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MCLE Self Study
Edited by Barbara Kate Repa

Substance Abuse
Curing the Ills of Work-Related Stress
Amy O'Keefe

On-the-job stress is responsible for many illnesses: high blood pressure, headaches, fatigue, heart attacks, asthma, insomnia, and depression. According to Dr. Andrew Weil, a proponent of integrative medicine, which combines ideas and practices of alternative and conventional medicine, "All illnesses should be assumed to be stress-related until proved otherwise. Even if stress is not the primary cause of illness, it is frequently an aggravating factor." (Spontaneous Healing (Ballantine Books, 1995), 264.)

Stress is a consequence of any force or event that upsets balance-and lawyers who are chronically out of balance are likely to exhibit frustration, irritability, or impaired judgment. Performance begins to suffer when stressed-out lawyers lose the ability to concentrate, focus, or complete tasks at work beyond mere paper shuffling. They may harbor a growing sense of dissatisfaction with the practice of law and ultimately burn out. And the accumulation of unrelieved stress can even cause lawyers to miss deadlines and make other errors leading to disciplinary action or malpractice claims.

Though some level of stress is inherent in every job, the legal profession undeniably bears more than its share. Lawyers are 3.6 times more likely than other workers to suffer from depression due to the unique stressors that accompany the legal environment. (Amiram Elwork, Stress Management for Lawyers (The Vorkell Group, 2d ed., 1997), 15.) Those stressors may include billable hours, heavy workloads, job complexity, unpleasant litigants and coworkers, backed-up court systems, and increasingly fierce competition.

It is no wonder, then, that lawyers are at a greater risk than the general population for substance abuse, suicide, anxiety disorders, divorce, and stress-related illnesses such as hypertension, heart attacks, and strokes. (E. Ostrow, "Clear the Obstacles to a Balanced Life," Trial, July 2003.)

Many of us have at one time or another turned to alcohol or drugs to unwind or for a pick-me-up after a particularly stressful event or grueling day at work. When the use of alcohol or drugs becomes compulsive, such habits turn into dependence. Compared to the general population, alcoholics suffer from significantly higher rates of psychiatric disorders such as depression and anxiety. (Elwork, 105, 108.)

Research confirms that stress is a major contributor to initiating and continuing alcohol and drug use. (Kathleen T. Brady and Susan C. Sonne, "The Role of Stress in Alcohol Use, Alcoholism Treatment, and Relapse," Alcohol Research and Health, 25, no. 4 (1999).) Work-related stressors, in particular, have been shown to be related to elevated alcohol consumption and problem drinking. (Michael R. Frone, "Work Stress and Alcohol Use," Alcohol Research & Health, 23, no. 4 (1999).)

The extent to which job stress influences drinking behavior depends on the type of stress experienced. Workers employed in high-stress jobs-that is, jobs with high demands and low control-generally have a higher risk of developing drinking problems compared to workers in occupations with low demands and high control. (Brady and Sonne.)

Most would agree that the practice of law easily falls within the definition of a high-stress job, especially in litigation, with its adversarial protocol, deadlines, and unpredictable outcomes. So the complexity and demands of lawyering may partly explain why the rate of substance abuse among lawyers, around 18 percent, is twice the national average. (Elwork, 15.) Based on this figure, an estimated 20,000 or more lawyers in California are believed to abuse alcohol or drugs. (Alex Ricciardulli, "Help for Addicted Attorneys," California Lawyer, January 2002.)

Substance abuse and related mental illnesses often have a deleterious impact on performing legal services. Approximately 40 percent to 70 percent of disciplinary proceedings and malpractice actions are linked to alcohol abuse or mental illness. (Elwork, 104.)

Job stress is a costly problem of epidemic proportions that lawyers and law firms cannot afford to ignore. According to the National Institute of Occupational Safety and Health, one-fourth of employees view their jobs as the number one stressor in their lives, and problems at work are more strongly associated with health complaints than are any other life stressor-even more than financial troubles or family problems.

Chronic psychological stress is associated with high blood pressure-a major risk factor for death and disability related to coronary heart disease, heart attacks, strokes, kidney disease, and vascular complications. And high systolic blood pressure has been "linked with decreased cognitive performance, memory loss, and the loss of healthy brain tissue." (Roland McCraty et al., "Impact of a Workplace Stress Reduction Program on Blood Pressure and Emotional Health in Hypertensive Employees," Journal of Alt. Complement. Medicine, 9, no. 3: (2003): 355-69.)

Stress is a major contributing factor in between 75 percent and 90 percent of primary care physician visits. And healthcare expenditures are nearly 50 percent greater for workers who report high levels of stress. (William Atkinson, "Strategies for Workplace Stress," Risk and Ins., Oct. 2000.)

Job stress is not simply an individual problem, either; depression and other mental illnesses stemming from job stress can be devastating to a company's bottom line. "If a person is moderately or profoundly depressed, if he or she has a true anxiety disorder or a true stress disorder, the level of productivity in the workplace is going to be greatly diminished. These disorders take their toll in the workplace," according to Dr. Ron Leopold, national director of MetLife Disability. (Lori Widmer, "A Not-So-Hidden Workplace Cost," Risk and Ins., July 2002.)
High levels of emotional distress have been found to be among the most costly health problems to employers in terms of absenteeism, disability, and failure to meet productivity standards. (McCraty et al.)

In fact, Dr. Paul Rosch, president of the American Institute of Stress, estimates that job stress costs American industry "$300 billion a year in terms of diminished productivity, employee turnover, and insurance." Stress is a major factor in 40 percent of turnover, and unanticipated absenteeism costs companies an estimated $602 per worker annually. (American Institute of Stress, And there is no insurance that currently compensates employers for lost productivity, turnover, or absenteeism.

Stress also contributes to 60 percent to 80 percent of all work-related injuries, which can be costly on a number of levels. (Atkinson.) The National Council on Compensation Insurance calls stress claims "the nation's fastest-growing occupational disease category." (John Kamp, "How to Prevent Employee Stress Claims," National Underwriter Prop. and Cas. Risk and Ben. Mgmt., Aug. 17, 1989.) In California the number of workers compensation claims for mental stress increased by almost 700 percent over eight years, and 90 percent were successful, with an average award of $15,000 compared to a national average of $3,420. (American Institute of Stress.)

"It's often said that stress is one of the most destructive elements in people's daily lives, but that's only a half truth," according to Dr. Bernie Siegel, a noted cancer surgeon and authority on stress management. "The way we react to stress appears to be more important than the stress itself." Indeed, according to Siegel, "the onset and course of disease are strongly linked to a person's ability and willingness to cope with stress." (Bernie Siegel, Love, Medicine, and Miracles (Harper & Row, 1986), 70-71.)

In August 2003, MSNBC News reported that of the 80 percent of workers who feel stress on the job nearly half said they need help coping with it.

Unfortunately, some of the coping mechanisms lawyers develop to survive a stressful work environment simply are not effective and may even be counterproductive to good health. A prime example is self-medication with drugs or alcohol to the point of dependency.

Lawyers are also notorious for neglecting to take care of themselves when the pressures of work intensify. Think about the last time you were in the midst of a work crisis or preparing for trial. Did you labor late into the night, forgo eating proper meals, drink unending cups of coffee to stay awake, and put off sleep despite feeling exhausted? At times like these, it is important to get nourishment to replenish the body's resources and maintain a sufficient level of immunity against bacteria and viruses. An excessive amount of coffee not only elevates stress hormones and exacerbates insomnia, it can sometimes make concentration more difficult, diminishing productivity. Getting by on the rush of adrenaline is, ultimately, a short-term survival mechanism that, if repeated often enough, can have devastating long-term consequences, including high blood pressure and increased risk of heart disease. Alternatives to coffee might include short rest periods or naps, a walk around the block, or quick energy-boosting exercises that can be done at the office. These alternatives help clear the mind and rejuvenate the body, leading to increased productivity.

Although work-related stressors cannot be eliminated entirely-there will always be deadlines, trials, billable hours, difficult cases, and troublesome clients-there are productive ways of coping with stress before it builds up and becomes debilitating. Proper nutrition, restful sleep, and regular exercise are a good start. It is also important to manage time efficiently and take regular vacations.

Another positive coping mechanism is to engage in an activity that induces a sense of relaxation, whether through bodywork therapies, hypnotherapy, yoga, meditation, or other relaxation methods. Because stress and relaxation cannot coexist within the body at the same time, actively causing the body to relax is an effective way to reduce stress. For stress-related illnesses, Dr. Weil recommends "all relaxation methods that appeal to you in order to give the healing system the best possible chance to solve any problems on the physical level." (Weil, 264.)

Relaxation is an altered state of consciousness that lies somewhere along the continuum between sleep and being fully awake, where the mind remains alert and engaged. Deep relaxation has been described as pleasurable, divine, and peaceful. It inhibits the body's release of stress hormones while stimulating the brain's production of endorphins-natural opiates that act to decrease the perception of pain and create a state of well-being. This "relaxation response," a term coined by Dr. Herbert Benson, associate professor of medicine at Harvard Medical School, "acts as a built-in method of counteracting the stresses of everyday living which bring forth the fight-or-flight response." (Herbert Benson, The Relaxation Response (HarperTorch, 2000), 169.) With regular practice, the relaxation response lowers blood pressure in hypertensive individuals and has been proven effective in treating headaches, cardiac rhythm irregularities, premenstrual syndrome, anxiety, and mild and moderate depression. Regularly eliciting the relaxation response has also been associated with reductions in drug use, alcohol intake, and cigarette smoking.

Misconceptions about relaxation foster the myths that relaxation makes people lazy or less effective. In fact, just the opposite is true. Learning to relax will actually result in increased alertness, clarity of perception, creativity, and insight. A meditative practice that regularly elicits the relaxation response trains the mind to become a more powerful tool for focusing attention, enhancing concentration, and developing a knowing intuition. A focused mind allows for more efficient decision making, strategic thinking, innovation, and skillful communication. These are all skills that prove beneficial in the practice of law.

Proof of the effect of relaxation on the mind was shown in one study involving massage therapy. The participants in that study, despite being more relaxed after receiving massage, demonstrated increased alertness and improved speed and accuracy in math computations. (T. Field et al., "Massage Therapy Reduces Anxiety and Enhances EEG Pattern of Alertness and Math Computations," Internat'l J. Neurosci., 86, nos. 3-4 (1996): 197-205.) Furthermore, "studies of people who meditate regularly have shown that their physiological age is much lower than their chronological age." (Siegel, 74.)

Relaxed people potentially get more done than their stressed-out peers because they are not diverting a substantial portion of their energy to the task of holding onto stress. Stress consultant Richard Carlson reminds us that "relaxed people can still be superachievers and, in fact, relaxation and creativity go hand in hand." (Richard Carlson, Don't Sweat the Small Stuff ... and It's All Small Stuff (Hyperion, 1997), 144.)

It's risky to make employees responsible for reducing their own stress because, left to their own devices, people tend to keep doing what they are accustomed to doing-internalizing stress and allowing it to build.

Employers, however, need not simply stand by while productivity diminishes and the costs of stress go up. They can help employees cope with stress by bringing stress relief to the firm. Many workplace experts agree that "effective risk management for stress claims is possible" and that employers "can and should take steps to prevent stress claims before they occur." (Kamp) The right stress-management program, when used consistently, can lead to tremendous benefits for individuals as well as the firm.

In recent years a wealth of scientific research has shown that "stress management in work settings can be effective in enhancing worker physical and psychological health." (L. R. Murphy, "Stress Management in Work Settings: A Critical Review of the Health Effects," Am. J. Health Promotion, 11, no. 2 (1996): 112-35.) For example, on-site programs that "include relaxation therapies, exercise, and biofeedback have been shown to reduce the physiological symptoms such as hypertension, and increase job satisfaction and job performance." (F. Stein, "Occupational Stress, Relaxation Therapies, Exercise & Biofeedback," Work, 17, no. 3 (2001): 235-45.) Many employers now offer employee assistance programs that may provide counseling and therapy for employees suffering from stress or chemical dependence.

Another study showed that a "positive emotion-focused intervention" produced favorable changes in blood pressure and psychological measures "accompanied by organizationally relevant improvements in workplace satisfaction and perceived value of work contribution." (McCraty et al.)

When lawyers are not operating under the cumulative effects of stress on the job, they are healthier, happier, more productive, and less likely to sustain a work-related injury or disability.

Amy O'Keefe ( is a partner at O'Keefe & O'Keefe in Berkeley and a certified Reiki master and teacher. She offers on-site relaxation training for stress management.

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