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Ten Things Every Lawyer Should Know About Substance Use

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Ten Things Every Lawyer Should Know About Substance Use

Addiction is a great equalizer. Among attorneys, substance use is particularly concerning; it is pervasive and covert. Approximately 50-75% of lawyer discipline problems involve substance use. Paradoxically, the qualities that can propel a lawyer to success can also put a lawyer at risk. In this presentation, we introduce ten things that every attorney should know about substance use. Topics include the incidence of substance use disorders, contributing factors, the ethics of impaired lawyering, strategies for addressing substance use, and practical tips for increasing resiliency.

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Jason Potter: Welcome to 10 things every lawyer should know about substance-use by Quimbee. My name is Jason Potter, and I'm a staff presenter at Quimbee, thanks for joining us. In a New York Times article, "The Lawyer, the Addict." Eilene Zimmerman reflects on the tragic death of her ex-husband, Peter, a prominent partner at a Silicon Valley law firm. She writes, "One of the most successful people I have ever known died a drug addict, amidst half filled syringes, a spoon, lighters, a tourniquet, and many pill bottles." Reflecting on the wreckage of the day she discovered him, Miss Zimmerman notes that, "Of all the heartbreaking details of his story, the one that continues to haunt me is this, the history on his cell phone showed that the last call he ever made was for work. Peter vomiting, unable to sit up, slipping in and out of consciousness had managed somehow to dial into a conference call."

   Although strides have been made to change the culture of the legal profession, a culture of ambition, perfection, and self-sufficiency continues to permeate profession. Substance-use can be regarded as a quick release from the overwhelming pressure or a means to keep up, and it's effective until it's not anymore, and when it's not, the results can be tragic as it was in Eilene Zimmerman's husband's case unless it's treated. In this presentation, we'll introduce 10 things that every attorney should know about substance-use, we'll look at the research, we'll present important resources for seeking help or for helping others in need, and we'll introduce, and even practice some coping strategies to help increase resiliency in this demanding profession. Substance-use can be a matter of life and death, and will be displaying a few QR codes on your screen during the presentation, so you can place some of the resources we mentioned directly into your smartphone for quick access in a time of need.

   Number one, substance-use by lawyers is pervasive and underground. There really isn't much research on drug use among lawyers or drug use among lawyers versus white collar professions or versus the general population, for that matter. The most comprehensive, most sighted research involving the issue of attorney substance-use is a 2016 American Bar Association Commission on Lawyer Assistance Programs, Hazelden Betty Ford Foundation study, it was a survey of 12,825 licensed working lawyers from 19 states. There was roughly an even split of men and women, mostly Caucasian are 91.3% in fact, the survey measured the prevalence of concerns about depression, anxiety, stress, alcohol use, and substance-use, whether the participants had sought treatment before, and what barriers stood between them, and needed treatment or help. It assessed alcohol use drug use and mental health symptoms using three or four diagnostic tests.

   One survey used is called audit, it was developed in 1982 by the world health organization, it's one of the most accurate screening to tests for dependency, this survey is actually included in your course materials as an example. In terms of alcohol, according to the research of all legal and illegal substances listed, alcohol use is the most frequent substance that attorneys turn to, approximately 84.1% of respondents indicated that they've used alcohol within the past year contrast the general population which is about 65%, in fact, attorneys drink in a manner consistent with alcohol use disorder at a rate higher than any other professional career, the rate for problem drinking among this cohort was about 26% contrast physicians and surgeons who have a rate of approximately 15.5%, and contrast the general population of which 6% of adults over 26 qualify as problem drinkers. In terms of mental health, 28%, 19%, and 23% struggled with depression, anxiety, and stress, respectively. 61% said they had concerns with anxiety at some point in their careers, and 46% of respondents indicated they had concerns with depression at some point. So as compared to the general population, lawyers have three to four times the rate of depression, and two times the rate of problem drinking.

   Now substance-use, 3,419 attorneys surveyed answered the questions about substance-use, and that means that about 75% of the attorneys skipped every question about substance-use on the survey of those who did answer these questions about use within the past year. Here's the breakdown, of those who did answer approximately 15.7% said they use sedatives, 10.2% said they used marijuana, 5.6% said they used opioids, 4.8% said they used stimulants, and 0.08% said they used cocaine. While the study concluded that attorneys have greater alcohol use, depression, and stress than the general population, the data was inconclusive regarding the rate of substance-use versus the general profession, almost 21% of attorneys who had indicated they used drugs in the past year, indicated an intermediate level of concern about their use, only 3% indicated that had severe concerns, these figures don't jive with anecdotal evidence about substance-use among lawyers.

   A reported 50 to 75% of lawyer discipline problems involve substance-use, and these types of disciplinary issues are not uncommon. According to one New York recovery center, opioid addiction and addiction to benzodiazepines or Xanax are two major trends among lawyers. The recovery center reported that almost every attorney that comes in for treatment, even if they drink are also using drugs, Xanax, Adderall, opiates, cocaine, and crack, there are also numerous reports of legal stimulant usage like Adderall turning into illegal stimulant usage such as methamphetamine, one attorney reported using Adderall for productivity then turning to crystal meth when he could no longer receive a prescription for legal stimulants, "I would stay up all night and work from home so I could use crystal, then at the firm the next day do bumps in the bathroom so I could stay awake and see clients, and then I'd do it all over again." A lack of conclusive data and potential under-reporting are not surprising, alcohol is legal, alcohol is socially acceptable. As one author of the ABA study said, "Admitting you drink too much is not directly at odds with your role as a licensed attorney." And the opposite is true for illegal drug use.

   Number two addiction to substances is not a choice. Addiction to substances diagnosed substance-use disorder is severe substance-use typified by a laser focus on using particular substances so much so that it overcomes the individual using them. They keep using those substances even when they know it's creating issues in their lives, this according to the American Psychiatric Association, so severe substance-use is a diagnosed psychiatric condition. The newest revision of the diagnostic manual for mental disorders or DSM five defines substance-use disorder as a problematic pattern of using alcohol or other substances that result in impairment in daily life or noticeable distress. In the DSM five, each specific substance is addressed as a separate use disorder, alcohol use disorder, stimulant use disorder, and so on, and almost all are diagnosed through the same criteria. According to the APA, the list of substances to which people can develop addictions are alcohol, marijuana, PCP or LSD or other hallucinogens, inhalants, opioid painkillers like codeine, oxycodone, and heroin, sedatives, cocaine methamphetamine, and tobacco.

   Substance-use disorder is a primary chronic disease of the brain that affects the reward, motivation memory, and related circuitry. A primary disease means that an addiction is a lot more than a behavioral problem, when we see a friend or family member take on some harmful behaviors, like spend all their grocery money on scratch tickets or devour a box of Oreo cookies or dye their hair over and over to the point of hair loss, we tend to fixate on the compulsivity of this, and we might suggest some be behavioral changes like, "Stop buying scratches, if you want to lose weight, lay off the Oreos or girl give that hair a rest." Substance-use disorder is also chronic, think of it like diabetes or HIV, they're not curable, they are deadly without engaging in a full range of treatments, but they can go into long term remission, and those with them can lead healthy lives with proper, acute, and long term care.

   For substance-use disorder, the harmful behavior of using drugs which was likely a choice initially progresses, and that behavior becomes a symptom of a disease that's lodged in a number of places in the brain, drug use is no longer a choice at this point, so telling people with substance-use disorder to just stop is an improper focus on the symptom and not the underlying problem. Substance-use also typically starts as a behavioral coping strategy. If your job is stressful, you might decide to eat at a favorite restaurant, drink glass of wine, exercise or walk the dog, knit, go hunting or do cosplay. Drug use disorder can start as a quick and effective way to connect, to relax, to escape or to be productive, but it can easily, and unconsciously become the go-to strategy. After all, it initially seems so effective, one attorney said that she suddenly started associating Adderall with producing good work product, and it went downhill from there.

   Focusing on changing behavior might work depending on how hardwired that compulsion is, the causes of this progression boil down to psychology, environment, and biology. It's understood that genetics and biology are at least 50% of the cause. Psychology and environment also play roles, nothing about these causes are a matter of willpower or choice. Some people's use may not progress depending on these factors. From a clinical perspective, it's not about the drugs, in the words of Dr. Michael Miller, "Addiction isn't just a social problem or a moral problem or a criminal problem, it's a brain problem." Sometimes the behaviors attendant to addiction like possession of illegal drugs are criminal, but it's not about the drugs, it's not about bad choices or moral bankruptcy, addiction is about hard-wiring, not the behaviors that hard-wiring commands.

   Number three, good lawyers are especially at risk. There's a normalized culture of relief seeking and escapism in the legal profession, it shouldn't come as a surprise given the numerous stressors for lawyers, including workload, long hours, lack of vacation, billable hour expectations, interpersonal difficulties, little support, comradery or mentorship, I could go on. As the desire to escape increases the vulnerability to substance-use a highly effective means of escape also increases, this vulnerability is amplified by the normalized culture of substance-use in the profession, drinking has been the accepted go-to activity to celebrate a big win or blow off steam after a long week or to meet and make friends with clients, so lawyers are already made vulnerable by their environment. Now substance-use disorder feeds on the qualities that make you a good lawyer, for example, a good lawyer is self-sufficient, but when not in check, this can lead to feelings of isolation, it often leads to lack of support, lack, mentorship, and peer support, lawyers are trained to figure it out themselves, this can lead to a reluctance to ask for help.

   A good lawyer is also a problem solver, but left unchecked, this can lead to controlling and unfeeling behaviors. Lawyers are trained to think rationally in the film double jeopardy in 1999, one character said, "I'm a lawyer, what we think isn't supposed to matter." And if what a lawyer thinks doesn't matter, then how a lawyer feels is even more irrelevant, that's not thinking rationally. When a law student in class says, "I feel that the law is wrong here." For example, it's not unheard of for a professor to respond, "I don't care what you think, what does the law say?" A good lawyer is also detail oriented, but unchecked, this can lead to perfectionist behavior year. The existence or non-existence of the Oxford comma has been the deciding factor in a number of contract and labor disputes, this is the type of focus on detail that lawyers need to bring to their work.

   A good lawyer is also a zealous advocate, it's high stress and it's competitive. A good lawyer is also a multitasker, but that can lead to serious pressure and a lack of time to decompress. Task juggling attorneys abound, but multitasking has been proven to be inefficient and distracting, and the longer the multitask goes on, the more difficulty people have keeping it all sorted out in their brains. A good lawyer is also able to endure stress, but when left unchecked, this can lead the lawyer to have feelings of invulnerability, all of these things can make you a highly successful law lawyer, but they can also lead to substance-use disorder.

   Substances are a temporary, highly efficient way to bring you from isolation to connection, from control to escape, from perfectionist to more of a perfectionist, from high stress to relaxation, from lack of time to lack of sleep, from invulnerability to invincibility, add to this that fact that many attorneys are already carry with them mental health challenges that could easily have taken root during law school, in fact, in a 2015 wellness study of law students polling 4,000 law students from 15 law schools, 42% said they needed help with mental health issues, responses of 25% of them indicated that they should have follow up regarding alcohol use disorder, 14% reported using prescription drugs without a prescription in the last year, 27% reported having an eating disorder, and 21% reported having suicidal thoughts. Another study of law students reported that before law school, 8% reported concerns about alcohol, by the third year of law school that rose to 24%, and famously in one Yale Law School study, 70% of law students polled experienced depression. The place of higher education where attorneys learn to practice law is a pressure cooker, there's pressure to study long hours, to score some Adderall, and extend study time, and manage life commitments, the cost, the expectation, the expectation of exhaustion, the drive for perfection, and the desire to escape it all.

   One reason the rate of mental health issues among law students is so foreboding is that the research shows that co-occurring conditions like depression or anxiety can drastically increase the severity of substance-use. As the national task force on lawyer wellbeing concluded, too many lawyers and law students experience chronic stress, and high rates of depression, and substance-use, the current state of lawyers health cannot support a profession dedicated to client service, and to dependent on the public trust. So we have a high level of risk, but we also see a high level of fear about seeking help.

   Number four, the longer the road to getting help, the shorter the road to discipline. An important study in the International Journal of Law and psychiatry found that the longer attorneys with substance related problems remain untreated, the more likely they are to be defendants in malpractice suits, that study found that 60% of the attorneys who entered the Oregon State Bars Professional Liability Attorney Assistance Program, had a malpractice suit filed against them while suffering from substance-use. Now, many personal factors can lead to disciplinary issues, depression or other mental health issues, unaddressed physical or health related issues, substance-use disorder, financial stress, career burnout or serious family issues. Unlike the others, however, the personal factor of substance-use is often by its very nature, a criminal activity, and when substance-use disorder substantially affects the representations, this may lead attorneys to avoid seeking help until things get really bad, and when substance-use disorder substantially affects the representations, this may lead to malpractice suits regarding attorney competence.

   Enter rule one, ABA model Rule 1.1 states, "A lawyer shall provide competent representation to a client, competent representation requires the legal knowledge, skill, thoroughness, and preparation reasonably necessary for the representation. Comment one states that one relevant factor is the level of preparation and study the lawyer is able to give the matter. Comment two highlights some important skills, requiring sound, reasoning, critical thinking, and synthesis. Rule 1.3 may also come into play, we've included this in your course materials. Rule 1.3 states, "A lawyer shall act with reasonable diligence and promise in representing a client." Comment one indicates that this means with zeal and without unreasonable delay. Rule 1.16(a)(2) states in relevant part, "A lawyer shall not represent a client or where the representation has commenced shall withdraw from the representation of a client if the lawyer's physical or mental condition materially impairs the lawyer's ability to represent the client." This is an important one, it may not take a separate criminal act to implicate rule eight.

   If an impaired attorney commits a criminal act that implicates Rule 8.4(b), 8.4(b) states, "It's unprofessional misconduct for a lawyer to violate or attempt to violate the rules, commit a criminal act that reflects adversely on the lawyer's honesty, trustworthiness or fitness as a lawyer in other respects, (c), engage in conduct involving dishonesty, fraud, deceit or misrepresentation, and (d), engage in conduct that is prejudicial to the administration of justice." Even if an attorney hasn't been charged with any crime of use or possession, at least one court has found that a finding of use and possession by a disciplinary board can trigger a violation of Rule 8.4(b).

   Now, there are several ways that disciplinary action could be initiated against an attorney with substance-use disorder. First, a client files a complaint against an attorney for lack of competence, failure to communicate, misappropriating client funds, and so on. Second, the attorney could be arrested for driving under the influence, and the DA notifies the state bar, especially if the attorney hasn't already done so. Third, the attorney self-report it's upon suspicion of malpractice, and fourth, an interested party, like a clerk, a judge, an attorney on the other side calls the bar to notify them that the attorney has a problem. It's important to note that ABA model Rule 8.3(a) doesn't require reporting an attorney without actual knowledge of the unethical conduct, states have treated this differently in the context of substance-use, actually. Rule 8.3 states, "A lawyer who knows that another lawyer has committed a violation of the rules of professional conduct that raises a substantial question as to the lawyer's honesty, trustworthiness or fitness as a lawyer in other respects, shall inform the appropriate professional authority. Some states have broader reporting rules than the ABA rule though make exceptions for attorneys who formally seek assistance while the ethical issues implicated by attorney substance-use are significant, disciplinary bodies and judges are making huge progress in supporting attorney recovery efforts.

   One court stated that the whole purpose of the disciplinary process is to protect the public, and the legal profession while also assisting the lawyer to successfully overcome their addiction, and regain their status as a productive member of society. Number five, when the profession supports an attorney's recovery, the results can be outstanding. There's exquisite proof of this in the recent case of Lawyer Disciplinary Board versus Sidiropolis, it's a West Virginia case from June 7th of 2019. In that case attorney Sidiropolis, we'll call him Mr. S, practiced law in West Virginia, to manage the pain from a car accident, Mr. S was prescribed opioid pain killers in large quantities. He tried many different types of therapy for his pain, but the opioids per provided the quickest relief from the pain, and allowed him to work. Five or six years later, Mr. S realized he was addicted to them and couldn't stop, because he couldn't get the medication from the clinic anymore, he started getting it off the street, he tried various techniques for kicking the habit, but nothing worked.

   So he continued to use the drugs and due to their high cost, he resorted to heroin, it was stronger and cheaper. Mr. S still practiced law while using heroin, but he started winding down his practice so he could seek inpatient treatment, about that time, Mr. S did a run for heroin and was stopped by police who discovered 10 bricks of heroin in his car. Upon his arrest, Mr. S self-reported the incident to the state disciplinary body facing serious federal drug charges, he contacted co-counsel at his firm who agreed to take on his representations. Mr. S joined a 12-step program and contacted the state Lawyer Assistance Program to get help for his addiction. Mr. S was accepted into the federal drug court program and started a rigorous program of daily group therapy, cognitive behavioral therapy, individual therapy, and community service. Once he completed the program, the federal charge against him was dismissed, during the disciplinary process the court was presented with testimony by his past and present program sponsors describing his passion, dedication, and time commitment to going through the 12-steps to his faithfulness, to his recovery, as well as his efforts to help others that extended above and beyond.

   Mr. S was involved in starting a retreat for recovering addicts so they would have some place to go on a holiday, he also helped start a new narcotics anonymous meeting, he became a sponsor and was soon sponsoring about a dozen young men. After Mr. S's charges were dismissed, the Lawyer Disciplinary Board filed disciplinary charges against Mr. S saying Mr. S had violated Rule 8.4(b) of the state's code of professional conduct by committing criminal acts involving heroin. The facts, violation, and sanctions were stipulated by all parties. In its decision, the Supreme Court of Appeals of West Virginia declared that, "A lawyer is a key player in our legal system, and a lawyer committing a serious criminal act is not to be taken lightly. Such an action certainly damages the public's perception of lawyers and by extension our legal system." However, the court found that the evidence established that Mr. S was an individual who is not only passionate and committed to maintaining his own sobriety, but someone who has gone to great lengths to help others overcome their addictions, the court also noted that Mr S performed 500 hours of community service, and submitted to more than 150 urine screens with all of the tests being negative.

   The court was moved by Mr. S's statement that he felt a real duty to share recovery with other people, and I can't do that and return to drug use. In weighing the proper sanction, the court stated, "The conduct underlying these disciplinary proceedings is quite serious and reflects how addiction issues particularly involving heroin are becoming too common, however, this proceeding offers encouragement that recovery is possible with the proper assistance." The court's stress that Mr S's criminal act can't be ignored, the court also went out of its way to recognize Mr. S's hard earned recovery, and his dedication to his own sobriety, and to that of others around him, the court mandated a two year suspension, but also affirmed great strides Mr. S had achieved to make amends for his conduct, to restore his competence as a practicing attorney, and to help others overcome addiction. Mr. Sidiropolis' story is a powerful illustration that there have been great strides in the legal profession support for lawyers with substance-use problems. It's also a moving and not uncommon example of the recovery and redemption that can occur once a lawyer gets help, whether that's voluntary or not.

   Number six, it's possible to get treatment discreetly. Attorneys with drug use disorder have reported the following reasons for not seeking treatment, concerns about privacy and confidentiality, not wanting other people to discover that they need help, a perceived inability to or perceived difficulty with taking time off for treatment. So let's address these right now, first, there are numerous programs that are confidential, every state, as well as the District of Columbia, Puerto Rico, and the US Virgin Islands has a Lawyer Assistance Program that exists to support law students, attorneys, and judges who are struggling with substance-use as well as a range of other issues such as mental health, family challenges, burnout, stress, and others. For example, the Massachusetts LAP, lawyers concerned for lawyers, holds groups for practicing lawyers with ADHD, for super moms, for professional conduct, and for substance-use recovery.

   Some LAP programs such as the Oregon Attorney Assistance Program offer counseling for compulsive and challenging behaviors even planning for retirement, these programs typically provide direct counseling or referrals to other treatment options, some like the Texas Lawyers Assistance Program assists with funding for inpatient treatment, the North Carolina LAP facilitates interventions, LAPs are usually completely separate from disciplinary authorities. Many programs are open to both lawyers and their families, spouses or significant others, these programs are often staffed by attorney volunteers who are in recovery, so reaching out to a state LAP is an excellent way of making like-minded contacts, these programs are free and always confidential. So the QR code that I've placed here will scan a link onto your phone with a QR reader, and that link is a link to the ABA's Directory of National LAP programs, so there are LAP programs listed and helpful resources for every state and territory.

   Second, the reasons for an attorney's absence can also be kept confidential. If an attorney has substance-use disorder and any other serious mental health disorder like bipolar depression, the logistic taking time off aren't difficult under the federal Family Medical Leave Act as well as state analogues , and access to mental health information must be strictly controlled under these laws. FMLA leave can absolutely be taken for substance-use treatment as long as the treatment is provided by a healthcare provider or a provider of healthcare services on referral, it doesn't cover absences due to substance-use, just the treatment part. To determine if FMLA applies to you, FMLA requires employment for at least 12 months and at least 1,250 hours of employment in the year proceeding. Also, the employer must have 50 or more employees within 75 miles, both of those conditions must apply to receive FMLA benefits, but if they don't check state Family Medical Leave Law, they tend to be broader, also there must be presence of a diagnosed serious illness, the individual will must have a diagnosis, but the diagnosis isn't required to initially apply for the leave, the individual just needs to provide enough information to the employer indicating that the leave is due to an FMLA protected condition.

   For example, on the application, one may indicate a serious mental health disorder, and that can be enough, initially, you have to submit the required paperwork and the employer may require you to submit a certification of a provider, it requires detailed information about the medical condition at that point. If the employer has an HR, only one person in that department is permitted access to that information, and they're held to strict confidentiality requirements. If the employer doesn't have an HR department, the ultimate recipient is also held to a strict confidentiality requirement. If the application is approved, the leave will be unpaid, but the job will be secure for 12 weeks unless you are considered a key employee, there's an excellent guide on FMLA leave in the course materials. At the firm management level, it's important that attorneys understand that if an attorney has a serious health problem, client matters can and must be handled by other attorneys, and everyone at the firm should be aware that a serious health problem under FMLA and state analogues includes addiction.

   Number seven, recovery requires willingness and vigilance. When someone with substance-use disorder seeks treatment and stops using, they are said to be in recovery. Recovery is the process of change through which an individual achieves abstinence and improved health, wellness, and quality of life, it's the ongoing process of putting and keeping substance-use disorder in remission. Like other chronic diseases, achieving and holding onto recovery requires both the support of family, peers, and the community, it requires fundamental lifestyle changes and may even require or incite a complete change of core values. One attorney reflecting on his road to recovery said, "I had to change everything, I couldn't just be around old faces and places anymore, and that included a stressful work environment, they were just too triggering." It requires vigilance because I am unconsciously attracted to the dark side, with many decisions I make at work and in life, I need to ask myself, "Is this going to take me closer or distance me from my drug of choice?" If the answer is closer, I think about everything I've gained from being in recovery and everything I lost in active use before I act on that decision.

   Another attorney in recovery said, "I didn't know what my values were before I started recovery." Maybe my values bounced between seeking perfection and seeking relief, and certainly career success was thrown in there. Through recovery, I have learned what my core values really are, and their broader life values that I can also apply to my work as a lawyer, they are presence, authenticity, vulnerability, and community. To me, these are the markers of success now in life, and in the legal profession. There's a wide range of clinical resources available to recover from substance-use disorder, some of these clinical resources available include, but certainly aren't limited to inpatient acute overdose treatment, inpatient detoxification, substance-use treatment programs can be inpatient, residential or outpatient, sober-living environments, behavioral therapies such as coping strategies, craving mitigation, dual diagnosis treatment, and group and individual therapy, support groups like 12-step programs, and long-term relapse prevention. Now we're going to examine several of these options, first, substance-use treatment programs.

   When an individual first enters treatment, the appropriate level of care must be determined, according to the American Society of Addiction Medicine, level .05 is early intervention, level one is outpatient services, level two is intensive outpatient hospitalization service, these are typically appropriate for those who have stopped using and need recovery skills, relapse skills, and behavioral therapy, level three is a residential inpatient service, it can be low intensity to high intensity, and these are typically appropriate for patients who have functional in impairments or require a stable space to help with recovery. Many individuals just can't recover from substance-use disorder unless they go to another controlled environment, so they are removed from the triggers in their lives as well as from access to the drugs of their choice. And level four is medically managed intensive inpatient services, these are appropriate for people with functional deficits like withdrawal risks, serious medical or mental health issues, issues that prevent the person from progressing in recovery, they may be voluntary or involuntary as is the case when a patient presents a serious danger to themselves or others. Now, the patients typically travel between levels of care through the continuum. These programs have a range of costs from fully covered by insurance to up to $60,000 for a private luxury 30 day residential treatment program like the Betty Ford center. Lawyer Assistance Programs can help guide the impaired attorney to an appropriate program, a primary care physician can also assist.

   Next, I want to touch on sober-living environments. For someone in recovery, the first year of recovery is the most demanding, while an attorney in early recovery has made significant changes already, their home and work environments may not have changed, and may present the same triggers. Those in their first year are told that recovery must come first above anything else, this is because relapses during the first year are so common, although some substances like heroin and methamphetamine have higher rates of relapse, the risk of relapse is great for all substances especially given the culture of stress and perfection in lawyering. Back in that environment, attorneys can easily and unconsciously resort to the same harmful behavioral coping strategies that led to their addictions in the first place, this can happen for people with all chronic diseases, only 50 to 60% of patients typically fully comply with their treatment protocols.

   One option for legal professionals in their first year of recovery is starting off in a sober house. A sober-living house is a home where individuals in recovery reside temporarily as a means to transition back into their lives, these homes are usually located in residential neighborhoods, they don't have a clinical feel, they're homes, they facilitate connection with others in recovery, and they're protected by rules and guidelines that support recovery, they typically require, for example, periodic group meeting, attendance and chores, and they range in size, cost, and comfort, and they may be geared towards men, women, people of color, and LGBT individuals, for example. They can also be full of working professionals including medical and legal professionals, in fact, it's not unheard of to have two to three working attorneys from prestigious law firms even law professors or other legal professionals in recovery under the same roof. Living in a sober-living house doesn't require one to give up one's permanent home, you just can't be there while you are a member of the sober-living house, and no one at work has to know where you sleep. Sober-living homes are a fantastic discreet option for attorneys in recovery who need support during non-working hours.

   Number eight, it's all about connection. In the Ted Talk, everything you know about addiction is wrong, journalist Johann Hari reviews recent research on the underlying causes of addiction, and concludes that the opposite of addiction is not recovery, its connection. He argues that addiction is about the pleasurable effects of substances though it may be at first, addiction often starts as a behavioral response to an individual's inability to feel wholehearted and make meaningful connections with other people. Substance-use either makes it all easier to engage, to connect, it smooths over the inadequacies or it makes the pain caused by isolation more tolerable, either way, it typically ends in loneliness and isolation. In the big book of alcoholics anonymous, an impaired lawyer writes, "For years, I was alone and afraid my life had narrowed to work and the bottle, and work remained in the picture only because it was necessary to enable me to buy the bottle, the isolation and loneliness that alcoholism brought weighed heavily on me, however, recovery is about gaining wholeheartedness, learning the value of living in connection and practicing the skill of connecting on a daily basis."

   This is what support groups like narcotics anonymous are all about, let's discuss these programs for a moment, let's see if we can tell you some things you weren't already aware of before. Support groups available for substance-use include 12-step groups and non 12-step groups. What are 12-step programs all about? These programs provide individual action steps to leading a wholehearted life free of alcohol addiction, they're fellowships of people who share their experience, strength and hope with each other, that they may solve their common problem and help others to recover from alcoholism or addiction, the only requirement for membership is a desire to stop drinking or using. 12-step programs for substance-use include Narcotics Anonymous, Cocaine Anonymous, Crystal Meth Anonymous, Marijuana Anonymous, Dual Recovery Anonymous, and Alcoholics Anonymous. The basic principles are unity, recovery, and service, the unity principle refers to the fellowship aspect of the program, and it's primarily achieved through attendance at meetings, the recovery principle of the program refers to the 12-steps of Alcoholics Anonymous which provide the foundation for recovering from addiction, the service principle refers to the service work formed for the good of the program for its members or for those still suffering from addiction.

   So here are some important features of 12-step programs. First, it's anonymous, that means last names and places of work, career or home are never requested or expected, it also means that what is shared, and who attends meetings are also confidential. Second, it's in a group setting, the 12-steps of recovery are discussed and applied in a recovery group, above all members of these groups emphasize self admission of the problem they are recovering from. And third, they depend on sponsorship, a sponsor is a more experienced recovering addict who guides new members of the group much like a mentor. According to the related 12-step program of Narcotics Anonymous, a sponsor is simply another addict in recovery who is willing to share his or her journey through the 12-steps.

   Now, here are some things you may not have known about 12-step programs, you don't have to identify as an alcoholic or addict to attend a meeting, people who are unsure or are not addicts, and are just curious can absolutely go, don't worry about the, "My name is so and so, and I'm an alcoholic stuff." All you need to say is, "My name is so and so, and I'm a friend of AA or I'm a friend of NA." That's it, also, you don't have to speak at a meeting, if you happen to be asked to speak or it's your turn, you can just say, "My name is so and so, I'm a friend of AA or NA, and I just pass." Additionally, substance-users can go to most Alcoholics Anonymous meetings, many people seeking recovery from substance-use go to AA meetings, and they identify as addicts, not alcoholics at those meeting meetings. Most on a meeting directory look for whether a meeting is open or closed, closed means the meeting is reserved for people with alcoholism, otherwise you're golden. So there are more AA meetings than meetings of other 12-step groups. Unless it's a closed meeting, there's no reason why someone in recovery for substance-use shouldn't attend an AA meeting, and you can try out a meeting online without even stepping into a room, and that's especially the case since the COVID 19 pandemic hit.

   Other well established group programs include Refuge Recovery and Smart Recovery. Refuge Recovery is a popular Buddhist oriented approach, and there are four steps in this program, meetings exist across the country. Smart Recovery are free face to face and online mutual help groups based on the harm reduction model, they use Cognitive Behavioral Therapy or CBT exercises, these are not abstinence based, and there are meetings for this program around the country as well. Number nine, everyone can be a resource. Addiction is chronic, progressive and deadly, if the person receives treatment, substance-use disorder can go into remission, but many attorneys don't seek treatment themselves or consider themselves high functioning, so treatment just isn't necessary. Sometimes attorneys need the help of the people around them, the preamble of the ABA model rules reminds us that we are a self-regulating profession, it says, "The legal profession's relative autonomy carries with its special responsibilities for self-government." So we have an obligation to promote the competence of all lawyers, not just ones in our practice group. If you see signs of impairment, what do you do? First, you should promptly examine any ethical responsibilities to be sure they're properly discharged, if those duties exist.

   That aside, attorney colleagues need to be willing to either personally reach out or do through an intermediary, this can save a life, not just a career. There is a tension here between helping a colleague with a substance-use problem, on the one hand, people want to do something, and on the other, they don't want to get someone in trouble where they might lose their license. For many people, it's a difficult dilemma what to do and how to do it, but the worst thing one can do is do nothing. The recommendation of the American Psychiatric Association is to step in early and take advantage of an assistance program, reporting someone to the licensing board should be a last resort, one thing you can do is seek intervention assistance by your state's Lawyer Assistance Program or LAP.

   Seeking understanding, and support from them before intervening is a good way to go and develop capacity to confront them. Here are a couple things to remember, first, don't enable or hide anything in order to assist the impaired individual in covering up anything, this is likely to be an ethical violation, and it certainly is a clinical misstep. People with substance-use disorder will only get worse if their behavior is enabled. Second, do not gossip about the situation, it's a matter of life and death, and one of the core concerns that prevent attorneys from seeking help is privacy and confidentiality, don't make the barriers to getting help even greater.

   Number 10, developing resilience is key. There's a movement underway in the legal profession involving lawyer well-being. According to the National Task Force on Lawyer Well-Being, it's a continuous process where lawyers seek to thrive in each of the following areas: emotional health, occupational pursuits, creative or intellectual endeavors, sense of spirituality or greater purpose in life, and physical health, and social connection with others. The National Task Force on Lawyer Well-Being national report emphasizes that lawyer well-being is neither the absence of illness nor a state of being happy all the time rather it's having the skills to make choices in life that support our ability to fulfill our professions ethical duty of competence. In the working group's toolkit that a company is their report, resilience is a process that enables us to bounce back from adversity in a healthy way, practicing resilience allows attorneys to emerge stronger.

   Now resilience is critical for lawyers, for example, a lawyer who loses a huge trial may feel pessimistic or beaten down or dazed or burned out, the lawyer may become riddled with feelings of anxiety, hungry for escape, and certainly more at risk for reaching to substances for relief from all this, with a quicker resilience reflex attorneys can bounce back from adversity without internalizing loss or seeking outside ways to expunge those feelings of inadequacy. Now what can attorneys do to develop resilience? Well, they can make intentional changes to mindset. An excellent example is Amy Polo's account of changing her mindset around nervousness, she says, "I think it's glorious to be nervous, being nervous is great." How often do we get to be nervous on a daily basis? Being slightly nervous means you care, and you are alive, and you're taking some kind of risk, hurray for being nervous. A friend once told me to substitute the word excitement for nervous, that way you acknowledge the physical feelings without putting a negative spin on things. So to answer your question, sometimes I get so excited about weekend update that I want to throw up.

   Another thing you can do is cultivate presence. Many of the stresses of lawyering are caused by things that occurred in the past or things that may occur in the future. Lawyers aren't really good at living in or appreciating the present, and the whole purpose of using substances is often to escape the present. Practice taking responsibility for making your present life work for you and appreciating what occurs in the present. All you really have is your immediate experience, you can practice this by sitting without an agenda for two minutes and shifting from doing to being, also practice gratitude, intention setting and acceptance.

   Gratitude is a fantastic tool to snap back. Every morning write a gratitude list with five items on it, it resets worry, it's instant perspective, and one idea is to send random gratitude texts during the day. Acceptance is an important tool, only worry about things you have control over, commit to that. Setting an intention for the day or for the week is also important, reorient yourself around that intention throughout the day, also find your team who are the people who bring you closer to wholeheartedness, find them, and your team should include a team of your experts, peer support, primary care physician, therapist, and even psychiatrist, also practice mindfulness and meditation. For those of you who are willing, we will be doing a silent one minute meditation right now, for those of you who are unwilling, just leave your video playing, I'd like you to bring gentle and consistent attention to your breath for or one minute, and when your attention wanders, bring it back. Namaste. Lawyers are human beings, and so they're subject to vulnerabilities and setbacks, but we should also be able to recover from them and be stronger for it. Thank you for joining me for this presentation about substance-use in the legal profession by Quimbee, to learn more about the content of today's presentation, please check out the course materials, we hope that you will join us again.

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1h 26s

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