. The approach is called "cognitive" in part because it requires clients to exercise logical reasoning in solving life's problems. Since lawyers are trained practitioners of rational analysis applied to practical problems.

When seeking professional help, however, my advice is to look for a psychotherapist who appreciates the perspectives of several schools of thought, not just cognitive therapy. These other schools of thought have taught us a number of important lessons, including: the importance of helping patients understand how their current problems are often related to earlier life experiences; how helpful it is to examine and strengthen patients' personal relationships; that people do better with psychotherapists whom they perceive to be understanding, non-judgmental, caring and trustworthy; that modern medications for depression can be a useful tool as well.

Turning to the topic of medications, there are a number of highly effective anti-depressants available today. Among the latest is a type known as a serotonin-specific reuptake inhibitor. It helps restore the balance of serotonin in the brain, a neurotransmitter that has been found to affect moods. This type of medication is sold under such brand names as Prozac, Paxil, and Zoloft. An even newer type of medication that affects two neurotransmitters, serotonin and norepinephrine, is sold under the brand name of Effexor. These medications are both effective and have few side effects. It is best to have them prescribed and their effects monitored by a psychiatrist. Nevertheless, most family physicians are familiar with these drugs and commonly prescribe them in less severe cases of depression.

While there are times when all that is needed are medications, in general, they are most effective in combination with psychotherapy. Medications take the edge off negative moods, help clarify thought processes, and increase patients' ability to participate in psychotherapy. What medications don't do is help people correct their core negative beliefs about themselves and the world, most of which have been learned over a lifetime of experiences. Changing such beliefs often requires more than just medications.

SELF-HELP FOR MILD DEPRESSION AND EXCESSIVE DRINKING FOR LAWYERS

If your symptoms of depression or alcoholism are chronic or acute, the best advice I can give you is to seek help, either from a professional or a self-help organization. However, if your symptoms do not warrant outside intervention, there are a number of steps that you can take on your own. The fact that the rate of depression and alcoholism among lawyers is at least twice the national average, suggests that part of the problem is the stress that comes with the practice of law. Here are some steps you can take.

DEALING WITH MILD DEPRESSION

The first thing to do when you are depressed is to improve your eating, drinking, exercise and sleep habits. These steps will help lift your sadness by affecting certain mood altering brain chemicals. Unfortunately, depressed people tend to do just the opposite; they disregard their diets, increase their alcohol or drug intake, stop exercising and don't adhere to a normal sleep schedule. You need to resist such urges.

Similarly, when you are depressed you need to pay particular attention to certain external or environmental factors that contribute to the way you feel. For example, depressed people tend to isolate themselves and become more idle. You need to do just the opposite. As much as possible, surround yourself with people you like and keep yourself busy. If you can't seem to do your important work effectively, do the less important work or even your chores. Make an effort to schedule experiences that will raise your spirits or cause you to laugh. You will be surprised how difficult it is to stay depressed under the influence of uplifting environmental forces.

Ultimately, however, you will need to confront the negative thoughts and emotions that are at the core of your depression. The first thoughts you may need to face are: "I can't do anything about my depression. Nothing will work." Ask yourself to only imagine doing some of the things that are recommended throughout this article. Then, ask yourself to try implementing just one or two of them. Once you shift from a passive to an active mode, and begin to actually work on solving your problems, you will find that some of your gloomy feelings may start to be replaced by glimmers of hope.

Depressed people often have a number of mental habits that are very dysfunctional. They tend to assume the worst, discount the positive, personalize events, blame themselves or others, overgeneralize and magnify things. These habits are embedded in statements like the following:" Unless I get a few more cases soon, this practice is doomed; people are not calling because I must not be that good." Thoughts like these need to be brought into conscious awareness, cross examined and revised.

Another common trait among depressed people is that they tend to be perfectionistic about what they expect of themselves, what they think others expect of them, and what they expect of others.Such expectations evoke a great many "should" statements, which in turn trigger guilt, fear of failure and fear of rejection. Using the techniques described elsewhere in this article, become aware of your perfectionistic thoughts and revise them. Strive for excellence, not perfection. Expect complications and recognize that the probability of your making errors is 100%. Adopt the attitude that there is no such thing as failure, only opportunities for improvement. Learn to measure your success by whether you are moving in the right direction, and not always by whether you have achieved your ultimate goal.

Since much of the advice here involves changing part of your personality, it could be one of the most difficult tasks you will ever undertake. For this reason, you may want to consider the possibility of seeking professional help.

DEALING WITH EXCESSIVE DRINKING

When it comes to excessive alcohol consumption, the first and best thing you can do for yourself is admit that you have a problem. Most people who drink too much simply deny it. If a little voice inside of you or someone who cares about you says that you are drinking too much, you probably are. There is an easy experiment that you can conduct to prove to yourself that you do not have a problem: stop all alcohol consumption for several weeks.

People who don't have a drinking problem, may find it inconvenient to abstain from alcohol for several weeks, but they are able to do it without much difficulty. If you can't abstain from drinking alcohol, find it difficult to do, or get irritated at the thought of it, then it is very likely that you do have a problem. Unless your condition is truly minimal, the best self-help advice I can offer you is to seek the aid of a professional or of a self-help group that specializes in this area. If yours is not a serious drinking problem, however, you can attempt to confront it yourself.

First, get a better understanding of why it is so difficult for you to abstain from alcohol. Determine the psychological role alcohol plays in your life, objectively measure the amount and frequency of your alcohol intake, and think about the negative effects that this has on you. Although it does take a little extra effort, you will get more insight into your drinking behaviors if you keep a daily diary of them. By way of further evaluating your drinking problem complete the following check list of alcohol dependency signs:
 

• Do you rely on alcoholic drinks to help you relax or be comfortable in social situations?
• Do you rely on alcoholic drinks to help you think better, be more creative, or work harder?
• Do you rely on alcoholic drinks to help you manage your moods, feel less depressed or tense, or forget your problems?
• Do you find yourself thinking about or having an urge to get an alcoholic drink at different times of the day?
• Do you often find yourself drinking more than others around you?
• Do you often experience regret about your drinking patterns?
• Do you find yourself lying or giving excuses about your alcohol intake?
• Do you often drink alone or hide liquor?
• Do you get intoxicated and have hangovers or memory blackouts?
• Is your drinking affecting your daily activities, such as being on time or getting your work done?

Once you have a better understanding of your drinking problem, try again to abstain from alcohol use for several weeks. Before doing so, know that all human experiences can be viewed as being composed of the following sequence of elements:

Stimulus > Thought > Emotion > Behavior

Since what you are trying to reduce is behavior, one way to proceed is to gain better control of the elements that precede it. For example, one thing you can do is get control of the stimuli or environmental factors that contribute to your drinking behaviors. This may include disposing of the liquor that you have at home or in the office, or refraining from going to places where liquor is readily available. You will find it much easier to reduce your drinking urges and behaviors when less liquor is available.

Similarly, you will need to get control of drink inducing thoughts and emotions that get triggered by external stimuli. Let us say that you have gone out to lunch with a client who orders a drink. When the waiter turns to you, you may find yourself thinking: "My client will be offended if I don't order. Besides, a drink will make me feel less anxious." These thoughts will trigger such emotions as fear of rejection and hope that tension will be reduced. The emotions will impel you to say: "I'll have a martini, please." If you learn to interrupt such thoughts and emotions and practice replacing them with healthier ones, your drinking patterns will change for the better. You can systematically root out the thoughts and emotions that trigger your drinking behaviors.

HOW TO GET HELP

If you are ready to reach out for help with your mental health or substance abuse problems, the organizations listed below will provide you with educational materials, lists of appropriate self-help groups, and referrals to mental health professionals. All of them are sensitive to your concerns regarding confidentiality. I recommend that you try their world wide web sites first, as they will provide you with much of the information you desire right on your computer screen and will link you to many other relevant resources.

LAWYER-SPECIFIC RESOURCES

In 1988, the American Bar Association created the Commission on Lawyer Assistance Programs (CoLAP; formerly known as the ABA Commission On Impaired Attorneys) and charged it with the task of educating the profession on both legal and treatment issues related to substance abuse and mental illness. In addition, the Commission has been supporting the development of lawyer assistance programs throughout the United States, Canada and Great Britain. It publishes a Directory of State and Local Lawyer Assistance Programs, educational materials, pamphlets, audiotapes and videotapes.
For further information contact:

Commission On Lawyer Assistance Programs
http://www.americanbar.org/groups/lawyer_assistance.html

In addition to contacting CoLAP (above), you can locate local organizations, self-help groups and professionals who provide helpful services to lawyers, by referring to your local legal directory, contacting you local bar association, or reading the relevant ads and articles in your local legal publications. Lawyer Assistance Programs (LAP) are now available in most localities. Their purpose is to help prevent and treat lawyer impairments through education and intervention oriented services. Most LAPs have toll-free hotlines. They take great care to protect the confidentiality of all communications and are an excellent resource for getting both legal and treatment information.

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

A number of agencies under the U.S. Department of Health and Human Services can provide you with valuable information and advice regarding a wide range of mental health and substance abuse problems. Much of it is free for the asking. For further information contact:

National Institute of Mental Health (NIMH)
http://www. nimh.nih.gov/

The National Clearinghouse for Alcohol
 http://www.health.org/index.htm

National Institute on Alcohol Abuse
and Alcoholism (NIAA)
http://www.niaaa.nih.gov/


SELF-HELP GROUPS

Self-help groups are designed to empower people who share similar concerns by bringing them together. They provide emotional support, information and practical help. There are self-help organizations for a wide range of problems, ranging from alcoholism and depression to coronary disease, gambling, debt and single parenting. Many groups have national offices with local branches throughout the US. Local branches can be found in your telephone directory, under the special section that lists human services. Most self-help groups will mail you a free set of informational materials with no questions asked. Here is a list of several national organizations that will provide you with useful information and a list of local self-help groups:

Alcoholics Anonymous (AA)
http://www.casti.com/aa/

International Lawyers in Alcoholics Anonymous (ILAA)

Secular Organizations For Sobriety (SOS)
http://www.codesh.0rg/sos/#whatis

National Mental Health Consumers'
Self-Help Clearinghouse
http:/www.libertynet.org/~mha/cl_house.html


PROFESSIONAL HELP

Finding a mental health professional is like finding a lawyer. Most people think that it is best to get a personal recommendation from a family member, friend or physician. Alternative methods include looking in the local telephone directory or seeking referrals from professional organizations, universities, and hospitals. In addition, there is the option of calling someone whose name appears in the media.

The are three basic types of mental health professionals: psychologists, psychiatrists and social workers. At times, each of these professions claims to have superiority in certain domains. For example, some psychiatrists claim that their ability to prescribe drugs as well as administer psychotherapy, makes them uniquely qualified to treat all mental illnesses. Some psychologists claim that their greater reliance on psychotherapy than on drugs and their special expertise in testing, makes them better diagnosticians and psychotherapists. In truth, however, such generalizations are simply not useful in finding someone to help you with your specific set of problems.

It is best to rely on the reputation of the particular professional rather than of his or her profession. Interview several mental health professionals before making a choice. The initial meeting, often granted at no cost, can help you establish the individual's credentials, experience, treatment preferences, and personality. Liking and trusting your provider is important
in general health care, but it is critical in mental health care. Similarly, since much of the treatment will require your collaboration, the treatment strategy needs to make sense to you. Remember that it is possible for you to work with more than one provider. For example, a psychologist or social worker can act as your psychotherapist, while your family physician or psychiatrist monitors your medications.
 

• See Law School: The Most Depressing Three Years of Your Life for more information.