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Real-World Evidence is useful for validating crossover adjustment approaches, particularly when the adjustment is required because a trial does not accurately reflect a health technology assessment (HTA)-relevant population. We use the MAVORIC trial advanced stage mycosis fungoides and Sézary syndrome cutaneous T-cell lymphoma population and data from the Hospital Episodes Statistics to explore and validate crossover adjustment methods.
The MAVORIC trial compared mogamulizumab to vorinostat in patients with mycosis fungoides (MF) or Sézary syndrome (SS), subtypes of cutaneous T-cell lymphoma. However, the treatment comparison within MAVORIC may not represent an HTA relevant population from a UK perspective: (i) 72.6 percent of patients randomized to vorinostat switched to mogamulizumab and (ii) vorinostat is not used in current clinical practice in the UK. This study explores methods to adjust treatment effect estimates using different crossover adjustment methods and Real-World Evidence.
This medicine is subject to additional monitoring. This will allow quick identification of new safety information. See www.mhra.gov.uk/yellowcard for how to report side effects.
An advanced stage (stage ≥IIB MF and all SS) population was included. Three methods were considered for treatment crossover adjustment. A synthetic control arm was created using the Hospital Episodes Statistics (HES) dataset. Predicted survival for the MAVORIC control arm, post-crossover adjustment, was compared to the HES to inform the selection of the appropriate methods for adjustment. A direct comparison between mogamulizumab (reweighted to represent the distribution of MF/SS patients in the HES) and the synthetic control was also conducted.
Following crossover adjustment of the vorinostat arm, using the inverse probability of censoring weighting method, the overall survival (OS) hazard ratio (HR) estimate for mogamulizumab vs. vorinostat was 0.45 (95% confidence interval (CI): 0.19, 1.07). This adjustment method was considered the most appropriate based on an assessment of assumptions and a comparison of OS between the adjusted vorinostat data and the HES data. The OS HR estimate for reweighted mogamulizumab vs. synthetic control from HES was 0.33 (CI: 0.21, 0.50).
Real World Evidence from the HES database can be used to validate crossover adjustment methods and to better reflect current clinical practice in the UK. Results using both methods support each other.
The legal workplace, like all others, is a space of emotion. Emotions are present and displayed both within all work being undertaken and through interactions with other people, whether clients, co-workers, judges, opposing counsel or other third parties. The way emotions infuse, impact upon and are influenced by interactions with others was a sub-theme which arose during the focus groups. In working with others one can benefit from social support, guidance and camaraderie as well as the enjoyment of companionship. All these factors can positively affect wellbeing. On the other hand, working with others in an overly competitive professional environment can cause stress, annoyance and conflict, which can negatively affect wellbeing, and in the more serious cases can contribute to mental ill-health. As discussed in Chapter Three, the legal environment, like many professional spaces, is often considered to be an unemotional field, with practitioners adopting personas of rational, cool objectivity within it. Yet if an individual sat and consciously tracked their emotional states throughout their working day, they are likely to find that they are regularly emotionally impacted by their daily work and social interactions, both positively and negatively. These emotions, by extension, can affect the actions of that person and their perceptions about their own wellbeing or satisfaction within the workplace. In turn, what individuals say and do as a result of how they manage their emotional states is likely to also affect other people's emotions and wellbeing. Being cognizant of the working environment, the role of the people within it, and its daily uplifts, as well as its stresses or strains, is important for employers so that they can promote better wellbeing. Having supportive co-workers or management can engender positive emotions, which can lead to greater job satisfaction and enhanced productivity. An adverse working environment, it is obvious to say, will have the opposite effect.
This chapter will explore the interactional demands placed on legal professionals. These include meeting the demands of clients, dealing with vulnerable persons and working with colleagues and judges. It will also explore the nature of the relationship between legal professionals and other persons within their work environment.
Within this volume so far, the term ‘profession’ or ‘professional’ has already been used on many occasions. The fact that this volume, and the research supporting it, focuses on ‘the legal profession’ arguably makes this profusion of use inevitable. However, the conceptualization of, and sense of belonging to, a profession has important connotations which impact upon the perceptions of those within it, including the focus group participants in this study.
One of the key themes emerging within the focus groups was around professional formation and development, in other words the process of becoming a legal professional and working as part of the legal profession. More specifically, discussions during the focus groups explored how participants viewed the training and support they were provided with during their academic and vocational legal education and training, with participants talking about the extent of their preparedness for legal practice. The differences arising between different roles and sectors or specialities within law were also considered. At the heart of this process of professional formation and development is the notion of professional identity. In other words, the ways in which individuals interpret their role as a lawyer (Field et al, 2013). This identity will not only draw upon an individual's own personal values, beliefs and motivations, but will also be shaped by their experiences within legal education, training and practice and their perceptions of how others see their professional role (Hall et al, 2010). For example, a lawyer who chooses to specialize in criminal defence work may have a strong personal commitment to pursuing truth and justice, while also taking an adversarial and combative approach to representing their client, based on their observations of the norms of courtroom behaviour (for further examples, see Bergman Blix and Wettergren, 2018).
This sense of professional identity is arguably becoming more important as the notion of being a legal professional is increasingly understood as going beyond compliance with the core ethical standards imposed by regulators (eg the SRA's Code of Conduct for solicitors in England and Wales). The idea of being a professional is now commonly viewed as requiring lawyers to display a range of ‘professional’ behaviours and characteristics (Hamilton, 2008).
Legal professionals are thought to have higher levels of mental health issues and lower levels of wellbeing than the general population. Drawing on qualitative data from new research with legal practitioners, this in-depth study of mental health and wellbeing in the UK and Republic of Ireland's legal sector is a timely contribution to the urgent international debate on these issues. The authors present a comprehensive discussion of the cultural, structural and other causes of legal professionals' compromised wellbeing. They explore the everyday demands and difficulties of the legal working environment and consider the impacts on individuals, the legal profession and wider society. Making comparisons with systems overseas, this is an invaluable resource that provides evidence-based suggestions for swift and effective organisational and policy-related interventions in the legal sector.
Many lawyers feel unhappy too frequently or experience chronic health issues. In any courtroom image with prosecution and defence lawyers poised tensely, in any photograph of lawyers grouped around a corporate meeting table negotiating a merger or acquisition, in any shot of lawyers campaigning for social justice, the likelihood is one or more of those individuals are affected by poor wellbeing or mental ill-health. This may be because they are experiencing problematic levels of stress, clinically significant symptoms of anxiety or depression, or are facing overwhelming demands and challenges. These opening sentences may seem counter-intuitive when common media portrayals of the legal profession depict legal practice as high status, prosperous, even glamorous, with lawyers characterized as ambitious, as well as amoral and emotionless. Equally, the idea that lawyers can be suffering seems to challenge certain public perceptions of the law and lawyers as dry, dusty and lacking humanity. However, there is an international body of evidence demonstrating that lawyers experience significant issues in relation to their wellbeing and mental health. This is not about an occasional individual lawyer who is struggling in their work, this is an issue which, evidence suggests, permeates throughout the legal profession and across jurisdictions. Overall, it appears that lawyers experience lower levels of wellbeing and higher levels of mental health issues than the general population. As lawyers themselves are not fundamentally lacking in terms of their ability to manage life's stressors, and a person's work and social environment has a powerful impact upon their mental wellbeing (Ryan et al, 2010), this suggests it is the practice of law itself which can cause or exacerbate such issues: in short, practising law can make people sick.
Does this matter? A recent blog post on the topic of lawyer wellbeing in the United Kingdom (UK) elicited several comments from readers of the blog who suggested it does not (Graffin et al, 2019). Broadly paraphrased, the pattern of their responses was as follows, first, ‘suck it up and enjoy being rich’ and, secondly, ‘if you can't stand the heat, get out of the kitchen’. Such sentiments neatly encapsulate the misconceptions which often surround such discussions.
In this chapter the conceptual and theoretical definitions of general stress will be briefly described to provide a grounding for an understanding of stress in the workplace. Following this, stress in the workplace (work stress for brevity) will be defined to more closely hone in on this study's focal area – stress in the legal profession – and the practical realities of stress in the legal workplace will be explored.
In the findings described in this chapter the focus will be, first, on how participants conceptualized and identified stress in practical terms as it manifested in their daily working lives. Second, the descriptions of key workplace (and personal life) stressors and destressors will also usefully inform discussion about the factors that contribute to, or can mitigate, stress at work. Third, notions of the typical reactions and responses to experiencing highly stressful conditions in the workplace and in legal work will be examined in depth. Finally, consideration will turn to how best to promote positive responses for those in the profession and a consideration of how to better address the issues and stressors raised.
The ‘S’ word
One of the most commonly adopted definitions of stress coined by Lazarus and Folkman (1984, p 19) states: ‘Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.’ There are some key components of this conceptual definition that are relevant to consider. First, the inclusion of cognitive appraisal by the person means that stress involves perception and subjective interpretation. As a result, things that may be perceived as stressful (stressors) will vary from person to person based on an individual's appraisal of their environment and context. For example, while one barrister may view being self-employed as freeing and exhilarating, another may interpret this as resulting in financial insecurity and find it highly stressful. Secondly, this definition implicitly involves a consideration of coping processes in relation to whether an individual considers such stressors to be ‘taxing or exceeding his or her resources’. For example, one barrister may feel the financial skills needed to maintain self-employment are outside of their skillset and may feel highly stressed by this, whereas another may feel equipped in their skills regarding this aspect of their profession.
‘[T] his pressure to keep performing… that's something we need to be able to say to the lawyers: “you don't have to, it's quite okay to seek help”.’ (Charlotte, solicitor, London)
This chapter will discuss the concepts of mental health and wellbeing, assessing how they are perceived within the legal profession. It will discuss the historical evolution of these terms, before considering the ‘wellness turn’ in law (Collier, 2019). It will then consider how elements of the legal profession have begun to acknowledge the growing concerns around wellbeing. This is often characterized in a way which places additional pressures on individual practitioners to self-care. This chapter will draw on the focus group discussions around mental ill-health and how legal practitioners’ experiences of mental ill-health remain heavily stigmatized within the profession, leading to possible loss of career opportunities, promotions or work.
What is mental health and wellbeing?
The concepts of mental health and wellbeing are ubiquitous. However, they are contestable, nebulous concepts which carry with them a heavy burden of historical baggage concerning how we perceive and treat the ‘abnormal mind’. Reference to the term ‘mental health’ can be found in the English language well before the 20th century (Griesinger, 1865), but technical references to mental health were not found as a discrete discipline before 1946. At this time, the WHO and Mental Health Association were founded (Bertolote, 2008). The WHO articulated a definition of mental health in 1950 and has subsequently refined it (Bertolote, 2008). The contemporary definition is not a definition of mental health per se, but of health in a general sense. For example, the WHO Constitution describes health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO, 1946). Therefore, we can see that mental health is clearly connected with wellbeing, encompassing the individual, their functioning and their social context. However, it is not the same as wellbeing. Someone diagnosed as having a mental health condition can have relatively high levels of intrinsic wellbeing (ie people with mental health conditions can live well). At the same time, an individual with low levels of wellbeing may not actually meet criteria for being diagnosed with a mental health condition.
At the time of finalizing the manuscript for this book, we are working in lockdown amid a global pandemic. As human beings, it is inevitable that such an invisible but pervasive threat will generates high levels of stress, anxiety and worry, impacting on our mental health and wellbeing in myriad ways.
For many lawyers, the pandemic has meant adjusting to new remote ways of working, often while juggling heavy family responsibilities and other commitments. This has significant practical consequences, from finding an adequate desk and physical place to work, and dealing with technical issues involving Wi-Fi and computers, to upskilling oneself in order to deal effectively with colleagues and clients at a distance. Emotionally and psychologically it also involves adjusting to new routines and rhythms, different ways of interacting (often with far fewer non-verbal cues to assist effective communication) and new work–life boundaries without the usual physical separations in place.
Other lawyers may have been furloughed (granted a leave of absence), set adrift from their usual moorings of work, colleagues and clients. This leaves them suddenly adjusting to a different pace of life and, potentially, experiencing a sense of isolation and loss. It may be a time of rest and relaxation, but it may also be a time of fear and anxiety over their job security and career progression. The forecasts of an economic downturn and potentially deep recession can only add to such fears, even for those still working, as they think about the possible impacts on the legal sector and their future role. Conversely, the pandemic may also highlight to lawyers their personal vulnerabilities related to their health, and may make salient the central importance of their own, and their families’, health and wellbeing. This personal reflection may cause shifts across the legal sector in the importance of work–life balance once the pandemic is over. In light of this, our book comes at an ideal time to rebalance the conversation towards a future that encourages healthy work practices for both individuals and organizations.
1 What does emotional wellbeing at work mean to you and do you think it is important?
2 How would you describe the emotional wellbeing of those working in your sector of the legal profession? Which sector or sectors do you think are most likely to give rise to issues in terms of threatening emotional wellbeing?
3 Have these levels of emotional wellbeing changed in recent years? If so, why?
4 What do you think are the key factors which influence the emotional wellbeing of legal professionals?
5 What sources of support and guidance are you aware of currently in relation to emotional wellbeing in the legal profession?
6 To what extent do you think employers in the legal profession seek to promote an emotionally healthy working environment?
7 To what extent do you think the regulators and other bodies within the legal profession (such as the Law Society and the SRA for solicitors) seek to promote an emotionally healthy legal culture?
8 What you do think legal professionals currently focus on when undertaking continuing professional competence activities?
Emotional self-regulation and competencies
1 What approaches do you think individual legal practitioners in your sector tend to take to dealing with emotions?
2 What (if any) emotional competencies would you see as relevant to your sector of the legal profession?
3 Can you give any examples of good practice within the legal profession in terms of encouraging emotional competencies and wellbeing?
4 The Open University and LawCare are currently developing a set of online materials focusing on emotional wellbeing.
a. What type of content would you like to see included?
b. How would you like this to be delivered?
5 Is there anything specific which would encourage you to use these online resources and/or recommend them to others?
6 Are there any topics or content which you think should be avoided?
7 Can you give us one piece of advice to bear in mind when developing these online activities?
The mental health and wellbeing of legal professionals is important. The Introduction to this volume highlights the personal, ethical, economic and societal costs of ignoring or dismissing their relevance and significance. These range from individual suffering to impaired client service and care; from the financial cost of high attrition rates within law firms, to the damage wrought upon the concept of the rule of law. Issues of mental health and wellbeing intersect and influence many other aspects of the legal profession, its role and its work. The international evidence on lawyer mental health and wellbeing, together with the findings of the focus groups, all indicate that a sizeable number of individuals within the legal profession are experiencing compromised mental health and low levels of overall wellbeing. Therefore, there is an urgent need to address the causes and consequences of this by formulating a manifesto for change for the profession.
To be able to address these causes and consequences, it is necessary to begin to unpack and explore several apparent tensions within the field. First, there is the need to formulate a definition of wellbeing itself. As Chapter One explains, the term itself is contested and arguably somewhat nebulous, with the hedonic and eudaemonic traditions often being contrasted and/or dichotomized. The role of emotional intelligence or literacy (or, as the authors prefer to call it, emotional competence) has also been acknowledged, at best, only partially. For many participants in the focus groups, the emphasis appeared to be on managing to ‘cope’, however the authors argue that the ability to move beyond simply coping and to flourish and thrive (Baron, 2007) should, at the least, be an aspiration when considering the way forward for those practising law. Second, there is the need to strike a balance between promoting individual resilience and self-care, while acknowledging and tackling the wider cultural and structural issues which impact on mental health and wellbeing. Third, there is the question of how to reconcile the ‘wellness turn’ in both society and the legal profession (Collier, 2019) with the stigma that many of the focus group participants still perceive as being present within the practice of law. These themes effectively underlie both the discussions in each individual chapter and the potential solutions discussed later.
This chapter will explore arguably the most important theme to emerge from the authors’ empirical work, the cultural and structural factors which influence mental health and wellbeing in the legal profession. The term ‘culture’ refers to ‘learned patterns of beliefs, values, assumptions, and behavioural norms that manifest themselves at different levels of observability’ (Schein and Schein, 2016, p 2). It is these patterns that shape, and can be shaped by, the professional identity formation and development of individuals within the profession, as demonstrated by the references to the lawyer persona in Chapter Two. They are also embedded within the way a profession is organized and structured (eg the use of chargeable hours as the basis of billing in many law firms).
As Chapter Two explained, the law school experience has a pivotal role to play in the identity formation of legal professionals, including perpetuating, or even creating, elements of accepted legal culture and constructing notions of a lawyer persona. However, there are a range of other influential factors which also shape the culture of the legal profession, including how lawyers are portrayed within the media and the influence of key stakeholders within the legal profession (such as the Bar Standards Board or the SRA in England and Wales). Culture within the workplace and among colleagues within law also plays a key part in informing how legal professionals act and behave (Holmes et al, 2012). Of course, it would be incorrect to argue that culture always has a negative impact on individuals, but it shapes the way individuals view their role, which is closely linked to how people feel about their jobs, and their performance within them. This, in turn, has direct relevance to both their individual wellbeing and the collective wellbeing of others within the profession.
Alongside the influence of organizational culture, the focus groups demonstrated the sense of commitment which lawyers have to the legal profession itself. This was referred to in Chapter Two, where participants referenced the profession's high status and privileged nature. It appeared from the focus groups that early career employees are willing to tolerate poor working practices to attain the status and anticipated future gains it is perceived as providing.
For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans.
Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760).
We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans.
Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.