Legal Community Proposes Law Schools Incorporate Stress Management into their Curriculums

The first year of law school is a time of significant stress. Last week, Law.com reported on a post made in the r/lawschool sub-reddit by a user who described their experience as a first semester law student. The poster noted that because of stress, they suffered from unintentional weight loss, vision changes, headaches, acid reflux, and newly acquired tremors after the first semester. The thread quickly garnered many replies. While some expressed sympathy and concern, over 70 comments by other law school students described similar stress-induced physical ailments including weight gain, low energy, poor nutrition, constant fatigue, eczema, and anxiety.

Charles N. Todd, Dean of Students for the University of Chicago Law School, speaking to Law.com about the thread, described the first year of law school as “one of the steepest learning curves.” However, he continued on to say that, “I tell students all the time that it’s not going to get any easier. The demands of your time will not go away once you leave school. In fact, you’re going to have more things with family responsibilities, life, and work, so we really want them to learn how to develop healthy habits in law school so those will sustain them throughout their career.” 

The initial reddit poster followed up to share their decision to visit a doctor and noted their intention to create healthier habits the next semester. Dean Todd recommended taking small breaks throughout the day to incorporate healthy activity. “It doesn’t have to be this big interruption in your day, it could be a 10-minute break to color or to have some healthy food or do some stretches because you’ve been sitting a long time,” he said. 

Others in the legal community suggest that law schools should take more responsibility for student health. Janet Thomas Jackson, a law professor at Washburn University School of Law, calls for law schools to take an active role in promoting wellbeing and mental health within their student populations. In an article written for Bloomberg Law, she noted how frequently law students and legal professionals are impacted by depression. According to the Dave Nee Foundation, “Depression among law students is 8-9% prior to matriculation, 27% after one semester, 34% after 2 semesters, and 40% after 3 years.” Further, just as Dean Todd noted, the foundation’s data shows that stress and its associated effects do not necessarily recede after law school. Rather, lawyers are the most frequently depressed professional group within the U.S., and lawyers suffer depression at a rate 3.6 times that of non-lawyers. 

Jackson suggests that the legal community not accept this as inevitable; she proposes that law schools integrate discussions of physical and mental health throughout student’s tenure, starting at orientation. And prior to starting classes, law schools should educate students and their families on the “expectations and predictable stressors” of law school, resources for seeking help, and insight into healthy habits and effective stress management. She notes that students of color should receive additional support, including safe spaces and communities where they can share their experiences and feel a sense of belonging. Finally, Jackson recommends that self-care practices and physical and mental health be integrated into the curriculum. “In other words, law schools should play a primary role in normalizing discussions and actions around the mental and physical care of its students,” she said.  

Related Blogs: Law School Students Still Not Receiving Adequate Mental Health Support

Positive Learning Environments and Regular Feedback Result in Lower Levels of Depression Among Medical Residents

The impending physician shortage, coupled with the problem of physician burnout, has led to important discourse over the treatment and training of future physicians. Medical training programs are looking to improve wellbeing among medical students and residents through various avenues including reduced tuition, investments in wellbeing programs, and mental health resources. But are they doing enough? A recent op-ed published by the AAMC, by Srijan Sen, MD, PHD, suggests medical residency programs need systemic changes on top of the current efforts focused on building individuals’ resilience and wellbeing.  

Dr. Sen, along with collaborator Connie Guille, MD, analyzed data collected via the Intern Health Study to highlight the negative impacts of residency on interns’ health and propose data-based solutions for a healthier environment. The Intern Health Study, a longitudinal study that includes responses from more than 20,000 medical trainees, shows that the rate of depression increases “Five-fold within the first few months of residency” and remains higher throughout training with “about one out of four residents screening positive for depression at any given time during residency.” Dr. Sen goes on to note that beyond the questionnaire responses describing stress, there are physical indicators as well. “Telomeres, a cellular marker of aging, shorten five times as much during internship as during a typical year of life…” And, what’s more, a compromised physician is more likely to make medical errors and to provide lower-quality care to patients.

Dr. Sen references a 2019 study that reviewed over 50 internal medicine programs using residents’ feedback and information collected in national databases. The findings show variation in the depression rates between programs; more importantly, the variation showed consistency with some programs regularly registering high and others low. When Dr. Sen compared the programs, the findings showed that while the volume of hours, type of work (administrative versus patient care), and work-family conflict all impact the rates of depression, another critical component differentiating the high and low depression programs was the type of learning environment.  “A key factor among low-depression programs was residents reporting that their inpatient rotations were a positive learning experience. Another was receiving timely and appropriate feedback from faculty. Both of these factors indicate that a focus on education, and specifically directed education from faculty, makes a major difference.”

The findings are particularly pertinent given an article published last week in the NY Times by Perri Klass, MD. The article, which is in response to a recently published JAMA Pediatrics article (Walking on Eggshells With Trainees in the Clinical Learning Environment), speaks to the difficulties that many faculty members feel providing feedback to trainees. While the medical community is working hard to end the harassment and bullying of residents that typified many interns’ experiences historically, some feel the pendulum has swung too far and that they are unable to provide criticism, tough feedback, or make interns feel discomfort without retribution or poor evaluations.

Dr. Klass quotes Dr. Janet R. Serwint, professor emerita of pediatrics at Johns Hopkins, who says, “When I look back at my career and my life and how important some of that feedback was, and it was hard for the giver to give to me, I’m sure, but they did it in a respectful way… I worry that the balance is swinging in such a way that it’s all about, oh, you are wonderful.” During her time as the vice chairwoman of education and the residency program director, she said that some faculty would mention problem residents, but often they had not broached the issues directly with them. “It’s the discomfort, or the worry of retaliation and evaluation.” Furthermore, Dr. Melanie Gold, lead author of the JAMA article, goes on to say that she has also struggled with interns unwilling to experience discomfort during medical training. Her examples include a student who complained to a course director about transgender health’s inclusion in the curriculum and others who, due to religious objection, were unwilling to even observe a patient consultation. Dr. Gold went on to say that many faculty members feel ill equipped to engage in the resulting difficult conversations.

While these articles are written from differing perspectives, they describe a shared desire by residents and faculty for meaningful feedback and instruction. Given that discomfort is an inherent condition of medical training, the data would suggest that some programs are able to navigate this discomfort better than others. Dr. Sen says that “Faculty members also need to learn trainees’ specific strengths and weaknesses and then provide thoughtful, specific feedback that truly supports their learning. Programs ought to encourage faculty to invest the time necessary to support learners and reward them for doing so.”

Following this discourse is important for future medical students and interns who are applying to medical school or residency programs. Applicants can distinguish themselves by showing that they understand the role that feedback—positive and negative—plays in preparing for a medical career. Demonstrate this understanding by using interviews and essays to describe situations where negative feedback spurred improvement, learning, and connection with others despite discomfort. Just as faculty must be willing to consider how best to promote learning, trainees must demonstrate an openness to the criticism and discomfort necessary and inevitable in the preparation for a medical career.

Further, when evaluating programs, applicants should take into consideration the learning environment. Observe the interactions between faculty and interns, and question current and former program participants about how and at what frequency feedback is offered. It may also be worthwhile to engage administrators or admissions representatives on how the program structure trains and supports faculty in providing feedback, facilitating difficult conversations, and creating a positive learning environment. While more visible wellbeing investments can be compelling, it is critical to look closely at the structural elements of a program that data shows matter to the lives of residents: hours worked, tasks performed, work-life balance, and the learning environment.

Law School Students Still Not Receiving Adequate Mental Health Support

Forty percent of recent law school graduates say that their school is not doing enough to support students’ mental health and assist students struggling with the stress and pressure of law school. An additional 31 percent do not know, while only 29 percent answered favorably, saying that they feel their school is doing enough. This is according to the Kaplan Bar Review survey results released earlier this month, which include data gathered from over 300 recent law school graduates. Despite the well-documented struggles that law students face and the recommendations for sweeping reforms put out by the American Bar Association in August 2017, there have been few noted improvements. Tammi Rice, vice president, Kaplan Bar Review commented on the survey results saying, “What students are telling us is that law schools need to do a better job of providing the kinds of services that they need for self-care, and also communicating how those services can help them. This is an important conversation to have. We have to conquer the stigma traditionally associated with mental health, particularly in the legal community… May, in particular, can be an emotionally taxing month in the life of law school graduates, as it is when they begin preparing to take the July bar exam…”

 The Kaplan Bar Review survey also asked students for their opinions on the state bar examiners’ ability to inquire about past mental health and addiction issues. Seventy-four percent of students were opposed to the bar examiners’ application asking if the applicant has ever been treated for a mental health issue. At 61 percent, there were fewer, but still a strong majority who were opposed to the bar application asking about past treatment for a substance abuse issue.

 These high numbers were no surprise in the wake of last year’s successful movement to update the mental health questioning on the Virginia Bar application. Law school students, who saw the questioning as a barrier to getting treatment because of the stigma, organized and sent letters to the Virginia Board of Bar Examiners, who were examining the mental health questions. After receiving a recommendation from a Supreme Court of Virginia committee coupled with “valuable input” from lawyers, judges, law school deans, and students, the bar has—as of January 1, 2019—eliminated the question asking applicants to disclose past mental health treatment. The board also edited another question to focus on conduct and behavior. “Knowing that the students who hope to one day join the Virginia Bar will not have to experience fear of ramifications for disclosing any treatment they sought during law school on their bar applications is a wonderful thing,” said Catherine Woodcock, last year’s Student Bar Association president at Washington and Lee University. “The more we normalize and encourage sound mental health and wellness, the better we will be as a profession.” In January, the Michigan Supreme Court also gave notice that it is studying “whether questions regarding mental health should be included on the personal affidavit that is part of the application for the Michigan Bar Examination, and if so, what form those questions should take.”

Law schools and legal professionals still have considerable ground to cover in increasing awareness of mental health needs within the profession. However, kicking off this month, is “Minds Over Matters,” a year-long deep dive into the mental health and well-being of law professionals by Law.com and its affiliate professionals. This site and its affiliate ALM partners, which cover a wide-ranging scope of legal topics are looking to “more deeply cover stress, depression, addiction, and other mental health issues affecting the legal profession. We aim to create a place for open dialogue, to shine a light on these issues that have so long been stigmatized, and to hold the profession accountable to work toward change. With ALM’s broad coverage of the legal profession, we think we are uniquely situated to address these issues.”

All prospective law students, recent law graduates, and legal professionals should stay abreast of these trends and follow the work showcased on law.com. Prospective law students will want to be conversant on these issues for interviews and as they consider the cultural fit of various law school programs. Current students and recent law graduates will want to educate themselves on how to begin cultivating their own wellbeing despite the stress of law school and their upcoming professional lives. These groups may also want to look out for opportunities to engage with and make changes within their own state’s board of bar examiners. As seen in Virginia, a group of engaged students can make a difference.

Selecting a Law School that Values Student Well-Being

When selecting a law school, prospective students have many things to consider, including rankings and prestige, program specialties, and job placement rates. Another, however, is garnering a great deal of media attention in the wake of last week’s International Mental Health Day: student wellbeing and the availability of mental health support programs.

According to the Dave Nee Foundation, depression among law students is 8-9 percent prior to matriculation, then jumps to 27 percent after one semester, 34 percent after the first year, and 40 percent after three years[i]. Two studies, conducted by the American Bar Association and Yale Law School in 2014, also showed a high percentage of law students indicating that they needed psychological assistance. In the ABA Survey, 42 percent of students reported that in the past year they needed help with a mental health or emotional problem. [ii] And in the Yale Study, 70 percent of students reported experiencing mental health challenges while in law school[iii]. These studies and others like them, have increased awareness of the mental health challenges faced by both law students and the legal profession.

A report released in August 2017, by the American Bar Association’s National Task Force on Lawyer Well-Being, made recommendations for sweeping reforms that stakeholders throughout the legal profession can make to improve well-being and ultimately the competence and dependability of the profession. Specifically, the task force calls upon law schools to[iv]:

• Create best practices for assisting students experiencing psychological distress;
• Assess law school practices and offer faculty education on promoting well-being in the classroom;
• Empower students to help fellow students in need;
• Include well-being topics in courses on professional responsibility;
• Commit resources for onsite professional counselors;
• Facilitate a confidential recovery network;
• Provide education opportunities on well-being related topics;
• Discourage alcohol-centered social events; and
• Conduct anonymous surveys related to student well-being.

The report also highlighted examples of law schools that offered programming to meet the recommendations:

• Northwestern University’s Pritzker School of Law: created a well-being curriculum including workshops, mindfulness and resilience courses, and meditation sessions
• Touro College Jacob D. Fuchsberg Law Center: established a student-volunteer program to train students on recognizing mental health problems and referring them to assistance
• American University Washington School of Law: implemented random “check-in” outreach, which invites students to a brief conversation with the Student Affairs office

As a prospective law student, you may be wondering how this information can help inform your school selection. First, we suggest that you keep the task force’s recommendations top of mind as you research schools. Let their advice guide you as you’re learning about the culture of a school and the student body. Ensure that the schools you are applying to are taking the lead in breaking down mental health stigma through informative discourse and are proactively assisting students to seek help when they encounter problems. Be sure to ask administrators and faculty how they are working to address student well-being challenges. Then gather students’ opinions on the efficacy of these actions. Are current students aware of existing resources, clubs, and programming the administrators mention?  If so, how are the students engaging with the programs? And are student social and networking events promoting healthy, productive behaviors or do events center around alcohol or other potentially harmful ways to reduce stress?

Your law school experience will be pivotal. Ensure that you are selecting a school that values and promotes your wellbeing now, as much as it values your job placement.

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[i] http://www.daveneefoundation.org/scholarship/lawyers-and-depression/

[ii] http://www.ncbex.org/pdfviewer/?file=%2Fassets%2Fmedia_files%2FBar-Examiner%2Fissues%2F2015-December%2FBE-Dec2015-HelpingLawStudents.pdf

[iii] https://law.yale.edu/system/files/falling_through_the_cracks_120614.pdf

[iv] http://amlawdaily.typepad.com/files/lawyer-well-being-report.pdf