Washington Lawyer

A Conversation With Denise Perme

From Washington Lawyer, March 2008

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Denise J. Perme has been the Director of the District of Columbia Bar Lawyer Assistance Program since November 2006. Perme has more than 12 years experience in counseling and mental health, with a focus in substance abuse and employee assistance programs (EAPs). She has a bachelor’s degree in psychology from Trinity University and a master’s from the University of Maryland School of Social Work, with a concentration in occupational social work. Perme is licensed to practice clinical social work in Maryland and the District of Columbia and is certified by NAADAC/The Association for Addiction Professionals to work as a substance abuse professional, providing evaluations for individuals in the transportation industry who have violated U.S. Department of Transportation regulations regarding the use of illegal drugs and alcohol.

Perme has been trained in Critical Incident Stress Debriefing by Jeffrey Mitchell, the developer of the process, and is a certified trainer for the Myers-Briggs personality test. She has presented a variety of training and educational seminars to employees and managers in the public and private sectors while working with two national EAP providers.

Prior to joining the D.C. Bar, Perme was the clinical supervisor for First Advantage, a large national EAP and workplace services provider based in Rockville, Maryland, where she supervised a team of EAP counselors providing crisis and case management for different employers.

WASHINGTON LAWYER:
What is the Lawyer Assistance Program?

DENISE PERME:
The D.C. Bar Lawyer Assistance Program is a free, voluntary, and confidential program for lawyers, law students, and judges who are experiencing problems—such as addiction, depression, anxiety, or stress—that interfere with their professional or personal lives. The D.C. Bar Lawyer Assistance Program, formerly known as the Lawyer Counseling Program, was started in the mid-1980s by a group of lawyers in recovery from alcoholism. This group approached the Board of Governors about funding a program to help other impaired lawyers. The resulting program was developed with the guidance of the lawyers in recovery, who formed the Lawyer Counseling Committee.

Today, our Lawyer Assistance Committee is made up of 15 lawyers and two nonlawyers. It continues to advise and assist our professional staff in outreach efforts, policy development, and intervention planning. The members of the committee volunteer their time and effort because they want to help lawyers who are struggling.

What services does the Lawyer Assistance Program offer?
The services include free evaluations, short-term counseling sessions with licensed clinical social workers, referrals, intervention planning, monitoring, and volunteer mentoring.

Who is eligible to use the program?
Lawyers who are members of the D.C. Bar or who are planning on becoming members, law students enrolled at one of the six D.C. law schools if they intend to apply for Bar membership, and judges serving on any court located in the District are eligible for the program.

What services do you offer to individuals who are abusing alcohol or drugs, or who are engaging in other addictive behaviors such as gambling or Internet addiction?
We do a complete evaluation to determine the extent of a client’s problem, develop a clinically appropriate treatment recommendation, and refer the client to a qualified treatment program. We assist the client by finding a program within his or her health insurance network, if applicable, and we provide follow-up sessions to ensure the client is progressing in treatment and recovery. We also offer to connect the client with a mentor. The mentors are volunteer lawyers who have been through similar struggles and can help support the client in his or her recovery efforts. We also offer ongoing monitoring to help the client stay on track with recovery.

What do the mentors do to assist the clients? How involved are they in the process?
The volunteer mentors offer recovery support to clients by being available to speak by phone or attend a 12-step meeting with the client. The volunteer mentor support is similar to what a 12-step sponsor might offer, with the added benefit that the mentor also is a lawyer in recovery, so he or she is familiar with the particular challenges a lawyer is likely to face in early recovery. The mentor–client relationship is confidential and protected under Rule 1.6(i) of the D.C. Rules of Professional Conduct.

What are the warning signs of a substance abuse problem?
Addiction generally is defined as the inability to stop drinking, using drugs, or engaging in addictive behavior despite associated negative consequences. If you think you might have a problem with alcohol, drugs, or other addictive behaviors such as gambling, you probably do. Drinking or drugging frequently, binge drinking on weekends, drinking during the day, drinking or drugging every night, drinking alone, drinking or drugging to cope with stress, and drinking to become intoxicated all are warning signs of an alcohol or substance abuse disorder. People who have a family history of alcoholism have a higher risk of developing the disease.

Other warning signs include problems at work or at home because of drinking, and being arrested for driving under the influence (DUI) or drug possession. Previous unsuccessful attempts to stop drinking or using drugs also are a strong indicator of addiction. It is important to note there are other addictive behaviors that are increasingly affecting lawyers. These include, but are not limited to, Internet, sex, and gambling addictions.

Are alcohol and drug abuse the most common problems you see?
Last year 38 percent of all new cases handled by the Lawyer Assistance Program were related to alcohol, drugs, or other addictions, 25 percent were related to stress or life transitions, and 20 percent were for mental health problems such as depression or anxiety. Other clients presented with career and relationship issues. So, although concerns related to alcohol and other drug abuse made up the biggest percentage of cases, many people call the Lawyer Assistance Program for other kinds of problems.

Has recent scientific research advanced our knowledge of alcoholism and how it impacts the brain?
Yes. Alcoholism, or alcohol dependence, has been classified as a disease since the 1930s and was treated as such by many doctors well before then. Alcoholism is progressive, and if left untreated and unchecked, often is fatal. Today, the medical establishment understands addiction to alcohol and other drugs to be, specifically, a brain disease. There has been a lot of research in the past few years about the way the human brain becomes addicted to alcohol, drugs, and other process addictions such as gambling and sex addiction.

The focus of the latest research has been the impact of addictive substances or behavior on the activity of neurons in the brain, which leads to actual structural changes in the brain that result in altered electrical activity and brain metabolism in addicted individuals. These changes result in compulsive drug seeking and cravings, making it virtually impossible for the individual to stop the cycle of abuse without treatment and support. Brain scans have shown prolonged abuse of alcohol and drugs changes the structure of the brain, and these changes persist long after the individual stops drinking or abusing drugs. This helps explain why relapse episodes are so common even among individuals who are motivated to remain in recovery.

What is the success rate of addiction treatment? How likely is it that someone who goes through treatment and attends support groups is going to remain in recovery?
There have been many studies done to evaluate the efficacy of addiction treatment. It would be difficult to come up with an overall success rate based on all the studies done, but some recent statistics indicate 25 percent of patients who received treatment were completely abstinent a year later, and an additional 10 percent had significantly reduced their drinking to moderate levels and experienced no problems. In another study, 50 percent of patients were drinking significantly less after one year following treatment, and 36 percent were abstinent three years after treatment. The efficacy rates tend to vary some by study and treatment modality. Studies have shown the rates of efficacy for addiction treatment are similar to rates for other chronic diseases such as diabetes, hypertension, and asthma.

In recent years there has been a significant body of evidence that suggests moderate drinking has beneficial health effects. The so-called “French effect” suggests red wine is good for the heart. How does one define “moderate?”
Generally, moderate drinking is described as no more than two “drinks” (12 ounces of beer, a 5-ounce glass of wine, or 1.5 ounces of hard alcohol) per day for men and no more than one drink per day for women. Although it has been shown moderate drinking can have health benefits, many people take this information as tacit permission to abuse alcohol. The negative effects on people’s health from the abuse of alcohol far outnumber the positive effects of drinking alcohol.

Is drinking hard liquor more problematic than drinking beer or wine?
No. Alcohol is alcohol is alcohol. It doesn’t matter if the alcohol you are consuming is in a beer, a glass of wine, or a shot of whiskey. Standard servings of beer, wine, and hard liquor—a 12-ounce can of beer, a 5-ounce glass of wine, and a cocktail with 1.5 ounces of 80-proof spirits—all contain the same amount of absolute alcohol. From the standpoint of your liver and your brain, whether the alcohol comes from a Heineken, a glass of Pinot Noir, or a shot of Cuervo Gold makes no difference.

Is there a distinction to be drawn between someone who drinks regularly because he or she enjoys it and someone who is addicted? Is there a number of drinks per week that is simply too much and indicative of alcoholism as opposed to “social drinking?”
The majority of people who consume alcohol do not have an alcohol abuse problem and do not get addicted. For these folks, the American Medical Association guidelines recommend men consume no more than 14 drinks per week and no more than two per day. For nonpregnant women, they recommend no more than seven drinks per week and no more than one per day. That being said, if a non-pregnant woman drinks just two five-ounce glasses of wine with dinner two times per week, I would not be concerned.

If someone is regularly drinking three or more drinks in one sitting, there might be a problem, and we would recommend an evaluation. If someone drinks five or six days per week and consumes four or five drinks or more at a time, then the chances are much greater the person has developed a problem that needs treatment. Similarly, if a person binges on alcohol only once a month resulting in significant intoxication, this would indicate a problem. Many folks think they don’t have a drinking problem because they drink so infrequently. They may only drink three times a year, and in between they never touch alcohol. But when they drink, they cannot control how much they consume and they become intoxicated. That is indicative of a problem.

It is not simply about how many drinks a person has and how often he or she has them. Other questions that are important to ask: Why is the person drinking? Is he or she alone when drinking? Does he or she drink to cope with stress? Does the person drink to get intoxicated? Has the person made attempts to stop or cut down on the drinking? Have there been any consequences such as DUI charges, work problems, relationship problems, or others that are related to drinking? Does the person have trouble stopping once he or she starts drinking? There are a lot of factors to consider in determining whether someone has an alcohol abuse disorder.

Can you walk us through the intake process? What happens when someone picks up the telephone and makes the initial call?
During the initial call to the Lawyer Assistance Program, a short telephone interview takes place to assess if the person is at risk of danger or if there is an emergency of some kind. The caller is then scheduled for an initial face-to-face intake appointment with a counselor at the Lawyer Assistance Program, which generally takes about an hour and a half.

During the first appointment, the client will be asked to complete assessment paperwork that assists the counselor in evaluating the client’s problem. A full evaluation sometimes takes up to three sessions with the counselor. After the evaluation phase, the counselor and the client develop a plan for addressing the problem. The plan may include a referral to an outside provider of mental health or substance abuse counseling services and attendance at recovery support groups or other community services. The counselor may recommend the client to come in for short-term counseling or a referral to a long-term therapist.

What services do you offer to individuals with mental health or general counseling needs?
We offer the same services to all clients, no matter what the presenting problem is. We get many clients who present with mental health symptoms, work stress, career concerns, marital distress, and other life stressors. We offer free evaluations, short-term counseling, referrals, and connections with a volunteer mentor, if appropriate.

Are lawyers particularly susceptible to problems with alcohol, drugs, and other addictive behaviors?
Yes. The stress of being a lawyer today and the culture of many law firms definitely contribute to a higher incidence of alcohol abuse and addiction among lawyers. Many alcohol and drug abuse problems start in law school, where drinking is a big part of collegiate social culture. Consequently, the Lawyer Assistance Program is targeting the District’s law schools to introduce our services to students in the hope we will have an impact sooner in the disease process for some people.

In your opinion, does the legal profession as a whole take these risks as seriously as it should?
No. One of the biggest problems with getting people the help they need is the tendency for others around them to “enable” them in their addiction. This happens when a family member covers up the negative consequences of a loved one’s drinking or other addictive behavior such as calling an employer to report that the husband or wife won’t be in that day due to illness (read: hangover). It also happens at work when a manager or coworker ends up completing assignments because the impaired employee is absent or otherwise can’t perform. In law firms, many alcoholic lawyers are enabled because they may still be performing and bringing in work. Meanwhile, one lawyer’s marriage is in shambles and his kids won’t talk to him. Another lawyer isolates herself from friends and family while drowning her shame in a bottle. But somehow, he manages to get to court in the morning, and she manages to show up at the 9 a.m. meeting with opposing counsel.

Many people have the assumption that if someone is doing well at work then he or she is not really an alcoholic. That’s not true. There are a lot of functional alcoholics—or temporarily functional alcoholics—out there. Alcoholism is progressive, with early, middle, and late stages of the disease. Oftentimes the work performance is the last thing to go when the person is in the late stages of the disease. In other instances, fellow associates or partners know a coworker has a drinking problem, but no one does anything out of fear of hurt feelings, embarrassment, or a hostile confrontation. They enable the alcoholic by ignoring the behavior and telling themselves the person has to want help or needs to “hit bottom” before anything can be done. I think it’s important to emphasize that just because lawyers are able to do their job doesn’t mean they are not an alcoholic or addicted. If you are enabling someone to continue drinking excessively, make an effort to shift your thinking and consider taking action. You may very well save someone’s life.

Why is the rate of alcoholism so high among lawyers?
Various studies over the years have shown the rate of alcoholism in the general population ranges from 8 percent to 10 percent. Additional studies have indicated that from 17 percent to 19 percent of lawyers have alcohol problems. Law is a very stressful profession, and while stress itself does not cause alcoholism, if someone is susceptible to addiction because of his or her family history, work environment, or mental heath, then stress exacerbates the risk. In addition, many law firms include alcohol at their firm functions and make it readily available. Many lawyers start drinking to help relieve stress, only to find the alcohol abuse becomes a problem in and of itself.

That number sounds very high. It means that almost one out of every five lawyers has a drinking problem. Where does that data come from and how reliable is it?
There have been a couple of surveys done which indicate a high incidence of alcohol abuse among lawyer populations. One survey done in 1990–91 and 2002–03, the North Carolina State of the Profession and Quality of Life Survey, showed 17 percent of the 2,600 lawyers surveyed reported consuming three to five alcoholic beverages on the days they drank and a similar number using prescription medicines to reduce anxiety or depression, with 6 percent using mood-altering substances other than alcohol or prescription drugs. Another study referenced in the Journal of Law and Health[1] indicated 17 percent to 19 percent of lawyers have an alcohol problem. In addition, a survey of 801 lawyers in Washington State indicated 17 percent were problem drinkers.[2] In general these surveys are considered reliable today, although among Lawyer Assistance Programs there is interest in doing updated research in this area.

Does the high-stress professional environment you mentioned also contribute to other mental health problems such as depression, anxiety, and family conflict at home?
Yes, it can. Lawyers also have a higher rate of depression than the general population. The billing pressures, the long hours, and the constant conflicts of law practice can add up to a lot of unrelenting stress which can lead to chronic anxiety and depression. In the survey of Washington State lawyers mentioned above, 19 percent suffered from depression. In another study measuring the prevalence of depression in 28 different occupations in different locations around the country, lawyers most likely were to suffer from depression.[3]

Balancing work and a personal life is a huge challenge for many lawyers in private practice. For some, it is next to impossible given their positions and responsibilities, so they end up sacrificing time with their families and friends. Female lawyers face this problem, of course, but so do many men today who want to play a significant role in their children’s lives. For many lawyers, their mental health suffers, and they develop depression or anxiety disorders. Many clients who seek assistance from the Lawyer Assistance Program present this as their primary problem.

Do you provide services to individuals trying to get help on behalf of someone else?
If the caller is a family member or a coworker of a lawyer, we offer phone consultation to that individual to assist him or her with how best to help the person the caller cares about. We also can point them in the direction of support services that help family members and friends of an addicted individual. We also assist with planning and executing an intervention, if that is what is desired and deemed appropriate.

What is an “intervention?” How does it work?
An intervention is a well-planned, organized effort to encourage an impaired lawyer to accept treatment for addiction. During an intervention, people who are important to the addicted individual come together, with the help of a counselor, to communicate their love and concern to the individual as well as their determination to make sure the addicted individual agrees to go to treatment for the addiction. Most often an intervention is a last-ditch effort to save someone’s life or livelihood when all other attempts to convince the person that he or she has a problem have failed.

I would encourage managing partners, fellow associates, and family members to call us for consultation if there is a lawyer in their life who has a drinking or drug addiction problem. The call is kept strictly confidential, and nothing discussed is reported to the Bar or otherwise communicated to anyone.

Do you have any books you would like to recommend to someone who is struggling with an addiction problem or concerned about a friend or a loved one?
Actually, one of the benefits of coming into the program is our lending library. We can lend books on a variety of topics related to addiction or mental health or recommend a list of good titles. If you are a lawyer or the friend or loved one of a lawyer, and you want information about good books, please call us. Even if you are not a lawyer, we can talk to you over the phone about the issue and recommend some reading material or local resources.

What are the limits to the services the Lawyer Assistance Program can provide?
Our services don’t include group treatment, long-term psychotherapy, or consultation with a psychiatrist for medications. We assist with referrals to those services. In addition, we are not able to offer face-to-face counseling services to family members of lawyers.

Do you keep participants’ information confidential?
Yes, that’s very important. The program is completely confidential under the law. We do not release any information about a client’s participation in the Lawyer Assistance Program unless we have a signed release from the client. The licensed social workers who staff our program are under ethical requirements not to release any information about participants, and the information on clients is protected by federal confidentiality laws.

Are there limits to confidentiality?
Yes, the exceptions to Lawyer Assistance Program confidentiality include if the client is a threat to himself, herself, or someone else or if a client reports an incident of child or elderly abuse or neglect.

What sort of relationship do you have with the Office of Bar Counsel?
There are times when a client of the Lawyer Assistance Program also is in a disciplinary process with the Office of Bar Counsel. With a client’s written release, we may provide documentation to Bar Counsel of the client’s participation in the program. At other times, the Office of Bar Counsel may recognize an individual would benefit from our services, and they refer that lawyer to the program.

Do you work with insurers when making referrals to treatment programs?
Yes, we assist clients with accessing and clarifying their insurance benefits and refer them to an in-network facility or provider, if possible. If a client does not have health insurance, we attempt to refer him or her to low-cost or sliding-scale providers.

Are you involved with any inpatient or outpatient treatment programs?
We have experience with some excellent residential programs around the country that have a proven track record in helping lawyers. There are some very good local outpatient programs in the area. We don’t have any formal affiliation with these programs, per se, but we are familiar with their services and reputation.

What would you say to someone who knows he or she needs help but is terrified of picking up the telephone and making the call?
I would emphasize we are here to help, and the Lawyer Assistance Committee volunteers are here to help, too. Many of our volunteers have been through similar struggles with addiction or mental health disorders and want to help other lawyers who are struggling. I also would say our services—including the mentor relationship—are strictly confidential. The counseling sessions we provide are helpful and supportive, not judgmental and accusatory. We are professionals who care. We won’t report you to anyone, and we can get you the help you need. I would urge someone not to wait until his or her career, health, or life is in jeopardy before getting help.

Notes
[1] Beck, C. J. A. Sales, B., and Benjamin, G. A. H., “Lawyer Distress: Alcohol-Related Problems and Other Psychological Concerns Among a Sample of Practicing Lawyers,” Journal of Law and Health, 1995–96, 10 (1), pp. 1–60.
[2]. G.A.H. Benjamin, E.J. Darling & B.D. Sales, The Prevalence of Depression, Alcohol Abuse, and Cocaine Abuse Among United States Lawyers, 13 International Journal of Law and Psychiatry 233 (1990).
[3] W.W. Eaton, J.C. Anthony, W. Mandel & R. Garrison, Occupations and The Prevalence of Major Depressive Disorder, 32 Journal of Occupational Medicine 1079 (1990).

For inquiries, contact the Lawyer Assistance Program at 202-347-3131 or e–mail lap@dcbar.org.