The data have shown that attorneys struggle in greater numbers than the rest of the population with mental health issues ranging from substance use disorder (SUD) to anxiety, depression, and even suicide. With the onset of the current global pandemic, we thought it would be helpful to check in with two very different lawyer assistance programs (LAPs) to see how they were handling the needs of attorneys. I had the pleasure of interviewing Terri Harrington, JD, executive director of the New Hampshire Lawyers’ Assistance Program (NHLAP) and Dr. Diana Uchiyama, JD, PsyD, executive director of the Illinois Lawyers’ Assistance Program, current cochair of the Section of Litigation Mental Health and Wellness Task Force.
Comparing a small state with a large state with a very large number of lawyers, some common themes emerge.
T. NHLAP was formally established as a 501(c)(3) non-profit in 2007. It originated approximately 20 years earlier when a group of judges and lawyers started a private Alcoholics Anonymous [AA] group. That group grew by word of mouth. When the lawyers’ assistance movement took hold, then Supreme Court Justice Carolann Conboy and Probate Judge John Maher spearheaded an effort to establish an entity separate from the New Hampshire Bar Association (NHBA).
The state supreme court set up the program, which operates under the court’s rules, and ordered that it be funded through a mandated assessment of $20 per member of the NHBA, which collects the funds and distributes them to NHLAP. New Hampshire has a captive bar so all lawyers admitted to practice in the state contribute.
NHLAP provides a free, confidential, independent bridge to services that address a variety of mental health, medical, and substance use issue that impair the ability to competently practice law
D. Illinois’s program began in 1980 as a grassroots movement of lawyers and judges after it was determined that many people in the legal community were struggling with substance use issues. Similar to New Hampshire, our agency has grown and expanded over the years, and we also are a 501(c)(3) not-for-profit organization. We are funded by a small portion of the money that lawyers pay yearly for registration (we get $10 per attorney) and we get the money on a yearly basis from the Supreme Court of Illinois. Illinois LAP provides free, confidential-with-immunity treatment and support for all judges, lawyers, and law students in the state of Illinois. Currently we see more people who self-identify with mental health problems than substance-use issues. However, we do see many people who actually have both problems, but only identify one as problematic.
T. There is no single model for such organizations. Physician assistance organizations, for example, all have the same model and keep the same data regarding compliance monitoring and recidivism rates. Some lawyer assistance programs have good data, and others have none. There are no established best practices. That is one thing that makes it difficult to assess effectiveness. Some have clinicians on staff; others are peer supported, and some rely exclusively on volunteers. The budgets and funding source vary widely.
The ABA COLAP [Commission on Lawyer Assistance Programs] has been a good resource in the past, but it is not as active as it once was.
There are two annual meetings, a COLAP conference and an annual retreat for executive directors only, but there have been no such events recently due to COVID. There is a listserv which can be accessed by directors. That is a good source of support, information, and referrals.
Large states like Texas, California, and New York have “Cadillac” programs. Even our own neighboring state of Massachusetts has a well-funded and well-staffed program with two endowments funded by private donations and law firm donations in addition to assessments of individual lawyers.
D. Illinois tends to be unique in that we provide direct mental health services to the clients who outreach to our agency. Despite one of the lowest funding bases with the fifth highest concentration of attorneys in the country, Illinois LAP relies on fundraising which can be overwhelming. We solicit donations and support from the legal communities we serve, but always face an uphill battle to make sure that we have enough funds to provide the support that the legal community needs. We also have several unfunded sources including judges, law students, and attorneys who are identified as having mental health/substance-use issues referred to our agency from the ARDC [Attorney Registration and Disciplinary Commission], the disciplinary agency for attorneys in Illinois.
T. My budget is $146,000 per year, and it hasn’t increased much in recent years. We are fully dependent on the financial assessment paid by lawyers with their bar dues. I am a staff of one, and I am not a clinician. I am an attorney. When people call in to our 24-hour help line, I have to tell them that I am not a clinician and that I need to refer them out for substance-use assessment or psychiatric evaluation. We also need to refer out cognitive neurologic assessments for aging attorneys who may no longer be competent. We have no funds to pay for these assessments or for monitoring testing. These services are not usually covered by insurance, and the attorneys may not have the funds to pay for them. Since there is no staff other than me, there is little time to fundraise or seek alternative funds.
D. My budget in Illinois is about $740,000 per year. We get $10 per attorney from annual attorney registration fees, and despite requesting additional funding in March 2020 from the Illinois Supreme Court, our request was denied. We have a staff of five full-time employees and one part-time employee. Three of my staff are clinicians; including two who are lawyer/clinicians, and all have a specialty in substance-use treatment. We have a “Get Help” email address, and phone number that people can leave a request for follow-up care, and we also list our emails and cell phones on our website.
Our budget does not cover all of our expenses, including services for judges and law students, but we absorb the cost, and I am required to fundraise for additional financial support. We do an annual mental-health and substance-use training, have an upstate and downstate dinner, and ask for donations for CLEs that we do throughout the state related to mental-health, substance-use, and wellness topics. We also have online CLEs for which we request a minimum donation. We also look for sponsorships within the legal community. This allows us to have a Treatment Assistance Fund for upstate and downstate attorneys and we never allow anyone to be denied services. We have relationships statewide with other treatment providers, which allows people who need specific or intensive treatment access to care at a reduced cost or no cost depending on their financial need, and I review and determine how much funding I give to individual people.
T. We get anywhere from 40 to 75 referrals per year. Half of these are self-referrals, especially after I have done a presentation to a group of lawyers or judges or when I send out a newsletter. The remaining referrals come from attorneys who have received services from us before and recognize similar issues in others. We also get calls from clerks of court and judges.
When the organization first started, there were more issues of substance use, but we now see many more mental-health-related concerns. That may be because my focus is mental health, and the last executive director was more connected to AA community so she saw more substance-use issues.
D. We pride ourselves on increasing self-referral rates each year, which we correlate to our outreach to lawyers, judges, and law students through various methods. We have a big social media presence, my staff writes articles for various bar journals and agencies, we continue to increase our yearly CLEs throughout the state to law firms, government agencies, legal insurance companies, the judiciary and law schools and classes, and we have monthly office hours in all nine law schools in the state of Illinois (pre-COVID). Currently 69 percent are now self-referrals. We also get outreach from colleagues, law firms, the ARDC—the disciplinary agency for the state of Illinois—from treatment providers, family members, and law schools. We have been seeing an increasing number of people utilize LAP services each year, and generally see around 600 to 650 people yearly. The majority of people who outreach to LAP identify mental health issues as the main problem (60 percent) with the rest identifying substance-use issues.
T. The most common issues we see are substance-use disorder, often with a dual diagnosis, depression, anxiety, and burnout. Other issues include time management, gambling addiction, eating disorders, bipolar disorder, family-work/life balance, and threats of suicide.
We run two monthly peer-support groups, one for substance use and the other for anxiety and depression. These groups are not facilitated by a clinician, so they are not therapy.
Other than that, we facilitate referrals for assessment or therapy and assist with monitoring for compliance with programs. All contacts with us are 100 percent confidential.
D. In the current COVID pandemic, we are able to provide telehealth services throughout the state of Illinois. Pre-COVID, we had contractual relationships with specific providers outside of the Chicago area so that people could access services within their own communities. We also run weekly support groups for women, men, and young lawyers/law students. This provides an opportunity for people to socially make connections, find support from other legal members, and recognize they are not alone in their struggles. We also have two weekly AA, which met at our Chicago office pre-COVID, that now meet virtually every day to provide support to people outside of LAP.
Currently we are seeing a lot of people with significant mental health symptoms including depression, anxiety, and suicidal thinking. We are also seeing an increase in substance-use issues, and relapse due to the increased feelings of isolation people are experiencing. And of course the overlap between mental-health and substance-use issues is very common, and often unrecognized or undiagnosed prior to coming to see a clinician at our agency. All contact with Illinois LAP is confidential with immunity, so many people use our services instead of going through their HR department or EAP program.
T. Since COVID, there has definitely been a decline in referrals. It was almost as though the door slammed shut, and in speaking with my colleagues around the country, this seems to be consistent with what they are seeing. With people more isolated, working from home, and fewer court hearings, people do not have the same social constraints which lead them or others to refer them to us. It does not seem as though there is any shortage of people suffering from mental-health and substance-use issues, but they are likely suffering privately or in silence now. We have seen a recent uptick in referrals and expect the floodgates to open as people return to office environments.
My focus now is getting the word out about services we provide, gaining trust, and reducing the stigma in asking for help.
D. I completely agree that at the beginning of the mandatory quarantine in mid-March in Illinois, we saw a dip in referrals that we found highly unusual and concerning. This lasted until June when the quarantine restrictions became less restrictive and then we began seeing an increase in outreach but with people experiencing higher levels of depression, anxiety, substance-use problems, and suicidal thinking. We also saw an increase in people seeking out services who had never experienced mental-health problems and a high rate of return of people who had utilized our services in the past. We also anticipate problems to increase in the legal communities as the economic impact has been severe, there have been drastic changes to the work environment, and many people are feeling disconnected and socially isolated from groups that provided support and connection.
Attorney Harrington and Dr. Uchiyama are just two of the leaders of LAPs through the United States and territories working to enhance the well-being of attorneys and respond to their critical support needs. ABA COLAP maintains a list of the current programs and links to local organizations where attorneys and law students can seek confidential assessment and referral services.
