Outside Article Legal and Ethical Approaches to a Patient’s Request for an Emotional Support Animal

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Batya Swift Yasgur, MA, LSW

While cultural attitudes toward animals may vary, researchers note there is a "commonly held belief that pets can improve the overall quality of human life."1 In fact, there appears to be growing recognition of the important role that pets play in daily life. For example, many retailers now offer treats to customers' dogs and public spaces often now include animal relief areas.1 Market research indicates that revenue from the pet industry has increased dramatically, surpassing $100 billion for the first time in 2020.2

The positive impact of animals on people with physical or emotional disabilities is well established and supported by a robust body of literature.1 Trained animals can assist individuals with disabilities, facilitating their ability to live independently and participate more fully in society.1 Medical settings in which healthcare providers attend to patients who are physically or mentally ill (such as pediatric or psychiatric hospital environments) or dying (such as hospice environments) often make animal visits available to provide comfort and ameliorate suffering.1

The role of animals in assisting individuals with disabilities or other challenges continues to evolve and expand.3 Historically, certain animals have been used to help people with physical disabilities. For example, efforts to train guide dogs to assist blind owners began in Europe as early as the 19th century.3 The impetus for training guide dogs grew significantly in Germany following World War I, due to the large number of returning soldiers with visual impairments.3 In 1929, Dorothy Harrison Eustis, an American who had been training dogs for the military and police force in Europe, learned of the European guide dog schools and established the Seeing Eye School in New Jersey — the longest continually operating program in the world to train guide dogs for visually impaired people.

Today, use of animals by individuals with disabilities has increased in scope and complexity to also support people with specific psychological and emotional needs. However, it is important to recognize that only certain animal roles are covered under the Americans With Disabilities Act (ADA), which requires that people with disabilities be permitted to bring service animals with them to local government buildings and public venues.1 The ADA defines a service animal as "a dog that has been individually trained to do work or perform tasks for an individual with a disability. The task(s) performed by the dog must be directly related to the person's disability."4
The expanding role of animal companions for a variety of therapeutic purposes has led to some confusion not only with respect to terminology but also regarding the regulations governing various types of animals in this setting (Table 1).

Table 1. Terminology for Use of Service vs Emotional Support Animals

Term	Definition
Disability-related assistance animal	A broad term that encompasses all animals utilized with therapeutic intent by persons with a legally recognized disability
Service animal	As defined by the (ADA), a dog or miniature horse that has been individually trained to perform specific tasks for people with disabilities. Examples of tasks include:· Guiding people who are blind· Alerting people who are deaf· Pulling a wheelchair· Alerting a person to an impending seizure or protecting a person who is having a seizure
Psychiatric service animal	As defined by the ADA, a service animal that has been trained to perform specific tasks that mitigate a disability due to psychiatric illness; examples include:· Reminding a person with mental illness to take prescribed medications· Calming a person with post-traumatic stress disorder· Preventing a child with autism spectrum disorder from wandering away
Therapy animal	Any species of animal utilized by a trained handler, either through the animal's presence or through a guided interaction as part of structured animal-assisted therapy to provide therapeutic benefit for persons with illness and suffering
Emotional support animal	An animal of any species that does not qualify as a service animal under the ADA, which a medical provider has certified can mitigate a person's psychiatric disability through companionship rather than by any specifically trained task(s)
Pet	An animal kept for companionship or pleasure that is not clinically certified for therapeutic use in any illness or disability and that is not afforded any accommodations under the law

From Carroll JD1; Brown SE3; US Department of Justice.4
In particular, one area of controversy has involved emotional support animals (ESAs), which have become increasingly prevalent.1 Unlike a service animal, an ESA is defined as a "companion animal (pet) that helps to reduce disability-related impairment for a particular person through the animal's presence and everyday interactions."5 Notably, the ADA states clearly that animals that provide only "emotional support, wellbeing, comfort, or companionship" cannot qualify as service animals.4
It is important for providers to understand 2 areas of law that apply to ESAs: the Fair Housing Act (FHA) and the Air Carrier Access Act (ACAA). Unlike the ADA, both acts allow (or used to allow) ESAs under certain circumstances.
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Service Animal Regulations Related to Air Transportation and Housing

The ACAA, administered by the US Department of Transportation (DOT), requires airlines to permit individuals with disabilities to board airplanes with service animals. At one time people were also allowed to board planes with ESAs, including an array of animals — not just cats and dogs but also hamsters, squirrels, pigs, turkeys, kangaroos, and peacocks — leading to the perception that these owners "fraudulently claimed their animals were ESAs to secure their entry into the airplane cabin (instead of the cargo compartment) and avoid fees."1 On December 20, 2020, in response to these and other concerns, the US DOT released new rules stating that ESAs were no longer to be considered service animals and can be regarded by the airlines as pets, although bona fide service animals must still be permitted.6
The Fair Housing Act (FHA), administered by the US Department of Housing and Urban Development, allows "assistance animals," including ESAs, to be accommodated and included in accordance with its prohibition against discrimination in housing.7 The FHA defines an "assistance animal" as "an animal that works, provides assistance, or performs tasks for the benefit of a person with a disability, or that provides emotional support that alleviates one or more identified effects of a person's disability." Importantly, the FHA emphasizes that "an assistance animal is not a pet."7
Further, the FHA "requires a housing provider to allow a reasonable accommodation involving an assistance animal" if a request was made to the housing provider by or on behalf of a person with a disability and the request was "supported by reliable disability-related information." Information about the disability can be provided directly by the disabled person and/or by a third party such as a medical or mental health professional. Housing providers may also ask applicants to provide information about the disability-related need for the animal.8

Evidence of ESA Roles in Supporting Mental Health

Most research to date has focused on formalized animal contact in settings such as animal-assisted therapy. Fewer studies have focused on less-structured settings, such as pet ownership or use of support animals.9
One review of 27 studies evaluated the benefits on psychosocial health of assistance dogs trained to perform functions not specifically related to mental health (ie, guide dogs, medical dogs, dogs used by those with impaired mobility or hearing).10 Positive outcomes included "significant effects of having an assistance dog on the psychological wellbeing, emotional functioning, self-esteem, and vitality" of the owners.10 The investigators noted, however, that it was "difficult to draw any definitive conclusions" due to methodological weaknesses of some of the studies.
Authors of a meta-analysis9 of 17 studies on the role of a variety of companion animals (n=1727 pet owners) in managing mental health conditions found 15 studies had "qualitative evidence" of the benefits from the intense connectivity between people and their companion animals and highlighted the "multi-faceted ways in which pets contributed to the work associated with managing a mental health condition, particularly in times of crisis." All participants had a diagnosed serious mental health condition, a mental health problem associated with a physical health condition, mental health problems associated with a developmental disorder, or self-reported mental health conditions.
The meta-analysis emphasized several areas of benefit. Themes that emerged were the animals' role in alleviating worry, in providing comfort and calming support, and in mitigating against feelings of loneliness/isolation while providing owners with symptom distraction and the opportunity to engage in physical activity.9 However, the review also highlighted potential negative effects of pet ownership, including the practical and emotional burdens of caring for an animal and the psychological impact of losing an animal companiion.9

Beneficial Impact of Animals in PTSD and Severe Mental Illness

The authors of the aforementioned meta-analysis emphasized in particular the benefits of canine companionship realized by military veterans with post-traumatic stress disorder (PTSD), citing the results of a study by Stern et al.11 This finding is corroborated by Ruth Lanius, MD, PhD, professor of psychiatry and director of the PTSD research unit at the University of Western Ontario, Canada.
"I've clinically seen individuals who are traumatized and have PTSD, depression, anxiety disorders, substance use disorders, and dissociative disorders — and I am always amazed how keenly aware the animals are of the emotional state of the patient and how [these animals] seem to pick this up," stated Dr Lanius.
"When my patients with PTSD experience flashbacks, the animal picks up on that right away and often jumps up on them, tries to engage them with the present, and helps them become grounded again," explained Dr Lanius, who also holds the Harris-Woodman Chair in Mind-Body Medicine at the Schulich School of Medicine and Dentistry at the University of Western Ontario. "Patients also use their animals when they go to sleep, and the animals sometimes can pick up on when the patient has a reliving nightmare and can ground them by engaging them, licking them, or sitting on them — and that brings them back much more quickly into the present moment."
She noted that many patients with PTSD "didn't have secure attachment with a caregiver. Especially individuals who never felt safe with another person can benefit from an animal with whom they often feel safer than with another human being."
This sense of safety can help regulate the patient's dysregulated physiological state and help the patient feel "soothed" and calmer.
Authors of a recent small pilot study5 specifically assessing ESAs found that use of ESAs can yield "quantifiable reductions" in depression, anxiety, and loneliness in individuals with serious mental illness who live alone. In this study, 11 community-dwelling adults with serious mental illnesses were paired with a shelter dog or cat for a 1-year period. Participants' depression, anxiety, and loneliness were assessed at baseline and then at 12 months following receipt of their ESA. In all participants, significant reductions in measures of anxiety, depression, and loneliness were found at 12 months compared with baseline.
In addition, during home visits held at regular intervals during the study period, participants underwent saliva testing before playing with their animals and after 10 minutes of pleasurable interaction with the animals. The investigators observed a pattern of increased levels of oxytocin (a biomarker associated with bonding) and decreased levels of cortisol (a steroid hormone associated with stress) after 10 minutes of ESA interaction, although the degree of change did not reach statistical significance. Participants reported improvements in global mental health, motivation, feelings of comfort and affection, distraction from symptoms, and a sense of feeling soothed and calm.5
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Challenges for Mental Health Professionals

Psychiatrists and other mental health professionals are increasingly being asked to write letters certifying patients' and clients' animals as ESAs, as the number of requests to allow ESAs in residential settings has grown tremendously.1 This increase has also been reported on college campuses.12 Notably, for example, Washington State University's Access Center currently receives 60 to 75 requests each year on behalf of students asking permission to bring an ESA into their dormitory rooms — up from 2 to 3 requests reported in 2011.12
Certain online companies will — for a fee — offer ESA certification letters supporting a person's request for an ESA without requiring that the individual meet with or speak to a mental health provider.1 Both legally and ethically, this industry is remiss because these letters are provided largely in the absence of formal psychiatric evaluation and they include misinformation about ESAs.1 One study of 87 mental health practitioners found that 50% reported having made recommendations for ESAs, but 25.7% stated they actually did not feel qualified to make an ESA recommendation.13 Writing in The New Yorker, one author describes securing a letter supporting her need for an emotional support snake from a therapist whom she located through an online site, after a single $140 phone call.14
Brian Mohlenhoff, MD, associate professor of psychiatry at the UCSF Weill Institute for Neurosciences, in San Francisco, explained that psychiatrists and other mental health professionals encounter both legal and ethical challenges when patients ask them to write a letter certifying their animal as an ESA.
"The first [challenge] is to know the patient well enough to determine if he or she has a disability or not, which is obviously well within the capacity of people who are licensed healthcare providers," said Dr Mohlenhoff, who is also director of pharmacotherapy for the posttraumatic stress disorder program at the San Francisco VA Medical Center. This type of letter is similar to other types of letters requesting benefits, such as those for social security disability, he added.
A practitioner writing the letter must be prepared to say "no" to an inappropriate request, Dr Mohlenhoff emphasized. "Could the provider reasonably say 'no' and maintain the therapeutic relationship? You have to have the option to say 'no' on the table, otherwise it's not a true evaluation," he said.
For this reason, ideally the person conducting the evaluation and writing the letter should be a third party — a professional who is not the patient's own psychiatrist or therapist, explained Dr Mohlenhoff, adding that, unfortunately this "rarely happens."
Assembling the necessary information for an appropriate ESA documentation letter will likely require more than 1 patient visit.15 The letter should include15:

• The patient's name and date of birth;
• A statement confirming that the person has a disability recognized in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5);
• A statement describing the setting(s) in which the ESA is allowed; and
• Possibly a statement such as, "We recognize that allowing animals in public spaces is not without risk," if advocating for patient use of the ESA during air travel. Also consider stating that the patient is working with a veterinarian to ensure that the animal's health and vaccination records remain up to date.

The second provider obligation, Dr Mohlenhoff explained, is to be familiar with the laws relevant to specific requests for use of an ESA, such as during air travel or in various types of residences. He noted that it is "often left up to [an] individual housing manager what type of documentation for ESAs is requested and it also varies, based on municipality."
The third obligation is for the provider to feel comfortable that the patient will take good care of the ESA, Dr Mohlenhoff said.
The ethical obligation goes beyond an individual patient and animal. "You might not want to endorse a particular animal for a particular patient, especially if your understanding is that the animal might have some behavior issues," he said.
Providers who need to reject a patient's request should tell the patient why they made that decision, Dr Mohlenhoff advised. It is important to explain that you have an ethical obligation to not always say "yes" — for example, if you truly do not think a person has a disability level that warrants use of an ESA or if you are concerned about the safety or appropriateness of a particular animal.
A 2020 article by Younggren et al16 lays out a comprehensive roadmap that mental health professionals can follow when conducting an ESA certification.
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Guidelines for Mental Health Professionals Conducting Emotional Support Animal Evaluations

The mental health professional must be able to understand, recognize, and apply the laws that regulate emotional support animals (ESAs)

• These laws specifically apply to the Air Carrier Access Act and the Fair Housing Act.
• These laws include understanding what attributes the person must have in order to qualify as "disabled," based on the psychological condition. The presence of the animal must ameliorate some of the symptoms of that disability.

The mental health professional should conduct a thorough assessment of the individual requesting an ESA certification in order to establish a disability and a disability-related need.

• "Disability" refers to a physical or mental impairment that substantially limits 1 or more major life activities and/or a psychological condition that substantially interferes with the individual's ability to perform major life activities.
• It should be determined whether the presence of the ESA allows the individual to more effectively perform common activities of daily living (ADLs), reduces anxiety sufficiently to yield measurable improvements in concentration, or facilitates improved social interactions with other people.
• A necessary component of the comprehensive disability assessment includes an evaluation of malingering.

The mental health professional should consider if a given animal is capable of performing the functions of an ESA.

• Does the animal meet this particular individual's need for emotional support?
• What is the animal's temperament?
• Consideration of the animal's temperament should be context-dependent, taking into account the environment in which the animal is supposed to serve as an ESA (eg, a quiet home environment vs a busy airport).
• When necessary, the mental health professional should seek collateral information regarding the capability of the animal in question to serve as an ESA. For example, one option is to obtain documentation that the dog has passed the Canine Good Citizen (CGC) test. Another is to obtain information from an animal trainer, behaviorist, or veterinarian who has assessed the animal and its temperament in potentially stressful environments. Because this assessment is often beyond the skill set of most mental health professionals, information should be gleaned from the aforementioned outside sources, if possible.

The mental health professional should assess the interaction of the client with the animal to determine whether the animal's presence has a demonstrably beneficial effect on the patient.

• This beneficial impact should be directly relevant to the individual's disability and disability-related impairment.·
• The mental health professional should see the patient both with and without the animal present, to compare the individual's metal status and comportment in both contexts.

From Younggren JN.16
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ESA as Part of an Overall Treatment Plan

Providing a patient with a letter of support for an ESA should not take place in a vacuum. A patient visit should be "scheduled to encourage follow-up care and reassess the role of the ESA," according to a team of health experts writing in American Family Physician.15 They note that "a request from a patient for an ESA documentation letter provides an opportunity to reassess the patient's mental health status, confirm any relevant diagnoses, review current treatment, and discuss why the patient believes an ESA will be beneficial."15 It is useful to determine upfront what role an ESA might play in a patient's overall treatment plan.
It is also important to keep in mind that, when a mental health professional prepares a formal disability statement, the report and any associated data can become part of the patient's medical record, and the finding of a mental disability might lead to potentially adverse consequences for the patient.16 Examples of situations in which a disability finding can have unintended consequences are if the patient seeks government security clearance or (in some cases) life or disability insurance. Not reporting a disability finding on certain applications (eg, for employment, insurance, or security clearance) can have serious consequences. Moreover, documentation of a mental disability can become a factor in child custody disputes.16 Discussion of these potential consequences with the patient is a critical component of the informed consent process.16

References

1. Carroll JD, Mohlenhoff BS, Kersten CM, McNiel DE, Binder RL. Laws and ethics related to emotional support animals. J Am Acad Psychiatry Law. 2020;48(4):509-518.
2. Browne M. Pet industry sales in 2020 surpass $100 billion for first time. Supermarket News. March 29, 2021. https://www.supermarketnews.com/winning-pet-care/pet-industry-sales-2020-surpass-100-billion-first-time. Accessed September 15, 2021.
3. Brown SE. Individuals with disabilities and their assistance animals: A brief history and definitions. ADA Knowledge Translation Center Legal Brief No. 2.3. 2019. https://adata.org/sites/adata.org/files/files/Service%20Animal%20History%20and%20Definitions%20-%20final.pdf. Accessed September 15, 2021.
4. US Department of Justice, Civil Rights Division, Disability Rights Section. Frequently asked questions about service animals and the ADA. https://www.ada.gov/regs2010/service_animal_qa.html. Accessed September 15, 2021.
5. Hoy-Gerlach J, Vincent A, Scheuermann B, Ojha M. Exploring benefits of emotional support animals (ESAs): A longitudinal pilot study with adults with serious mental illness (SMI). Human-Animal Interaction. APA Division 17, Section 13. https://www.apa-hai.org/haib/download-info/exploring-benefits-of-emotional-support-animals-esas-a-longitudinal-pilot-study-with-adults-with-serious-mental-illness-smi/. Accessed September 15, 2021.
6. US Department of Transportation. U.S. Department of Transportation announces final rule on traveling by air with service animals. December 2, 2020. https://www.transportation.gov/briefing-room/us-department-transportation-announces-final-rule-traveling-air-service-animals. Accessed September 15, 2021.
7. US Department of Housing and Urban Development. Assistance Animals. https://www.hud.gov/program_offices/fair_housing_equal_opp/assistance_animals. Accessed September 15, 2021.
8. US Department of Justice, Civil Rights Division. U.S. Department of Housing and Urban Development, Office of Fair Housing and Equal Opportunity. Joint statement of the Department of Housing and Urban Development and the Department of Justice. Reasonable accommodations under the Fair Housing Act. May 17, 2004. https://www.hud.gov/sites/documents/huddojstatement.pdf. Accessed September 15, 2021.
9. Brooks HL, Rushton K, Lovell K, Bee P, Walker L, Grant L, Rogers A. The power of support from companion animals for people living with mental health problems: A systematic review and narrative synthesis of the evidence. BMC Psychiatry. 2018;18(1):31.
10. Rodriguez KE, Greer J, Yatcilla JK, Beck AM, O'Haire ME (2020) The effects of assistance dogs on psychosocial health and wellbeing: A systematic literature review. PLoS ONE 15(12):e0243302. doi:10.1371/journal.pone.0243302
11. Stern SL, Allen DD, Allison S, et al. Potential benefits of canine companionship for military veterans with posttraumatic stress disorder (PTSD). Soc Anim. 2013;21(6):568-581.
12. Bauer-Wolf J. Colleges see rise in popularity for emotional support animals. Inside Higher Ed. Published online May 21, 2019. https://www.insidehighered.com/print/news/2019/05/21/colleges-see-rise-popularity-emotional-support-animals. Accessed September 15, 2021.
13. Boness CL, Younggren JN, Frumkin IB. The certification of emotional support animals: Differences between clinical and forensic mental health practitioners. Prof Psych Res Pract. 2017;48(3):216-223.
14. Marx P. Pets allowed. New Yorker. October 13, 2014. https://www.newyorker.com/magazine/2014/10/20/pets-allowed. Accessed September 15, 2021.
15. Tin AH, Rabinowitz P, Fowler H. Emotional support animals: Considerations for documentation. Am Fam Physician. 2020;101(5):302-304.
16. Younggren JN, Boness CL, Bryant LM, Koocher GP. Emotional support animal assessments: Toward a standard and comprehensive model for mental health professionals. Prof Psychol Res Pr. 2020;51(2):156-162.

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