Personal Accounts: Lawyering, Psychiatric Treatment, and Schizophrenia: A Healing Interaction

A generation ago, having schizophrenia typically meant poverty and joblessness. But with the more effective antipsychotics approved since 1990 and (slightly) decreasing stigma associated with the illness, many young adults can return to school or work stabilized and cognitively intact after experiencing a first psychotic break. They can hope to maintain this stability for sustained periods if they take appropriate medication. Because of interference from the illness, people with schizophrenia customarily are not encouraged by mental health care providers to choose a professional career track. However, I offer my own career in law as an example of the way in which professional work can mitigate and accommodate symptoms of schizophrenia and thus make a professional career particularly suitable for people with schizophrenia.

I practiced law successfully for nine years, despite an onset of schizophrenia ten years before I began practicing. I found four factors central to my success as a lawyer: coming out of my withdrawal to attract mentors, learning to negotiate and align interests, surmounting symptoms through attention to details, and autonomy.

To see where law took me, it helps to know where I started out. Although I had experienced hearing voices, feelings of agitation, and insomnia from age 17, in the self-directed world of a liberal arts college I was able to work around my symptoms without revealing them. I experienced a great deal of private anguish, but no one suspected my secret. I found myself at a top-three law school and successfully managed the first academic year.

All of this success fell apart my first summer, when I was a summer associate. I had to work ten hours a day and then socialize with the other lawyers and summer clerks at lunch, on weekends, and on some evenings. The stress of being "on" for 50 to 60 hours a week without a break drove my voices into overdrive. I was practically aphasic with the lawyers I worked with, and I could not eat at the luncheons. I failed to contribute to taking a deposition when asked because I was overwhelmed by distracting voices, which were saying that I was an idiot and the firm's lawyers hated me and planned to blackball me to all the law firms in the city. In the end, the director of the summer program took me out to lunch to tell me, "Your written work is excellent in quality and quantity, but we doubt we can hire a lawyer so handicapped by shyness."

I came back from the clerkship determined to seek treatment. However, the psychiatrist I saw at the student health center could not reconcile my A- average at the law school with the schizophrenia I feared. He did not mention antipsychotic medication.

My second and third years were comparable with my first. I was academically successful, but my social withdrawal led me to struggle at law firm summer programs. I sought treatment again, but my new psychiatrist also discounted my fears of schizophrenia. After graduation I found a federal judicial clerkship and interviewed again with law firms. For my first permanent job, I chose a Washington, D.C., law firm that is equally renowned for the quality of its work and its tolerance for eccentricity.

My clerkship forced me into sustained treatment. I constantly "heard" my fellow clerks plotting against me to get the judge to withdraw his recommendation to the Washington firm and otherwise ruin my career. Eventually I went to the judge in a panic. He sensibly called the other clerks in and ascertained I was mistaken. He admonished me to get along with the other clerks and dismissed us. I knew if I was to keep any law job, particularly this one, I would need treatment.

I turned to a noted practice at a local hospital. Although my therapist discounted my report of auditory hallucinations as a transitory phenomenon and gave me a diagnosis of "social anxiety," he had all the tools of cognitive therapy at his fingertips. We practiced stroking, disarming, open-ended questions, thought and feeling empathy, and first-person statements. My relationships with the other clerks improved, but I had not fully mastered the techniques. The voices were unchanged. My therapist wondered openly to me how I could have done the homework so zealously and experienced so little real change in my condition.

When I completed the clerkship in 1989, I was highly symptomatic. I could not sleep, eat, or think at my usual level. I heard voices, including what I thought was the voice of God, and saw visions. I sought a psychiatrist but was unable to locate an appropriate one on my own. In this state, I joined the law firm. I turned in work that my supervising partner could not use, and he threw me back into the pool of unassigned attorneys. After a couple of short assignments that did not result in partners who retained me, I was sure I had failed at the firm. I took an overdose of sleeping pills one Friday but was found by a friend. This friend insisted I get into treatment. My therapist referred me to a local psychiatrist, which he had been unable to do earlier. That psychiatrist prescribed Mellaril and lithium. The voices and visions stopped overnight. I was sold on medication and the psychiatrist.

I also was stable enough to use the skills my therapist had taught me to find a niche in the firm's practice. A partner I had talked to from time to time, for whom I felt genuine affection mixed with the deference that associates tender to law firm partners, asked me to start discovery on a criminal case for him. Mandatory discovery in criminal cases is limited, particularly in the phase before indictment, as was the case here. In this case, without the documents we sought, the company might lose its primary business. People I had met and liked would go to jail. The motivation of the real-world stakes allowed me to perfect the negotiating and disarming skills I had learned in theory with my therapist but had not yet mastered. I persuaded 25 document custodians across the United States to copy bankers' boxes full of documents to which we had no legal right and to send them to me promptly. I also, in the words of the partner, "charmed" the client.

I had another opportunity to learn how to break out of my schizophrenia-induced withdrawal that fall. I had been working on an asbestos matter for another partner. One Friday morning, he told me he had to leave urgently for New York and that I would need to step in that day to prepare an important witness for an impending hearing. I was casually dressed and had barely set up the conference room when the witness appeared, dressed in business attire, with one of his colleagues and a lawyer of his own. I had never prepped a witness before, and I was viewing the exhibits, which were technical, for the first time. Around lunchtime, the witness threw the exhibits in my face, exclaiming, "You incompetent idiot!" I knew my position at the firm depended on my getting control of the room. I looked firmly at the witness, saying "You can cooperate with me now and catch your plane at 5 p.m., or you can stay over the weekend and be prepped by [the partner] on Monday. Which do you prefer?" He looked around the room at the hard eyes meeting him in response and cooperated. I had learned the hard alignment of interests that is negotiation.

Eventually I left the firm for a position with the government. I had had a psychotic break at the firm after working very long hours. In my interviews for my next job, I was candid: I told all future employers that I could manage a focused 55-hour week but was unable to do more than that for health reasons, which I did not specify. In four months, I received two offers.

I accepted a job writing federal appellate briefs. I attracted a mentor, my team leader, from almost my first day at the new job. Our relationship was based on a blend of genuine interest and affection, coupled with the deference and good work that had attracted my mentor at the firm. Again, my therapist had given me the building blocks, but it was the combination of the stability offered by the medication and the real-world urgency of the need to hold a job that made me able to use these tools effectively.

That first year of my federal job, and often thereafter, I was saved by the autonomy of a lawyer's position. Federal appellate briefs are completed on a 40-day timeline, with crunch times coming chiefly at the end. If I woke up with prominent hallucinations, I would head in to work anyway. I did not permit myself to miss work for anything short of overwhelming physical illness. Each day, as I focused the first two or three hours of work on the facts and case law at hand, the voices would typically dim, only to rise again as the day wore on and I grew tired. By 6:30 p.m., I could leave the office in good conscience, with a day's work done.

I received an outstanding rating my first year. Shortly thereafter, I became the point person on our team for "emergencies." That meant a couple of 80-hour weeks and skipping medication. With clozapine, my antipsychotic at the time, I had to sleep 12 hours a night after taking it to function the next day. I was assigned another emergency in short order and, after completing it, told my team leader I could handle an occasional emergency but not a glut. He told me that I was good at them and would continue to be assigned a disproportionate share. I adopted a risky strategy. I wrote my team leader a memo, reminding him of the statements I had made in my interviews that I had a chronic medical condition and specifying that I now took medication that required me to sleep 12 hours a night. I told him that if I continued to be assigned more than my share of emergencies, I would have to leave. In the end, our relationship was strong enough that he supported my request for what was in effect a reasonable accommodation: I would not have to work more than 12 hours in a day or 200 billable hours in a month.

After two years of productivity, a promotion, and bonuses while taking clozapine, I developed agranular cytosis, a drop in white blood cells that is fatal if left unchecked. My psychiatrist immediately stopped my medication—from 225 to 0 mg overnight. The withdrawal symptoms—nausea, vomiting, insomnia, and an inability to read a sentence with comprehension—lasted for three months and caused me to lose my job. Risperidone, the only other second-generation antipsychotic then available, did not help me. I called in every favor I had so that I could manage a transfer to another section of my division and take some time off to participate in an investigative drug study.

I was taking haloperidol, the control, in the drug study. I came back to work after two weeks on the open-label investigational drug, still unstable, and faced a new challenge: I was handling a large and complex case that involved accounting fraud, but I had no background in accounting. I took accounting at night and slowly made sense of the case over five months as I stabilized on the investigational antipsychotic. The autonomy of a professional job was crucial to my ability to keep working at the time. I was senior enough at this point to work unsupervised. Being able to work at my own pace allowed me to adjust to my new medication slowly as I mastered the intricacies of the case.

The investigational drug gave me another 14 months of successful practice before I developed tardive dyskinesia (TD), a neurological side effect of antipsychotics. TD often becomes irreversible if patients stay on the drug that has caused it or switch to a first-generation antipsychotic. My only choice, then, outside clozapine, was risperidone, which also causes TD. I then made an unwise choice, and one I have since often regretted: I stopped taking my antipsychotic. I rapidly decompensated and eventually had to resign. I have never regained the ability to work as a lawyer.

However, I still dream of returning to law practice and of various alternative careers. In each position, the qualities I learned as a lawyer—attracting mentors, knowing how to negotiate and align interests, surmounting symptoms, and leveraging autonomy—would prove helpful. They are also qualities that are accessible to and useful for many people with schizophrenia. I hope this essay will persuade mental health professionals to encourage people with schizophrenia to consider appropriate professional work with the confidence that such careers can accommodate and mitigate symptoms of the disease. We will all benefit from it.