Alcohol and depression in English and American lawyer disciplinary proceedings

by Jonathan Goodliffe


Published in "Addiction", September 1994. Based on a presentation to the Annual Workshop of the American Bar Association Commission on Lawyer Assistance Programs in September 1993.



A comparison of the approach of the US courts and of the Solicitor's Disciplinary Tribunal in England to disciplinary proceedings concerning lawyers suffering from alcohol dependence and/or depression. A richer case law in the USA indicates a more sophisticated approach, higher standards as to evidence and better support systems for lawyers in recovery. Useful lessons could be learned, from the American experience and the experience of doctors and dentists, by English lawyers.



Over the last 4 years it has become increasingly common for alcohol dependence to be mentioned as a factor in proceedings before the English Solicitors' Disciplinary Tribunal. Respondents to such proceedings have sought to excuse or explain their misconduct on the grounds of their addiction. These cases are only very briefly reported in The Law Society's Gazette but are of interest in shedding light on one of the more important underlying causes of default and professional negligence amongst solicitors.

I propose to examine some of the English disciplinary cases involving alcohol and to compare them to similar cases in the US courts (O'Keefe, 1992; Ochs, 1992; Heil, 1993), where there is richer case law, fully reported in the mainstream regional law reports, available in England from, inter alia, the Institute of Advanced Legal Studies. I shall also discuss cases mentioning depression, anxiety and stress, since disorders of mood and alcohol abuse may interact in a number of ways.


Kersey - the "but for" test

The classic American case on lawyer substance abuse in disciplinary proceedings is In re B. Franklin Kersey (1987) 520 A. 2d 321, decided in the District of Columbia Court of Appeals. Kersey was originally a talented and successful trial lawyer whose life ultimately came to be dominated by alcohol. According to the judgment of Newman J:

"... by 1984, Kersey's law practice was in complete disarray. He frequently missed court appearances or arrived late. He was unshaven, ill-dressed and dishevelled. His eyes were bloodshot and his breath smelled of alcohol or peppermint. When he did appear at court often he was confused, unprepared, and could not identify his clients ... Family, friends and colleagues tried to confront Kersey with his alcoholism, but their efforts were futile"(520 A.2d 321, 324).

Kersey faced disciplinary proceedings for 24 breaches of the Code of Professional Responsibility including:

Kersey was faced with the Board on Professional Responsibility's recommendation that he be disbarred. However, he was confronted and assisted by a support group for alcoholic lawyers established in the District of Columbia, and ultimately accepted treatment for his condition, stopped drinking and "... achieved and remained in a state of recovery" ((1987) 520 A. 2d 321, 325). A physician and the Executive Director of the Lawyers Counselling Program in Maryland both agreed that he had the mental capacity to perform at his previously high professional level.

The Court of Appeals noted various respects in which alcohol abuse can influence the performance of a lawyer:

"Excessive alcohol use affects the parts of the brain involving memory, emotion and higher level functioning ... Chronic alcoholism may lead to Korsakoff's syndrome, characterised by severe memory loss, impaired learning and brain injury ... or to alcoholic dementia ... Alcohol also acts as a depressant. Alcoholics suffer from feelings of futility, and they exhibit signs of reality distortion, such as paranoia, aggressiveness, extreme lack of confidence and an inability to accept criticism or to see how their behaviour is affecting others" (520 A.2d 321, 326).

The Court was satisfied that "... but for Kersey's alcoholism his misconduct would not have occurred. We hold that this `but for' test is the standard that must be met in order to prove causation in disciplinary cases involving alcoholism" (520 A.2d 321, 327). It was not necessary for Kersey to prove that his addiction was the only cause:

"... alcoholic behaviour, unlike insanity on the one hand or ordinary conscious behaviour on the other, is neither purely involuntary nor purely voluntary. Individuals who eventually become physically addicted to alcohol, at some point voluntarily chose to drink. Not all drinking alcoholics are totally unable to control their behaviour" (520 A.2d 321, 326).

The sentence of the court was that Kersey be disbarred but that the disbarment be stayed. Kersey was placed on probation for 5 years on the conditions proposed by the Board of Professional Responsibility, including total abstinence from alcohol, to be verified by a "sobriety monitor", supervision of Kersey's practice by a "practice monitor", and supervision of Kersey's financial activities by a "financial monitor" who should be a joint signatory on any trust (i.e. client) account maintained by him (520 A.2d 321, 328).


Alcohol addiction as mitigation in England

In Charnley (1990) No 4621, 5721/1989, a sole practitioner was the subject of an intervention under the Solicitors' Act 1974 on the grounds of suspected dishonesty. In subsequent disciplinary proceedings the complaints included:

After the intervention the respondent had received treatment for his alcohol dependence and had stopped drinking. Evidence before the tribunal included a psychiatric report, a report from the treatment centre where he had been an inpatient, and oral evidence from a fellow practitioner, the respondent's wife and a member of a support group for lawyers with drinking problems.

The tribunal accepted that the respondent had not deliberately misled the Solicitors Complaints Bureau:

"Clearly the respondent's judgment has been seriously hampered by the illness of alcoholism. He has taken enormous steps to deal with that problem and indeed appeared to have recovered to a considerable degree and the prognosis for his future recovery was excellent."

The Tribunal, by its findings and order, published in August 1990, suspended the respondent from practice for 2 year0501s and recommended to the Law Society that before granting him a practising certificate thereafter it should have a medical report satisfying it that he was both medically and physically fit to pursue a career as a solicitor.


The role of support groups and State Bar alcohol programs

There have been many more cases in the United States courts than in the English Solicitors' Disciplinary Tribunal where evidence of rehabilitation from alcohol dependence has resulted in the lawyer concerned preserving his livelihood. This is particularly the case in those jurisdictions with strong support groups for lawyers with alcohol and drug problems, and a State Bar programme on lawyer substance abuse backed up by a full time staff.

Where such programmes exist one of their objectives is to identify and help lawyers with drinking problems at an early stage of their condition with a view to minimising the damage that they would otherwise do to themselves, their clients, their profession and their families. The purpose of such programmes would be frustrated if a lawyer who achieved sobriety was unable to return to practice.

One of the pay-offs of this approach is that it is often the lawyer whose misconduct during his drinking was most serious who will be most active, once he or she has become sober, in helping other lawyers with drinking problems, either through participation in the State Bar programme or through self help groups such as "Lawyers Concerned for Lawyers" or Alcoholics Anonymous. Accordingly the evidence presented to the US courts in disciplinary cases often includes details of such good works. In Mississippi State Bar v Gautier (1989) 538 So. 2d 772. for instance, the Court noted that the disbarred attorney, who petitioned for reinstatement:

"... has devoted substantial amounts of time and effort in drug counselling of youth groups and all persons who would listen to him. He has made serious and continuing effort to help others avoid the same similar tragic and disastrous consequence by engaging in thoughtless conduct" (538 So. 2d 772, 775).

In Matter of Conine (1992) WL 67232, the respondent's involvement in pro bono legal work were similarly mentioned as a mitigating factor.

Equivalent evidence does not yet seem to be a feature of English cases. The only case of which I am aware in which it has been raised is Tang (1993) No 5240 6345/1993. In this case the respondent had failed to produce his accounts for inspection. He had left the country for Guyana by the time of the hearing and did not attend it. A medical certificate submitted by his psychiatrist mentioned that he was a member of Alcoholics Anonymous and was "doing voluntary work on a Semi-Government Committee to make a day centre for the care and counselling of alcoholics". The psychiatrist had advised him not to return to England for two years. The Tribunal suspended the respondent from practice indefinitely.


Quality of evidence

As the court in Kersey pointed out the path to recovery from alcoholism is not always a straight and narrow one. It is one thing to say that one is sober and another to prove it. The more exacting the standard of proof required by a court or tribunal in such cases and the more stringent the monitoring conditions imposed, the more likely it will be that the lawyers concerned will in fact maintain their sobriety.

Thus in Duncan (1993) No 5153 6218/1992, the decision of the Solicitors' Disciplinary Tribunal to strike off the respondent was clearly influenced by the fact that "the tribunal had before it no medical evidence as to the respondent's cure from or control of his dependency on alcohol."

In Grievance Committee v Keister (1992) 607 A. 2d 909, the same director of the Lawyer Counselling Program in Maryland who had vouched for Kersey, testified that he believed that the respondent in Keister had not used drugs since 1989. Counsel for the Bar moved for, and the hearing judge granted, a physical and medical examination. The examining doctor concluded that the respondent might still be addicted to alcohol and drugs, a urine analysis having showed the presence of cocaine metabolites. The respondent was suspended indefinitely with a right to apply for reinstatement when able to demonstrate that he was able responsibly to practise law. The Court adopted the following quote from the hearing judge who had commented on the respondent's objection to the medical examination:

"For the life of me I can't figure out how you can object to physical and mental examination, given the fact that you yourself introduced as an element of mitigation before the Inquiry Panel the fact that you had alcohol or drug problems that you say are in the past. If they are in the past, that's wonderful, but I don't think Bar Counsel was required to accept your word that this is ancient history."

In the Californian case of Re: Ewaniszyk on Disbarment (1991) 788 P. 2d 690, a majority of the Court was dissatisfied with the evidence of rehabilitation. It appeared to attach significance to the fact that the respondent had ceased to attend meetings of the Californian "Other Bar" support group. One dissenting judge took the opposite view (Judicial disagreement is common in US disciplinary cases. See, for instance, Demergian, infra). In In the Matter of Passenheim (1992) WL 34047, the Californian court rejected evidence of rehabilitation which included the testimony of an active member of "The Other Bar" but did not include medical evidence.

The Solicitors' Disciplinary Tribunal occasionally seems to be willing to accept less compelling evidence of sobriety and rehabilitation than would be regarded as satisfactory by most American courts. This is no doubt partly because the corroborative evidence that can be provided in US cases through the staff of the State Bar programmes described above is not available.

In Lawrenson (1990) No 4523, 5601/1989, the respondent's practice had been the subject of an intervention. He had, inter alia, committed a series of accounting breaches and been guilty of breach of an undertaking. He appeared in person before the tribunal and claimed to have been alcohol free for 9 months. The Tribunal seem to have been satisfied with a 3 month old medical report stating that he was "drinking only in moderation, was sober and there were no effects of alcohol withdrawal". The respondent was suspended for 2 years, but no requirement was imposed, as in Charnley (supra), that he should prove that he was sober before being granted a practising certificate.

In Morrison (1992) No 5034 6110/1992, a solicitor who had been struck off in 1982 applied to be restored in 1985. At that time he had described himself as an alcoholic. His application was regarded as premature and was rejected, but in 1992, on a further application, he was restored on his assurance, apparently without medical evidence, that he was "no longer drinking to excess".

Apart from Duncan (supra) there does not seem to be any case where evidence of recovery from drinking problems has been rejected as such by the Tribunal.

The concept of the "sobriety monitor" is unknown in England. Nor does it ever appear to be suggested that the tribunal should require respondents to submit to random urine tests during a probationary period, as is frequently done in the United States. On the other hand monitoring does take place in connection with schemes in the British medical and dental professions for helping sick members of those professions. Indeed, there is a separate statutory procedure for doctors, involving informal supervision backed by the threat of a Health Committee, which sits in private to deal with most cases of doctors who are the subject of disciplinary proceedings (Pritchard, 1992; General Medical Council, 1990).

In the American cases involving alcohol dependence, lawyers claiming to have recovered from their condition almost invariably claim to be totally abstinent. Where they do not claim to be abstinent, or to be suffering from the "disease of alcoholism", the fact that their misconduct may have arisen as a result of non-dependent alcohol abuse does not seem to be regarded as a mitigating circumstance (Florida Bar v Bazley (1992) 597 So.2d 796, Florida Bar v Palmer (1987) 504 So.2d 752).

The Solicitors' Disciplinary Tribunal, on the other hand does not insist on a commitment to complete abstinence (Morrison (supra) and Rees (1989) No 4271H, 5429/1988). In the latter case, a solicitor whose misconduct consisted mainly in failing to attend to correspondence, was suspended for 2 years and required, on applying for a practising certificate thereafter, to provide a medical report from a specialist doctor "confirming that the respondent's drinking habits have remained moderate and under control and expressing him to be mentally and physically fit to practise as a solicitor."


Exceptionally serious misconduct

The more serious the misconduct complained of, in principle, the more difficult it should be for a lawyer facing disciplinary proceedings to persuade a court or tribunal not to strike him off or disbar him. The approach to this issue varies between different jurisdictions of the United States.

In the Californian case of Re Demergian (1989) 768 P. 2d 1069, the respondent had committed a series of acts of misconduct and had served a term of imprisonment. A majority of the Court decided that he should be disbarred, in spite of what was on any view exceptionally good evidence of rehabilitation. It was partly influenced by the fact that the respondent had been addicted to illegal drugs as well as alcohol. At the same time it accepted that the rehabilitation of the respondent might be a basis for a subsequent petition for reinstatement.

In New York, on the other hand, the Courts follow the Kersey "but for" approach even in cases involving conversion of substantial client funds (Matter of Winston (1988) 137 A.D. 2d 385).

In New Jersey, however, the rule established by In re Wilson (1979) 409 A. 2d 1153, is that a lawyer guilty of knowingly commingling client funds will be disbarred, with no prospect of reinstatement, whatever evidence in mitigation may be adduced.

In England Lord Donaldson MR has indicated in several appeal cases that where a solicitor has been guilty of misconduct involving dishonesty he will generally be struck off without prospect of reinstatement. In the unreported case, No 5 of 1990, Lord Donaldson said:

"There is considerable public interest in the public as a whole being able to deal with members of [both branches of the legal profession] knowing that, save in the most exceptional circumstances, they can be sure that none of them have ever been guilty of any dishonesty at all."

More recently Sir Thomas Bingham MR, in Bolton v The Law Society [1994] 1 WLR 512 has indicated that a striking off order may be appropriate even where dishonesty is not established.

The application of these principles to cases involving alcohol dependence has yet to be developed. It is perhaps significant, however, that in Cook (1993) No 5166, 6259/1992, a struck off solicitor who sought to be restored to the roll relied unsuccessfully on Morrison (supra). The tribunal distinguished that case on the grounds, inter alia, that Morrison had suffered from alcoholism and depression, whereas Cook's explanation for his theft of client funds mentioned only "enormous strain" and "marital problems".


Alcohol and depression

The Kersey judgment mentioned the fact that alcohol abuse can cause depression. The relationship between the two conditions is of course much more complex.

In the United States the concept of alcoholism as a primary illness is perhaps more prevalent than in the UK. It has been adopted, for instance, in the American Bar Association's Desk Guide to Legal Malpractice (American Bar Association, 1993). According to Dr George Vaillant: "... once it occurs alcoholism has a life of its own and ... alcoholism is best thought of as a cause not a consequence of personality disorder" (Vaillant 1983). In the UK, on the other hand, the old fashioned symptomatic model of alcohol dependence according to which:

"alcoholism is a symptom rather than a disease ... There is always an underlying personality disorder evidenced by obvious maladjustment, neurotic character traits, emotional immaturity or infantilism" (Knight, 1937).

is still probably the approach of most doctors in general practice.

Unless the court or tribunal imposes stringent requirements as to evidence of rehabilitation and monitoring during any probationary period, the true nature of the underlying condition of a person presenting symptoms of alcohol dependence or depression may not emerge, especially where an addicted person seeks to conceal or play down the extent of his drinking.

In Howard (1988) No 4218, 5386/1988, the respondent attended a police station as duty solicitor when intoxicated. The police discovered that he had arrived by car. He was subsequently convicted of driving with excess alcohol and received inpatient treatment for alcohol dependence. A medical report giving him a good prognosis was produced to the Disciplinary Tribunal. He was fined ,500 and the Tribunal recommended that the Law Society should require him to provide a medical certificate that he had not relapsed into alcoholism.

Thereafter he was the subject of two further sets of disciplinary proceedings in 1991 and 1993 (No 5151, 6215/1992) involving breaches of accounts rules. In the latter proceedings the medical certificate stated:

"This is to confirm that Mr. John Howard is suffering from an anxiety depression state and is requiring night sedation to help him overcome his problem."

In view of the respondent's failure to rehabilitate himself he was, on the third occasion, struck off. Significantly the Law Society's Gazette report of the 1993 disciplinary proceedings mentioned neither his depression nor his alcohol dependence (Law Society's Gazette, 90/21, p. 38).

In Hawes v State Bar (1990) 797 P. 2d 1180, a lawyer with a dual diagnosis of alcohol dependence and bipolar affective disorder was charged with, inter alia, failure to carry out instructions, withdrawing from a retainer without taking adequate steps to avoid prejudice to his client, failing to return unearned fees and failure to co-operate with the State Bar investigation. He received treatment for his dependence and was prescribed and continued to take lithium carbonate for the affective disorder. The California Court found it unnecessary to impose any suspension.

There have been a very few other cases in the US courts involving affective disorder without alcohol dependence, and one mentioning schizophrenia (Matter of Rosner (1990) 576 A. 2d 889). In these the courts have taken a similar line to that adopted in the alcohol cases, generally requiring evidence of recovery or stabilization before withholding or lifting any suspension.

In the English cases depression, anxiety and stress are often mentioned, sometimes with and sometimes without medical evidence.

In Jarman (1990) No 4511, 5580/1989, the respondent stole nearly ,800,000 from partnership funds of which some ,500,000 was recovered. The respondent did not appear before the tribunal. Passing mention was made of a psychiatrist's report, filed in criminal proceedings, which indicated that the respondent was depressed, but that there was no evidence of psychiatric illness. He was struck off.

In Hart (1991) No 4974, 6048/1991, the respondent, who had failed to deliver accountant's reports, practised without a certificate, failed to keep proper accounts and used client's funds for his own purposes, was diagnosed as suffering from an acute depressive illness. He needed long term counselling. He continued to take medication and although he had improved he was not completely fit. On his second appearance in 2 years before the tribunal he was given an indefinite suspension with a recommendation that, in the event of the suspension subsequently being lifted, he should only be permitted to work in approved employment or as a partner in an approved partnership.

In Gardner (1988) No 4219, the respondent had used client's money for his own purposes and the purposes of other clients, breached undertakings, failed to account to a client and made misleading statements. The respondent explained his conduct by saying that he had suffered from depression and had been suicidal. His problems had caused him to resume drinking after 3 years abstention. He did not wish to resume practice and was struck off.


Addiction as an aggravating factor

In less serious disciplinary proceedings, where a solicitor is unlikely to be struck off or suspended, alcohol dependence is rarely if ever mentioned as a factor in English cases, probably because there is no advantage in the respondent bringing it into evidence. On the contrary a solicitor, not already in really serious trouble, may consider that he will simply be inviting further attention from the Solicitors' Complaints Bureau, or inviting the Tribunal to impose a suspension pending medical evidence of recovery, if he admits that he has a drinking problem. Although under section 35 of the Solicitors' Act 1974 the illness of a sole practitioner is a ground for intervention in his or her practice, this power has never been used on the grounds that the practitioner concerned is alcohol dependent.

Similarly, whereas evidence of alcohol dependence coupled with evidence of recovery may be accepted as mitigation, the opposite will often be the case where the court or tribunal is not satisfied that the lawyer has been rehabilitated. In Matter of Rea (1991) 173 A.D. 2d 953, for instance, the attorney had been suspended for one year, but failed to get reinstated thereafter because he could not demonstrate that he had maintained his sobriety.

There have been decisions in the US courts where a minor transgression has led to disciplinary proceedings, which have been used as a means of putting pressure on the lawyer concerned to face up to his problems.

In Matter of Willis (1989) 552 A. 2d 979, the attorney had failed to file a tax return, charged unreasonable fees in 8 separate matters, drawn a cheque against insufficient funds and neglected 6 matters involving clients. Evidence of a "remarkable recovery" from alcoholism persuaded the court to impose a suspension of 6 months rather than the period of more than a year which would otherwise have been appropriate.

It is perhaps less likely that in England alcohol would have been identified as a factor in such a case, or that similar pressure would have been put on the respondent to show that he had recovered from his condition.


The power of suspension

The power to suspend a lawyer from practice is frequently used in both the USA and in England. Suspension may be regarded either as a punishment or as an opportunity for the suspended solicitor to concentrate on getting better and maintaining his sobriety, or stabilising an affective disorder, free from the pressures of practice, during the early stages of his recovery.

As a result of the amendments introduced by the Courts and Legal Services Act 1990, the Tribunal now has the power to impose indefinite suspensions as well as suspensions for fixed periods. An indefinite suspension, when imposed on health grounds, might subsequently be removed when satisfactory evidence of recovery was provided. The Tribunal recently adopted this course in, for instance, Voyce (1993) No 5202, 6304/1993, where the respondent had failed to reply to correspondence. He did not appear before the tribunal but explained in a letter that he had suffered from depression. The Tribunal indicated that an application to remove the suspension should be supported by a report from the respondent's general practitioner and from a consultant psychiatrist.



Alcohol dependence and depression are clearly significant factors in many disciplinary proceedings in England. Most of these proceedings concern sole practitioners or partners in small firms. The problems created by the drinking of partners and employees of larger firms, are more likely to impact on their colleagues and perhaps less likely to come to the attention of the Solicitors' Complaints Bureau, unless or until the drinker loses his job and sets up in business on his own. Apart from those cases where alcohol and/or depression are raised by the respondent himself or where they are obvious because, for instance, the respondent has been convicted of driving with excess alcohol, there are probably many other cases where the fact that the solicitor is addicted is concealed. One of the features of alcohol dependence is the inability of the drinker to face up to the real cause of his problems even, sometimes, where the source of his livelihood is at stake.

The Courts in the USA and the Tribunal in England adopt a humane approach in disciplinary proceedings where misconduct is shown to be alcohol related and the practitioner concerned can show that he has come to terms with his condition. There are good reasons for this policy. It is in the public interest that the underlying cause of such misconduct should be identified, that lawyers with drinking problems should be able to admit to that fact and be encouraged to seek help. Furthermore the impact of alcohol dependence on professional performance and standards, and the fact that it is a condition from which recovery is possible, needs to be brought home to the profession as a whole. An understanding by lawyers of the relevance of alcohol dependence to the problems faced by their clients is, perhaps, equally important (Goodliff, 1989a, 1989b). Bissell and Haberman (1984) point out:

"As treaters of others, professionals may be unusually slow to seek help for alcoholism. Inappropriate treatment and long delays have been the rule. We cannot know how much harm is actually done to patients and clients by the alcoholic or drug using professional, but it must be significant.

There are similarities between the English and American experience as well as obvious distinctions. In the USA there is perhaps greater awareness in society as a whole about alcohol abuse and dependence and their consequences and thus less of an inclination, on the part of the colleagues of a drinking lawyer, to cover up and ignore the problems. In most states there is now an infrastructure of support systems for identifying and helping sick practitioners. At the same time the American problem is probably more acute since many cases now mention cocaine (O'Keefe, 1992) and other illegal drugs, as well as alcohol.

The English Solicitors' Disciplinary Tribunal seeks to strike a balance between enforcing high standards of honesty, fair dealing and competence within the profession on the one hand, and, on the other, treating in a humane way those solicitors whose careers have been affected by alcohol dependence, clinical depression and other related conditions. It remains to be seen whether any change of approach emerges, now that the Tribunal is, since April 1994, sitting in public rather than in private.

There are, perhaps, a number of possible approaches which might be adopted by the Tribunal and/or the Law Society/Solicitors' Complaints Bureau, based on the experience in the US and within the medical profession:

The statutory powers to implement measures of this kind are contained in section 47 of the Solicitors Act 1974 which provides, inter alia, that the Tribunal "shall have power to make such order as it may think fit", and in section 12, under which the Law Society may issue a practising certificate subject to conditions.

Any such initiatives will, however, depend largely for their success on the profession as a whole developing a more pro-active policy towards alcohol dependence and related conditions. There are signs that this is beginning to happen.

Society for the Study of Addiction to Alcohol and other Drugs 1994




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Bissell & Haberman (1984) Alcoholism in the Professions, p. 4 (New York, Oxford University Press).

General Medical Council (1990) Annual Report (London, General Medical Council).

Goodliff, J. (1989a) The Alcoholic Client, Solicitor's Journal, 133, pp. 678-80.

Goodliff, J. (1989b) The Alcoholic Lawyer, Solicitor's Journal, 133, pp 958-959.

Heil, P.S. (1993) Tending the Bar in Texas: Alcoholism as a

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Knight, R. P. (1937) The Dynamics and Treatment of Chronic Alcohol Addiction, Bulletin of the Menninger Clinic, 1, pp. 233-50.

Ochs, M. S. (1992) Attorney Alcoholism and Substance Abuse - a Disciplinary Counsel's Viewpoint, New York State Bar Journal, 64, pp. 36-38.

O'Keefe, R. P. (1992) The Cocaine Addicted Lawyer and the Disciplinary System, St Thomas Law Review, 5, pp. 217-235.

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Vaillant, G. (1983) The Natural History of Alcoholism, p. 169 (Cambridge, Massachusetts, Harvard University Press)