Law and Human Behavior © 2012 American Psychological Association 2012, Vol. 36, No. 6, 538–547 0147-7307/12/$12.00 DOI: 10.1037/h0093993 The Effect of Attorneys’ Work With Trauma-Exposed Clients on PTSD Symptoms, Depression, and Functional Impairment: A Cross-Lagged Longitudinal Study Andrew Levin Avi Besser Westchester Jewish Community Services, Sapir Academic College Hartsdale, New York and Columbia University Linda Albert Deborah Smith State Bar of Wisconsin, Madison, Wisconsin Wisconsin State Public Defender’s Office, Madison, Wisconsin broadly. publishers. Yuval Neria Columbia University and New York State Psychiatric Institute, allied New York, New York disseminated its be of to one To date, few studies have examined mental health consequences among attorneys exposed to clients’ not or traumatic experiences. A longitudinal, 2-wave, cross-lagged study was used in a cohort of attorneys is (N ϭ 107) from the Wisconsin State Public Defender’s Office. We assessed changes in posttraumatic and stress disorder (PTSD), depression, and functional impairment over a 10-month period and tested the user effects of intensity of contact with trauma-exposed clients on symptom levels over time. Attorneys Association demonstrated strong and significant symptom stability over time in PTSD, depression, functional impairment, and levels of exposure. Analyses involving cross-lagged panel correlation structural equa- tion modeling path models revealed that attorneys’ levels of exposure to trauma-exposed clients had individual significant positive effects, over time, on PTSD, depression, and functional impairment. Gender, age, the years on the job, and office size did not predict any of the outcomes. Level of exposure to trauma-exposed Psychological of clients predicted reduction of weekly working hours over time, but there was no reciprocal relationship use between PTSD, depression, and functional impairment and level of exposure over time. These findings underscore the central role of exposure to trauma-exposed clients in predicting mental health outcomes American and emphasize the need to support attorneys by managing the intensity of exposure as well as addressing personal the emerging symptoms. the by for Keywords: attorneys, psychological trauma, posttraumatic stress disorder, depression, functional impairment solely copyrighted is To date, few studies have examined the mental health conse- these findings were not related to work experiences. In a study of intended quences among attorneys exposed to clients who have experienced 23 Canadian prosecutors using semistructured interviews, Gomme is or been directly involved in traumatic events (trauma-exposed and Hall (1995) reported symptoms of demoralization, anxiety, document clients). In addition, available quantitative studies of distress in helplessness, exhaustion, and social withdrawal. They linked these article attorneys have only been cross-sectional in nature. Focusing on symptoms to high caseloads of “sensitive cases” such as domestic This This depression, Benjamin, Darling, and Sales (1990) and Eaton, An- violence and incest as well as long work hours. Lynch (1997) thony, Mandel, and Garrison (1990) identified a 20% rate of reported that public defenders ranked work overload, the unpre- clinically significant depression in the attorneys surveyed, but dictability of trials, the frequent lack of a defense, harsh sentences, This article was published Online First April 2, 2012. This study was supported by the State Bar of Wisconsin and the Andrew Levin, Westchester Jewish Community Services, Hartsdale, Wisconsin State Public Defender’s Office. We thank Jeff Apotheker New York; Department of Psychiatry, College of Physicians and Surgeons, for his critique of the original design and support of the submission Columbia University. Avi Besser, Department of Behavioral Sciences and to the Westchester Jewish Community Services Research Committee, Center for Research in Personality, Life Transitions, and Stressful Life and Alex Zelenski for assistance in data gathering and management. Events, Sapir Academic College, D. N. Hof Ashkelon, Israel. Linda Albert, Grateful thanks are also extended to all of the participants in this Wisconsin Lawyers Assistance Program, State Bar of Wisconsin, Madison, study. Wisconsin. Deborah Smith, Assigned Counsel Division, Wisconsin State Correspondence concerning this article should be addressed to An- Public Defender’s Office, Madison, Wisconsin. Yuval Neria, Department drew P. Levin, Medical Director, Westchester Jewish Community Ser- of Psychiatry, College of Physicians and Surgeons, Columbia University; vices, 141 North Central Avenue, Hartsdale, NY 10530. E-mail: New York State Psychiatric Institute, New York, New York. [email protected] 538 ATTORNEYS WORKING WITH TRAUMA-EXPOSED CLIENTS 539 arguing with prosecutors, and dealing with angry clients and Method families as the most frequent and intense sources of stress, but the study did not measure specific symptoms of stress. A pilot study Participants and Procedure by Levin and Greisberg (2003) found that attorneys working in family and criminal courts demonstrated higher levels of second- We conducted a longitudinal follow-up study on a sample of ary trauma and burnout compared with mental health professionals attorneys working in the 38 offices of the Wisconsin State Public and social service workers, and these measures of distress corre- Defender’s Office (Levin et al., 2011). In that study, we collected lated with caseload. Comparing 50 attorneys working in criminal data in March 2010 via the Wisconsin State Public Defender’s courts with 50 working in the civil arena, Vrklevski and Franklin Office intranet to 307 attorneys, with an initial response of 238 (2008) found more depressive symptoms, subjective stress, and attorneys (78%). The data for the current study were based on a changes in sense of safety and intimacy among the criminal follow-up survey that was distributed in December 2010 to all attorneys. A personal history of multiple traumas predicted higher attorneys working in the office. This resulted in 142 responses, of scores on measures of vicarious trauma, posttraumatic stress, and which 107 were attorneys who had also completed the original depression. In another study comparing criminal and civil attor- survey, representing 45% of the 238 who initially responded. The neys, Hasnain, Naz, and Bano (2010) also found that criminal 107 attorneys (51 men and 56 women) were in their mid-40s (M ϭ broadly. attorneys reported higher levels of stress than civil attorneys. This 45.72 years, SD ϭ 11.0), with almost 16 years’ experience on the job (M ϭ 15.89, SD ϭ 11.03), working on average in local offices publishers. difference was seen among attorneys with more than 10 years’ ϭ ϭ experience but was not observed in attorneys in training. Pi- (total staff) of more than 10–20 people (M 2.40, SD 1.0). Preliminary analyses indicated that the means for hours worked, allied wowarczyk et al. (2009) reported that among 57 attorneys special- disseminated ϭ ϭ its izing in asylum cases, hours per week devoted to those cases t(236) 0.81, ns, caseload of trauma-exposed clients, t(236) be of 0.20, ns, size of local office, t(236) ϭ 0.09, ns, and background to correlated with trauma score. All of these studies of attorneys ␹2 ϭ ϭ one suggest a relationship between exposure to trauma and attorneys’ variables of gender ( 0.59 ns), age, t(236) 0.11, ns, years on not or t ϭ ns is symptoms but suffer from small sample size and, given their the job, (236) 0.55, , as well as the outcome variables of intrusion, t(236) ϭ 0.44, ns, avoidance, t(236) ϭ 1.42, ns, hyper- and cross-sectional design, do not elucidate the course of the symptoms ϭ ϭ or the direction of effects between exposure and symptomatology. arousal, t(236) 0.79, ns, depression, t(236) 0.22, ns, and user functional impairment, t(236) ϭ 0.47, ns, did not differ at the Association Studies of other human service professionals working with trauma- initial survey in March 2010 between the subset that followed up exposed clients such as social workers (Kassam-Adams, 1999), (n ϭ 107) and the remaining 131 participants. law enforcement officers (Follette, Polusny, & Milbeck, 1994), individual Survey materials were made available online by the survey and psychotherapists (Pearlman & MacIan, 1995) are also limited the office of the State Bar of Wisconsin. Potential participants re- by cross-sectional design. Some of these studies have linked in- Psychological of ceived an e-mail providing the necessary link to the questionnaires tensity of work-related exposure (Creamer & Liddle, 2005; Er- use and were encouraged to complete the survey from personal com- iksson, Kemp, Gorsuch, Hoke, & Foy, 2001; Kassam-Adams, puters on the job site. All participants received information regard- 1999) to secondary trauma symptoms, although other findings American ing the study in the form of an informed consent cover letter at the personal have suggested the primary importance of organizational and the start of the online survey packet. Proceeding to the questionnaire the work-related factors (Baird & Jenkins, 2003; Devilly, Wright, & by indicated consent. Participation was voluntary and anonymous and for Varker, 2009; Regehr, Hemsworth, Leslie, Howe, & Chau, 2004) there was no remuneration for participation. The research proposal compared with exposure. was reviewed and approved by the Westchester Jewish Commu- solely Recently, in a large cross-sectional study, our group examined