Identifying and Assisting
Clients and Colleagues with Major Health Issues
Doris C. Gundersen, MD
Medical Director
Colorado Physician Health Program
March 20, 2013
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Speaker Disclosure Statement
NOTHING TO DISCLOSE
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Objectives
• Review the 8 occupational hazards professionals face which can
undermine health as well as the quality of work
• Identify signs and symptoms suggestive of burn out and other
health problems
• Recognize the warning signs and risk factors for suicide
• Learn skills for successful intervention with a colleague or client
• COLAP and other resources
The Eight Occupational
Hazards Facing Professionals
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High Degree of Work Stress
Depression
Suicide
Addiction
Burnout
Poor Physical Health
Unhealthy interpersonal relationships
Professional Boundary Violations
High Degree of Work Stress
Attorneys and Physicians
(Occupational Hazard #1)
• Anticipated demands
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Long hours
Lifelong learning
Responsibility
Sacrifice
• Unanticipated demands
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Unhealthy workplace competition
Fewer jobs available for graduates
Devaluation of the Profession
Diminished compensation
Subordination of personal values to economic values in a work setting
Reduced resources/support with increased profitability expectations of the firm
(“billable hours”)
– Crushing workloads and unrealistic deadlines
MATRIX OF STRESS
Vicariously upsetting experiences
Mistakes
Complaints, threats of suits/professional discipline
Insufficient training in business, or necessary
politics
Needs of clients
Needs of staff
Needs of family
Needs of self (often ignored until burn out sets in)
MATRIX OF ATTORNEY STRESS
“The work never stops.”
No matter what else is going
on in life, the attorney must
deal with client needs, legal crises,
dissatisfied clients, bad
outcomes, ambiguity, complex
decisions, colleagues.
25% of attorneys experience anxiety
symptoms 3 or more times/month
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The
Epidemiology
of
Depression
(Occupational Hazard #2)
Depression in Primary Care Settings
 Depression is among the most common
conditions in primary care patients
(10% men and 20% women)
 Depression is not detected or adequately
treated in 40% to 60% of cases.
 Physicians infrequently bring up the question
of suicide with their patients, sometimes out
of fear that asking about suicide will trigger
suicidal behavior.
 Nearly 40% of those who die by suicide contact
their primary care physician within the month before they die
STIGMA AND SHAME
STIGMA AND SHAME
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Less friendly
Withdrawn
Irritable
Negative/pessimistic
Less available
Less spontaneous
Loss of humor
Signs of Depression
• Preoccupied
• Distracted
• One feels less connected to the
professional (“back off” vibe)
• Change in physical appearance
• Physical complaints
Attorneys and Depression
(Occupational Hazard #2)
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Attorneys are more prone to depression than any other profession
(1990 Johns Hopkins University study)
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Forty percent of law students meet criteria for clinical depression
(Andy Benjamin Study – 1986)
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The prevalence of depression among male attorneys is 19%
(ABA 2013)
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The prevalence of depression among male attorneys is twice
that of males in the general population
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Due to lack of self reporting, the rates may be higher
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Due to lack of recognition or false attribution to “stress”
treatment is often delayed
Chief Complaint = “Stress” in 47
Consecutive Intake Evaluations
Physician Population
25
20
15
10
5
0
Stress
PTSD
Acute Stress
Other anx
Dep
Bip
Psychot
Substances
None
The
Epidemiology
of
Suicide
(Occupational Hazard #3)
Suicide Among Attorneys
(Occupational Hazard #3)
• The rate of suicide among attorneys is twice that of males in
the general population
– (Utah State Bar J, Jan 2003)
– National Institute for Safety and Health
• One study suggests suicide is the 3rd leading cause of death
for attorneys
– (Canadian Bar Association 1997)
• Ages 48-65 is the highest risk demographic
Physician Suicide Rates Exceed That of
Attorneys
(2-4 times that of the general population)
• 350 to 400 physicians in the US
suicide each year
• Male doctors, rates are 40% higher than
for men in the general population
• Female doctors, rates are 130% higher than
for women in the general population
• These are conservative estimates:
– Death certificates do not always reveal suicide
– Suicides may be attributable to “accidental”
overdose/drowning/MVA
Miscellaneous Facts About Suicide
• 10th leading cause of death in US
• 2nd leading cause of death (ages 35-44)
• 3rd leading cause of death (ages 10-24)
• Ratio of suicide attempts versus completed suicides 25:1
• No nationally standardized data collection among physicians
or hospitals regarding attempts
Methods of Suicide
(US 2009)
Percent
Firearms
Suffocation
Poisoning/OD
Drowning
Other
Cutting
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Suicide Deaths and Major Psychiatric
Syndromes
90% w/ Mental Illness
Mental Illness
No Mental Illness
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Frequency of psychiatric disorder
diagnoses in completed suicides
70
Percent
60
50
40
30
20
10
0
Affective D/O
Personality Substance Use Anxiety D/O Schizophrenia
D/O
Risk Factors for Suicide
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Single/divorced
Chronic illness
Stress/overwork
Career dissatisfaction
Conflicted relationships at
home
• Losses – personal/
professional
• Conflict –
personal/professional
• Financial problems
• Family of origin issues
– Serious psychosocial
problems
– Abuse
– Neglect
• Family history
– Depression and suicide
– Substance abuse
– Psychiatric problems
Personality Traits May Contribute to
Suicide Risk
• Independence
• Perfectionism
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Creates a chronic feeling that nothing is good enough
It is driven by an intense need to avoid failure
Perfectionists are more vulnerable to depression, anxiety and
other health problems
• Competitiveness
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It interferes with the ability to show vulnerability or seek help
• Pessimism
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A common trait among attorneys
It can help an attorney excel by being skeptical of what clients, witnesses,
opposing counsel and judges say
It can help anticipate the worst scenario
Pessimism leads to stress and disillusionment
The Lawyer Personality
As children:
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Highly focused on academics
Great need for dominance, leadership and attention
Prefer initiating activity versus following another’s lead
Dominant fathers
Less concern for the emotional suffering of others expressed in homes of
future attorneys (compared to dentists and social workers)
Susan Daicoff, “Lawyer Know Thyself”, 46 American U. L Rev. 1337 1997
Deterrents to Suicide
– Dependent loved ones (including pets!)
– Religious beliefs
– New found hope (receiving good news)
– New found resources
– Changed perspective
» “A DUI is bad but most
(doctors/attorneys) aren’t revoked for
this”
– New interpretation of events
» “A mistake doesn’t make me a bad
(doctor/attorney/person)”
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Addiction Among Attorneys
(Occupational Hazard #4)
• It is estimated that 18-20% of attorneys have a drinking problem
– Alcohol Abuse
– Alcohol Dependence
• This is higher than what is observed in the general
population and physicians (10-15%)
• Liquor cabinets in law offices – time to rethink?
Addiction Defined
• A primary, chronic, neurobiologic disease with
genetic, psychosocial, and environmental factors
influencing its development and manifestations.
• Characterized by one or more behaviors
– Impaired control over use
– Compulsive use
– Continued use despite harm
– Craving
Law Students
• Law students experience more anxiety than the general population
• Psychiatric distress (OCD symptoms and paranoia)
• Students frequently turn to alcohol and other drugs to cope
• May establish a habit that ultimately leads to substance abuse and/or
dependence in later years
• Law students are universally resistant to reaching out for help
• Social isolation is the norm when under stress
American Association of Law Schools Study – 1994
Process Addictions and Social Media
• Compulsive viewing of pornography
• Gambling
• Sexual addiction
Workaholism is very
much like substance abuse
• Disrupts sleep
• Creates multiple family problems & destroys
marriages.
• Decreases your efficiency and your ability to
concentrate
• Makes you irritable and fatigued.
• Increases your risk of back problems, gastrointestinal disorders, heart disease and stroke.
Attorney Burnout
(Occupational Hazard #5)
• Depersonalization
– Detachment from others
– Protective Defense Mechanism
• Emotional exhaustion
• Diminished sense of
personal accomplishment
– Work loses its meaning
– No longer feeling a sense of efficacy
The Downward Spiral
Attorney/Physician Response to Stress:
WORK HARDER!
Loss of Avocational
Neglect of Family/Friends
 Reduced Joy
 Resentment
Guilt
Work Harder
Burnout
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Embraces challenge and
improves performance
Period of
maximum efficiency
Hyper-reactive
stage
Emotional exhaustion
stage
Breakdown
Audience Response Survey
• I have a personal physician for my health care
Yes?
No?
Poor Physical Health
(Occupational Hazard #6)
• Circadian Rhythm Disruption
• Sustained Stress is not Benign
– Sympathetic Nervous System Hyper arousal
• Elevated Cortisol Levels
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Irritability
Insomnia
Weight Gain/Diabetes
Osteoporosis
Hypertension/Stroke
Toxic to Neurons
Neurobiology of Chronic
Stress
• Endorphin depletion: decreased pain tolerance
• Serotonin depletion: sleep disruption and
depressed mood or mood lability
• Dopamine depletion: anhedonia
• Locus ceruleus hyperactivity: increased
noradrenalin; agitated, hypersensitivity
Unhealthy Interpersonal Relationships
(Occupational Hazard #7)
• High divorce rates in law school
• Higher divorce rates among female
attorneys
• “Thinking like a lawyer” doesn’t work
at home
• Adversarial nature of the profession:
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Subterfuge
Conflict
Distortion to persuade others
disastrous in personal relationships!
Professional Boundary Violations
(Occupational Hazard #8)
• Ubiquitous
• Boundary maintenance isn’t easy
• Failure to maintain boundaries
threaten work and home
• A lack of self care can lead to
exploitation of patients or clients
can can
Potential boundary issues
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Sexual contact
Physical contact
Verbal interaction
Self-disclosure
Collateral contacts
Fees
• Appointment times and
location
• Dual relationships
– Friend
– Business transactions
– Professional transactions
• Workplace behavior
Warning Signs of Deteriorating Health
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Decline in job performance
Absenteeism – emotional, physical
Attitude and/or mood
Troubled relationships
Professional boundary issues
Decline in appearance
Physical symptoms or illness
Other
• Financial problems
• Staff turnover
Loss of Function Hierarchy
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Community
Spiritual life
Recreation and avocation
Friends
Peers
Family
Work
IF WORK IS IMPACTED, PROFESSIONAL MAY BE SERIOUSLY ILL
If Concerned
– Trust your intuition
» “I’ve noticed……”
» “You seem …….”
– Normalize their feelings
» “Sometimes when under the stress
of a lawsuit it is not that unusual for
a (physician/attorney/client) to:
• Feel depressed
• Not Sleep
• Have thoughts of “I’d rather be
dead than go through this.”
– Ask: Have you had thoughts like this?
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What to Do
- Always take thoughts of suicide seriously
- Open a dialogue
- Be direct, matter-of-factly:
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Are you experiencing thoughts of suicide?
Do you have a plan?
Be willing to listen, allow expressions of feelings
Avoid being judgmental
(i.e. suicide is wrong/lecturing on the value of life)
Offer hope:
Take Action:
“There are solutions to this situation”
Let them know you are going to help
Do not leave the person alone if they are
acutely suicidal
Never Worry Alone!
Contact: COLAP
Colorado Lawyers Assistance Program
(www.colorado.lap.org)
– Barbara Ezyk, Executive Director (303) 986-3345
– Confidential assessments and referrals at no cost
– Educational resources
– Assistance with interventions
– Health monitoring at no cost
Colorado Lawyers Helping Lawyers
(clhl.org)
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For less emergent situations
Support
Online resources
Educational Resources
Support groups
Referral Information
Colorado Physician Health Program
(www.cphp.org)
– Sarah Early, PsyD, Executive Director (303) 860-0122
– Confidential assessments and referrals for physicians
• At no cost if licensed in Colorado
– Educational resources
– Assistance with interventions
– Health monitoring
• At no cost if licensed in Colorado
– Safe Harbor from Regulatory Agency