Emotional support animals

[cara susanna]

I recently saw a presentation on this topic that suggested ESA requests should be treated like a disability assessment, and forensic specialists even recommended including malingering tests.

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[Armadillos]

I appreciate it for how it reflects inappropriately medicalized issues back onto other institutions and people in society who should really be making decisions about what animals are allowed where...by refusing to take responsibility for saying "no I'm not going to do that."

This is my intention.

In my opinion the only thing a doctor or psychologist can reasonably be expected by society to add to this decision is a psychiatric diagnosis.

We are not trained to determine the safety, suitability, temperament or competency of an emotional support animal. So I provide the third party with a diagnosis via letter given to patient and it’s up to them to eye up the animal and make their own decision. I tell this to the patient when I write the letter.

 

[watto]

If you really feel your MD/DO trumps the rights of millions of private property and business owners so someone can have a living teady bear on someone else's property....that is the difference between the 2 degrees right there. Seems your horse is higher than mine.

And "without thinking about it" is also very problematic-- from both a legal and clinical standpoint. I actually think most MDs ponder the legal, clinical, and societal ramifications of how they use their powers, so I m not sure why you would make such arrogant and dismissive statement?

Yes, and I am an MD who does a ton of independent medical exams for Worker's Comp and I have no problem pointing out the sloppy diagnosis-making of docs who make decisions "without thinking about it." More frequently, the psychologist's assessments are more methodical, precise, and internally consistent than what I see in MD documentation.

 

[erg923]

Yes, and I am an MD who does a ton of independent medical exams for Worker's Comp and I have no problem pointing out the sloppy diagnosis-making of docs who make decisions "without thinking about it." More frequently, the psychologist's assessments are more methodical, precise, and internally consistent than what I see in MD documentation.

Noted. But this is also not a turf issue or a degree issue (Ph.D. vs M.D/D.O)...at least I'm not trying to do that. The other poster did that.

I also do workers comp file review, and formerly did some disability file review for Metlife, Lincoln Financial, and Atena, among others. Many times, during telephonic consultations, treating MDs/DOs cannot articulate the disability of their patients as it pertains to the standards of what they signed or wrote...which is very frustrating. There is alot of debate about whether they should be doing this at all.

I'm sure MDs/DOs have many documents shoved in front of them to sign (more so than me). However, that does not mean they should do it, or that they really know what they are doing when they do it.

Regarding ESAs specifically, its not about one's degree, but just plain common sense. At least "common sense" for a practicing mental health professional given the current state of the literature on this subject. There are many more creative and prescriptive ways to help your patients (even with animal assistance) without trampling the rights of others. I thinks the ESA letter thing is just lazy clinical practice, frankly.

 

[VA Hopeful Dr]

I appreciate it for how it reflects inappropriately medicalized issues back onto other institutions and people in society who should really be making decisions about what animals are allowed where...by refusing to take responsibility for saying "no I'm not going to do that."

I completely get that and agree - as I'm FM not psych I get more work notes than ESA requests. Pisses me off to no end. If you trust someone enough to work for you, you should trust them when they say "I'm sick"... At least up to a certain point.

 

[watto]

Noted. But this is also not a turf or degree issue..at least I'm not trying to do that. The other poster did that.

I also do workers comp file review, and formerly did some disability file review for Metlife, Atena, among others. Many times, during telephonic consultations, treating MDs/DOs cannot articulate the disability of their patients as it pertains to what they signed or wrote...which is very frustrating. There is alot of debate about whether they should be doing this at all.

I'm sure MDs/DOs have many documents shoved in front of them to sign (more so than me). However, that does not mean they should do it, or that they really know what they are doing when they do it.

Regarding ESAs specifically, its not about one's degree, but just plain common sense. At least "common sense" for a practicing mental health professional given the current state of the literature on this subject. There are many more creative and prescriptive ways to help your patients (even with animal assistance) without trampling the rights of others. I thinks the ESA letter thing is just lazy clinical practice, frankly.

I know - thought their reply was being quoted so it probably looked like I was antagonizing you! Apologies.

If at the very least MD's justified their observations, it would help the cases they are trying to support. Disability as evidenced by x, y, z. It drives me crazy when the note claims complete lack of ability to function and the mental status exam is documented as normal. Or when the doc fails to even articulate any alternative explanations for report of symptoms (including exaggeration of symptoms).

 

[FlowRate]

I completely get that and agree - as I'm FM not psych I get more work notes than ESA requests. Pisses me off to no end. If you trust someone enough to work for you, you should trust them when they say "I'm sick"... At least up to a certain point.

I've always found work notes to be the most asinine thing. Most people agree that you shouldn't be at work if you're vomiting. But vomiting doesn't mean you need an urgent appointment with your PCP. Same thing with having the flu. What does an employer want the PCP to write? "Yes, I saw the vomit, it was totally gross, this person definitely shouldn't be at work 'cuz they'd make other people vomit everywhere."

 

[nrmp]

Can you put an expiry date for validity of the letter?

 

[splik]

Can you put an expiry date for validity of the letter?

Per law, the letters are only valid for one year from the date. You could of course put your own expiration date on the letter.

 

[Sushirolls]

It recently dawned on me the whole ESA movement may just be a USA thing. Do people know if this is taking hold in other countries?

 

[lockian]

My 2 cents: some of my patients who face rental restrictions against pets live in public housing. I believe people should not be denied the therapeutic benefits of having a pet just because they're poor.

I also add a clause that I am not trained to evaluate animal behavior, have not met the specific pet in question, and that any damage the pet inflicts on the property or other tenants is the patient's responsibility. The law, if I recall correctly, states that ESA status doesn't absolve the renter from being liable for pet-related damages. It only overrides the restriction against having an animal, and forces the landlord to waive pet fees, if any (usually less than $50/month). Finally, properties with 4 units or less are exempt from the ESA laws, as are owner-occupied properties - which is reasonable, I think. And bringing the ESA to a public place is completely up to the public place, letter or no.

 

[Sushirolls]

My 2 cents: some of my patients who face rental restrictions against pets live in public housing. I believe people should not be denied the therapeutic benefits of having a pet just because they're poor.

Why? Tax dollars go towards that housing and in a round about way, depending on which housing type it is, tax dollars foot the maintenance of the housing too. Should tax dollars go towards housing another person's pet? Should tax dollars be used to supplement the increased housing damages needing repair/replacement for their scuff marks, urine, or feces degradation? The money someone in public housing spends on a pet could have been spent towards the costs of the public housing. A pet isn't cheap... vaccines, annual check ups, pet food, supplies for leashes/litter boxes, etc. Or perhaps the money spent on the pet could have been used for improving food insecurity? Covering an annual bus pass? Paying for medicare donut deductible? etc, etc

Pets are a luxury and not a right.

Therapeutic benefit is in question.

I posit that going to the city park, within walking distance, practicing yoga (or basic guided imagery meditation) can be more therapeutic. A city park is a tax payer supported resource that we all can benefit from, whereas Fido/Fifi only one person does.

 

[Ironspy]

I agree with the idea of charging for letters, but this amount sounds like a lot to me.

If you charge 3-500/hour in private practice $50 for a letter that takes 10-15 min to draft seems like a bargain.

 

[downwithDTB]

There is one animal with pretty good evidence as an emotional support animal: the properly trained h. Sapiens.

I wonder what would happen if I wrote an ESA letter specifying my partner as the ESA... they don't say it can't be a human animal anywhere, do they? I could provide both of our DSM-IV diagnoses. They are actually a licensed therapist and can therefore provide evidence based benefit. Certifying the no bathroom for 8 hours would be a stretch... It would probably go better if I wrote that I was the ESA for them actually. Has anyone tried this? Just seeing the look on the TSA folks faces might be worth the wasted plane ticket.

 

[Jules A]

My 2 cents: some of my patients who face rental restrictions against pets live in public housing. I believe people should not be denied the therapeutic benefits of having a pet just because they're poor.

I also add a clause that I am not trained to evaluate animal behavior, have not met the specific pet in question, and that any damage the pet inflicts on the property or other tenants is the patient's responsibility. The law, if I recall correctly, states that ESA status doesn't absolve the renter from being liable for pet-related damages. It only overrides the restriction against having an animal, and forces the landlord to waive pet fees, if any (usually less than $50/month). Finally, properties with 4 units or less are exempt from the ESA laws, as are owner-occupied properties - which is reasonable, I think. And bringing the ESA to a public place is completely up to the public place, letter or no.

I do believe animals can be therapeutic and in a perfect world anyone who wanted one would be able to have one however I also have concerns for the animal. In addition to believing an untrained animal should not be subjected to a stressful public situation like the severely anxious St. Bernard I saw in the bathroom at an airport I also know how expensive it is to properly care for animals and wish people were more cognizant of that fact.

 

[downwithDTB]

My 2 cents: some of my patients who face rental restrictions against pets live in public housing. I believe people should not be denied the therapeutic benefits of having a pet just because they're poor.

Should people in public housing who don't want to live near pets be denied the theraputic environment of not having pets around them? If you're writing for ESAs their neighbors can't pick no pet buildings. I like dogs but I hate how their owners in my building let them piss all over the sidewalks, bark non-stop and let them lick anyone without asking. I have family members with significant enough allergies that if there was a dog within a few appartments of them they would have to move. No so easy when you're in public housing.

Also, animals on average add expenses to building maintaince. Public housing already tends to be severely underfunded. At best it will take years to increase the maintenance budget to account for these increased costs. In the meantime every other tennent will be living in a dirtier building. Unless you're also sending a donation and a coupon for an allergist visit with each letter, I don't think it's quite fair to spread a mission of pets for the poor when it probably hurts more than it benefits.

 

[lockian]

To listen to you guys talk, animals are a menace to society and public peace.

However, the real damages are no worse than things people do. Babies cry, kids scream, families argue and fight at all hours of the night, developmentally delayed people do all of the above - all create noise and not all are easily quelled. Animals that are subject to a bare minimum of training go to the bathroom where they're supposed to, leading to minimal odor (litter box, outside). And what about smoking in one's apartment? That travels far more strongly and insidiously than pet allergens, and living in an apartment saturated with the past tenant's smoke is as bad as living in an apartment saturated with pet urine. Let's put it this way: I had a neighbor with a weed habit, and the smell from his weed habit bothered me far more than anything his cats did. I was barely aware he had cats.

Just because *some* people let their pets behave poorly everywhere doesn't mean all do. Just because the odd hyper-allergic person can't walk past their neighbor's door because their neighbor owns a cat doesn't mean the neighbor shouldn't have a cat (how many times have you seen someone be allergic to an animal in a completely different *unit* by the way?) And my CYA statement says just that - any issues the pet causes are on the tenant. That's just common sense.

 

[deleted480308]

To listen to you guys talk, animals are a menace to society and public peace.

However, the real damages are no worse than things people do. Babies cry, kids scream, families argue and fight at all hours of the night, developmentally delayed people do all of the above - all create noise and not all are easily quelled. Animals that are subject to a bare minimum of training go to the bathroom where they're supposed to, leading to minimal odor (litter box, outside). And what about smoking in one's apartment? That travels far more strongly and insidiously than pet allergens, and living in an apartment saturated with the past tenant's smoke is as bad as living in an apartment saturated with pet urine. Let's put it this way: I had a neighbor with a weed habit, and the smell from his weed habit bothered me far more than anything his cats did. I was barely aware he had cats.

Just because *some* people let their pets behave poorly everywhere doesn't mean all do. Just because the odd hyper-allergic person can't walk past their neighbor's door because their neighbor owns a cat doesn't mean the neighbor shouldn't have a cat (how many times have you seen someone be allergic to an animal in a completely different *unit* by the way?) And my CYA statement says just that - any issues the pet causes are on the tenant. That's just common sense.

But we all agree a landlord should be able to evict over smoking. The problem with these letters is the implication that you can force your pet on a landlord

 

[lockian]

But we all agree a landlord should be able to evict over smoking. The problem with these letters is the implication that you can force your pet on a landlord

A landlord *should* not be able to evict unless the pet actually does something evict-worthy, such as consistently disrupt the peace by barking 24/7, or by stinking up the whole hallway with urine. But a pet simply being there and being well-behaved should not be an issue, which is the case in most situations.

 

[downwithDTB]

A landlord *should* not be able to evict unless the pet actually does something evict-worthy, such as consistently disrupt the peace by barking 24/7, or by stinking up the whole hallway with urine. But a pet simply being there and being well-behaved should not be an issue, which is the case in most situations.

I would argue that this should be between you, pet owners, landlords, tennents and your legislators. We have laws protecting families and individuals with human babies and disabilities. Dogs don't need to live with humans to survive as a species. They do quite exceptionally on their own. Humans do need humans to survive. Science says humans do not benefit from ESAs and many ESA requests are for secondary gain.

I do not support using a medical license for the purpose of subverting laws that you don't like unless there is clear and significant well proven theraputic benefit and no legal alternative. I believe that it's highly unethical.

 

[Old&InTheWay]

But we all agree a landlord should be able to evict over smoking.

Unless the tenant has a note for emotional support cigarettes.

 

[hamstergang]

And my CYA statement says just that - any issues the pet causes are on the tenant.

Can you pass liability just by claiming so in a letter?

 

[Crayola227]

I would argue that this should be between you, pet owners, landlords, tennents and your legislators. We have laws protecting families and individuals with human babies and disabilities. Dogs don't need to live with humans to survive as a species. They do quite exceptionally on their own. Humans do need humans to survive. Science says humans do not benefit from ESAs and many ESA requests are for secondary gain.

I do not support using a medical license for the purpose of subverting laws that you don't like unless there is clear and significant well proven theraputic benefit and no legal alternative. I believe that it's highly unethical.

There are plenty of studies supporting at least a strong association between people with pets and all kinds of health benefits. Plenty of times we also accept patient report regarding the efficacy of something they do and the benefit they receive when evidence isn't overwhelmingly instructive. Iirc the evidence behind 12 Step and sobriety isn't terribly strong, but when someone says I'm sober because of the meetings or I haven't killed myself because of my dog, we tend to just go with it.

Fair enough if you want to say that evidence isn't compelling enough to make other people pay for it. Besides the fact that whether or not that's true, there's plenty of other poorly supported practices that get paid for.

Also, and this last part is not in any scientific question, is that as a species dogs do not get along just fine on their own. They are one of the most highly domesticated species on the planet. They might still be able to propagate and not go extinct despite how dependent we have made them on humans, but that isn't the same as getting along as a species.

I think humans have a moral obligation (and from a health standpoint it's pertinent to control animal populations) to deal with homeless dogs. And yes, some of those solutions will involve tax dollars of people who don't even like dogs.

They need to be captured, housed, spayed/neutered, put to sleep, or adopted out. We haven't maximized any one of these variables, and until we do it's a human health threat and responsibility. We need less dogs and more of the ones we have in homes.

I agree poor people should have access to pet ownership despite not being able to own their own land. Most of us are serfs these days. Even the poor who get housing on tax dollars are entitled to some disposable income and to spend money on things they want/need, within reason.

Yes they should be liable for damages to landlords or other renters. That is not the same as landlords just banning pet ownership because they don't want to deal with it. That doesn't mean that I'm against landlords offering pet-free housing shouldn't be allowed on principle.

But for me if there's a good case to be made for an exception to a rule (poor patient with significant health challenges, that pursues more than one line of treatment, that has a mental health condition that reasonably might have significant benefit from a pet, and they seem well enough to handle what challenges that "treatment" might have (and considering challenges to landlord/renters is actually keeping patient's interests in mind)) then that is why exceptions exist and we're called on to help facilitate them.

I agree it's abused, but that isn't the same as saying they should never be granted, either.

 

[deleted480308]

Doctors should not be involved in using govt power to force animals on landlords that don’t want them there.

 

[Mass Effect]

A landlord *should* not be able to evict unless the pet actually does something evict-worthy, such as consistently disrupt the peace by barking 24/7, or by stinking up the whole hallway with urine. But a pet simply being there and being well-behaved should not be an issue, which is the case in most situations.

Why shouldn't it be an issue if the landlord chooses not to allow pets? I don't understand this argument and actually think that it's incredibly insensitive to people who choose not to live around pets and choose to live in a building in which they're not allowed. My father was mauled by a dog and has been terrified of them ever since. He's allowed to choose to live in a place where dogs are not allowed. So if he were to move some place that doesn't allow dogs and be forced to be around them because of someone's ESA, I would absolutely use my own knowledge of mental health and lack of evidence for ESAs to challenge it. People who don't want to live with animals should not be forced to move from a "pet free" building because someone's psychiatrist decided their depressed patient should have a puppy.

And nope, I'm not sorry for taking that stand. I'll advocate for the mentally ill til the cows come home, but I won't advocate for something with such weak evidence when it comes to infringing on the rights of others.

 

[VA Hopeful Dr]

Why shouldn't it be an issue if the landlord chooses not to allow pets? I don't understand this argument and actually think that it's incredibly insensitive to people who choose not to live around pets and choose to live in a building in which they're not allowed. My father was mauled by a dog and has been terrified of them ever since. He's allowed to choose to live in a place where dogs are not allowed. So if he were to move some place that doesn't allow dogs and be forced to be around them because of someone's ESA, I would absolutely use my own knowledge of mental health and lack of evidence for ESAs to challenge it. People who don't want to live with animals should not be forced to move from a "pet free" building because someone's psychiatrist decided their depressed patient should have a puppy.

And nope, I'm not sorry for taking that stand. I'll advocate for the mentally ill til the cows come home, but I won't advocate for something with such weak evidence when it comes to infringing on the rights of others.

One of the biggest things that pisses me off is the lack of training.

True service dogs (seeing eye, seizure warning, stuff like that) are impeccably trained. Those dogs are better behaved than I am.

Contrast that with the patients who bring their ESA dogs to my office who piss on the floor and bark at me...

 

[Mass Effect]

One of the biggest things that pisses me off is the lack of training.

True service dogs (seeing eye, seizure warning, stuff like that) are impeccably trained. Those dogs are better behaved than I am.

Contrast that with the patients who bring their ESA dogs to my office who piss on the floor and bark at me...

That's because ESA has become code for anyone who wants to live in a no-pet building with a pet. Eventually, there will be a precedent and ESA will, hopefully, no longer be a thing.

 

[VA Hopeful Dr]

That's because ESA has become code for anyone who wants to live in a no-pet building with a pet. Eventually, there will be a precedent and ESA will, hopefully, no longer be a thing.

The airlines are starting to crack down recently so I'm hoping this is a sign things are starting to shift

 

[Jules A]

The airlines are starting to crack down recently so I'm hoping this is a sign things are starting to shift

There must have been a policy change at one of the hospitals where I work. A year ago there was a flurry of issues, patients bringing them to PHP and even admitted to the inpatient psych unit with their dog but that hasn't come up in a while.

Worth noting I am a total dog lover, they sleep in my bed, however it is inhumane for an untrained animal to be thrust into these situations and absurd that there is no training requirement as with actual service dogs.

 

[splik]

If you charge 3-500/hour in private practice $50 for a letter that takes 10-15 min to draft seems like a bargain.

how does it take 10-15mins to draft? It literally takes me 30 seconds to put a name into a template and print.

 

[Sushirolls]

how does it take 10-15mins to draft? It literally takes me 30 seconds to put a name into a template and print.

Open chart, review chart, make sure appropriate. Edit date/time/address on draft. Add to chart. Print, sign, review, put in enevelope, seal letter, put in mailbox.

Things add up.

*And well there is the time on that first draft.

 

[Liquid8]

It recently dawned on me the whole ESA movement may just be a USA thing. Do people know if this is taking hold in other countries?

A few years ago I heard ESAs were taking off in certain Australian states, but have only had one patient with a support animal in the last 5 years. When I first saw them they'd just got the dog, which was an untrained puppy who made a mess at the front reception. Before the dog they'd had multiple admissions each year to an interstate hospital for borderline/DID episodes, and in that particular place apparently every patient had an ESA.

The hospital I admit to has rules like only allowing one ESA at any one time which was put in place after a mini boom of patients wanting to bring their support animals in, but it seems like the rules changes have put people off. They still made it hard for my patient to bring in their ESA to both inpatient and outpatient programmes despite meeting all the criteria which also included getting formal training (over 12 months), testing and certification, but I think it was negative counter-transference from staff that started to get to them. While I'm sceptical about the role of ESAs, the good thing in this case was that having the ESA was associated with a substantial decrease in self harming behaviour and suicidal thinking, reducing the demand for admissions too.

It was quite a good learning experience, and while I have not had other patients wanting letters of support for ESAs, if it did occur I know who to refer them to for training, and those only looking for a pet are unlikely to bother.

 

[FlowRate]

Doctors should not be involved in using govt power to force animals on landlords that don’t want them there.

How much of this is actual use of government power vs. implied use? People present ESA's like they're an ADA service animal, but they're not. AFAIK there's no actual government force behind an ESA other than making a landlord wary that there is.

A few years ago I heard ESAs were taking off in certain Australian states, but have only had one patient with a support animal in the last 5 years. When I first saw them they'd just got the dog, which was an untrained puppy who made a mess at the front reception. Before the dog they'd had multiple admissions each year to an interstate hospital for borderline/DID episodes, and in that particular place apparently every patient had an ESA.

The hospital I admit to has rules like only allowing one ESA at any one time which was put in place after a mini boom of patients wanting to bring their support animals in, but it seems like the rules changes have put people off. They still made it hard for my patient to bring in their ESA to both inpatient and outpatient programmes despite meeting all the criteria which also included getting formal training (over 12 months), testing and certification, but I think it was negative counter-transference from staff that started to get to them. While I'm sceptical about the role of ESAs, the good thing in this case was that having the ESA was associated with a substantial decrease in self harming behaviour and suicidal thinking, reducing the demand for admissions too.

It was quite a good learning experience, and while I have not had other patients wanting letters of support for ESAs, if it did occur I know who to refer them to for training, and those only looking for a pet are unlikely to bother.

BPD is probably the top diagnosis where I'd readily buy an evidence base for simply having a pet being therapeutic.

 

[deleted480308]

How much of this is actual use of government power vs. implied use? People present ESA's like they're an ADA service animal, but they're not. AFAIK there's no actual government force behind an ESA other than making a landlord wary that there is.

I don’t see that as a defense of these letters

 

[FlowRate]

I don’t see that as a defense of these letters

It's not. It's worse because it is by definition the illegitimate use (threat) of government force.

 

[Old&InTheWay]

How much of this is actual use of government power vs. implied use? People present ESA's like they're an ADA service animal, but they're not. AFAIK there's no actual government force behind an ESA other than making a landlord wary that there is.

The Fair Housing Act requires that landlords accommodate ESAs. People can file complaints with HUD/FHEO. Here is what that process could look like: HUD.gov / U.S. Department of Housing and Urban Development (HUD). Also individuals can file private lawsuits.

Doctors should not be involved in using govt power to force animals on landlords that don’t want them there.

This kind of feels like a straw man; no one is really making this claim. You could make an analogous statement that doctors shouldn't be involved in using government power to force disabled people on landlords that don't want them there. The government gets to decide what is and is not discrimination. The role of a doctor/therapist/ect can sometimes be to determine whether someone falls into a certain protected class. I would agree that it is unethical and an abuse of power to make such determinations frivolously with the goal or end result of condoning/contributing to a patient's malingering or secondary gain.

The real questions in my mind are 1) who exactly is qualified to determine whether a person needs an ESA? 2) what are the standards by which you would judge this ? and 3) is it ethical for a treating psychiatrist to disclose clinical information for this purpose? (i.e. you risk harming the patient by damaging the therapeutic relationship if you decide the patient does not need an ESA).

 

[cara susanna]

There are plenty of studies supporting at least a strong association between people with pets and all kinds of health benefits. Plenty of times we also accept patient report regarding the efficacy of something they do and the benefit they receive when evidence isn't overwhelmingly instructive. Iirc the evidence behind 12 Step and sobriety isn't terribly strong, but when someone says I'm sober because of the meetings or I haven't killed myself because of my dog, we tend to just go with it.

Fair enough if you want to say that evidence isn't compelling enough to make other people pay for it. Besides the fact that whether or not that's true, there's plenty of other poorly supported practices that get paid for.

Also, and this last part is not in any scientific question, is that as a species dogs do not get along just fine on their own. They are one of the most highly domesticated species on the planet. They might still be able to propagate and not go extinct despite how dependent we have made them on humans, but that isn't the same as getting along as a species.

I think humans have a moral obligation (and from a health standpoint it's pertinent to control animal populations) to deal with homeless dogs. And yes, some of those solutions will involve tax dollars of people who don't even like dogs.

They need to be captured, housed, spayed/neutered, put to sleep, or adopted out. We haven't maximized any one of these variables, and until we do it's a human health threat and responsibility. We need less dogs and more of the ones we have in homes.

I agree poor people should have access to pet ownership despite not being able to own their own land. Most of us are serfs these days. Even the poor who get housing on tax dollars are entitled to some disposable income and to spend money on things they want/need, within reason.

Yes they should be liable for damages to landlords or other renters. That is not the same as landlords just banning pet ownership because they don't want to deal with it. That doesn't mean that I'm against landlords offering pet-free housing shouldn't be allowed on principle.

But for me if there's a good case to be made for an exception to a rule (poor patient with significant health challenges, that pursues more than one line of treatment, that has a mental health condition that reasonably might have significant benefit from a pet, and they seem well enough to handle what challenges that "treatment" might have (and considering challenges to landlord/renters is actually keeping patient's interests in mind)) then that is why exceptions exist and we're called on to help facilitate them.

I agree it's abused, but that isn't the same as saying they should never be granted, either.

Here's the thing, though. With an ESA letter, you are not saying "this animal helps this person feel better." You are saying this person is disabled and the animal improves functioning. We have no evidence that's actually true. Furthermore, as discussed earlier in this thread, saying someone is disabled is a very sticky thing in itself.

 

[deleted480308]

The Fair Housing Act requires that landlords accommodate ESAs. People can file complaints with HUD/FHEO. Here is what that process could look like: HUD.gov / U.S. Department of Housing and Urban Development (HUD). Also individuals can file private lawsuits.



This kind of feels like a straw man; no one is really making this claim. You could make an analogous statement that doctors shouldn't be involved in using government power to force disabled people on landlords that don't want them there. The government gets to decide what is and is not discrimination. The role of a doctor/therapist/ect can sometimes be to determine whether someone falls into a certain protected class. I would agree that it is unethical and an abuse of power to make such determinations frivolously with the goal or end result of condoning/contributing to a patient's malingering or secondary gain.

The real questions in my mind are 1) who exactly is qualified to determine whether a person needs an ESA? 2) what are the standards by which you would judge this ? and 3) is it ethical for a treating psychiatrist to disclose clinical information for this purpose? (i.e. you risk harming the patient by damaging the therapeutic relationship if you decide the patient does not need an ESA).

I disagree with govt interference in those other areas too

 

[Mass Effect]

BPD is probably the top diagnosis where I'd readily buy an evidence base for simply having a pet being therapeutic.

But where's the evidence? Anecdotally, I've had success with BPD patients and teddy bears.

The real questions in my mind are 1) who exactly is qualified to determine whether a person needs an ESA?

Why wouldn't it be the treating psychiatrist? If the ESA is supposed to be treatment to help with a mental health condition, then the mental health expert on-record should be the one making the determination, just as we do with ALL treatment options we offer patients.

2) what are the standards by which you would judge this ?

The same way I would judge any treatment I recommend -- is there evidence to support this treatment plan and what are the risks/benefits?

3) is it ethical for a treating psychiatrist to disclose clinical information for this purpose? (i.e. you risk harming the patient by damaging the therapeutic relationship if you decide the patient does not need an ESA).

Disclose to whom? If the patient wants an ESA and asks for a letter from you, you tell the patient you do not believe it's appropriate. Done. You don't disclose information about the patient to anyone under that circumstance.

 

[Sushirolls]

I've been getting a small spike of people lately asking for them in context of different living arrangements. I.e. moving, or temporary going some where while home gets remodeled - and the new place is against animals.

Patients then explain how valuable their pet is for them and why they need them and for their description of diagnosis XYZ. Yet, in my 90 minute consults (and possibly multiple follow ups) has this diagnosis ever been put down or considered.

I still say no I don't do ESA forms.

But I can't help but feel this is just another symptom of the decay of society around us.

 

[FlowRate]

I've been getting a small spike of people lately asking for them in context of different living arrangements. I.e. moving, or temporary going some where while home gets remodeled - and the new place is against animals.

Same. It'd be way too much hassle in this employed position to say no to everyone. The letter that I send them basically says, in much longer prose, "my patient thinks that their pet is helpful. I can not make any assessment of the animal itself." I do not recommend the animal as part of their treatment plan or opine as to whether I think it would be helpful to the patient. The letter basically serves to verify that they have a DSM diagnosis.

 

[Jules A]

I don't do them and it has been a while since anyone asked me. It was my hope that meant society had realized that a service animal and ESA are no longer to be used interchangeably.

 

[tr]

Same. It'd be way too much hassle in this employed position to say no to everyone. The letter that I send them basically says, in much longer prose, "my patient thinks that their pet is helpful. I can not make any assessment of the animal itself." I do not recommend the animal as part of their treatment plan or opine as to whether I think it would be helpful to the patient. The letter basically serves to verify that they have a DSM diagnosis.

Mine is similar.

I say they are under my care for a psychiatric condition, that support animals have been shown to be beneficial for humans with a variety of mental health needs (citations to Pendry et al., Int J Environ Res Public Health 2020 Mar 15;17(6):1909); Young C, Horton J. Canine and Equine Therapy for Mental Health: A Review of Clinical Effectiveness: Canadian Agency for Drugs and Technologies in Health; 2019 Aug 30. PMID: 31682391), and say it would be helpful for them to be able to keep/fly with their ESA **as long as this is compatible with [building/airline] policy and with the health and safety of the other [occupants/passengers].**

So basically I expressly say that my letter shouldn't be taken to override whatever other health/safety policies are in place. Seems like it should moot the whole exercise of the letter but in practice nobody has ever complained about the wording.

 

[Stagg737]

Mine is similar.

I say they are under my care for a psychiatric condition, that support animals have been shown to be beneficial for humans with a variety of mental health needs (citations to Pendry et al., Int J Environ Res Public Health 2020 Mar 15;17(6):1909); Young C, Horton J. Canine and Equine Therapy for Mental Health: A Review of Clinical Effectiveness: Canadian Agency for Drugs and Technologies in Health; 2019 Aug 30. PMID: 31682391), and say it would be helpful for them to be able to keep/fly with their ESA **as long as this is compatible with [building/airline] policy and with the health and safety of the other [occupants/passengers].**

So basically I expressly say that my letter shouldn't be taken to override whatever other health/safety policies are in place. Seems like it should moot the whole exercise of the letter but in practice nobody has ever complained about the wording.

I really like this, I may steal this wording and the citation for myself. I generally agree with most and don't write these letters but do have 1 or 2 patients whose "ESA" functions more like a service animal but they can't afford to put them through the training.

 

[AbnormalPsych]

Just adding these articles here since I haven't seen them posted:

Examining Emotional Support Animals and Role Conflicts in Professional Psychology​

Examining Emotional Support Animals and Role Conflicts in Professional Psychology

This article examines the role conflicts that psychologists may face in their practices related to the evaluation and certification of emotional support animals (ESAs). It reviews the legal differences between ESAs and service animals (SAs), outlines ...

www.ncbi.nlm.nih.gov

Emotional Support Animal Assessments: Toward a Standard and Comprehensive Model for Mental Health Professionals​

Emotional Support Animal Assessments: Toward a Standard and Comprehensive Model for Mental Health Professionals

Growth in the presence of Emotional Support Animals (ESAs) in our society has recently garnered a substantial amount of attention, both in the popular media and the professional literature. Public media abounds with stories focusing on the increasing ...

www.ncbi.nlm.nih.gov

 

[FlowRate]

Was reading up more on this lately and state law defines that a licensee approached by a patient desiring an assistance animal as a housing accommodation is obligated to:

(a) MAKE A WRITTEN FINDING REGARDING WHETHER THE PATIENT HAS A DISABILITY AND, IF A DISABILITY IS FOUND, A SEPARATE WRITTEN FINDING REGARDING WHETHER THE NEED FOR THE ANIMAL IS RELATED TO THAT DISABILITY; OR

(b) MAKE A WRITTEN FINDING THAT THERE IS INSUFFICIENT INFORMATION AVAILABLE TO MAKE A FINDING REGARDING DISABILITY OR THE DISABILITY-RELATED NEED FOR THE ANIMAL.

So I now feel less comfortable with my hedged way of writing my ESA letters. What is the bar for "disability related need" in this case? Is it more than "has DSM diagnosis and would feel sad about finding a different apartment/giving away pet"?

 

[birchswing]

I have a great fear of flying, and my therapist had been working with me on CBT approaches.

We had finally worked up to the point that he was going to guide me in CBT techniques on an actual airplane flight.

We each purchased a ticket, but something went wrong with his with only a week to go.

I called the airline regarding this nonrefundable ticket I had and told them I could not go on the flight without my psychologist. She looked into their policies and they couldn't give a refund. She asked me if I had something else I could use to assuage my fears on the flight. She told me how more and more fliers were bringing small dogs on the plane with them as emotional support animals.

My psychologist and I then put 2 and 2 together.

Humans are taxonomically animals. And my psychologist, a human, provides emotional support. Within the week, his colleague wrote out a letter affirming that my therapist, who for the purposes of this trip took the assumed name Buckles, was my emotional support animal.

Fortunately of rather short stature, it wasn't as difficult as it might have otherwise have been to get him to crouch down into the area under the seat in front of me, but leg room was a nightmare.

Buckles didn't handle the turbulence too well with his back contorted and his hip dysplasia aggravated, but what was more important was that he was able to help me handle the turbulence.

With every bump, I'd start to panic that the plane was crashing. As the seat hit his back, Buckles would yelp out, "Oww! Reframe your thought: Turbulence is a sign that the structural integrity of the plane is keeping winds from coming inside where you are safe!"

Now I feel like I can fly anywhere with Buckles safely stowed in front of me.

The only time we had any trouble was when the flight attendant asked if there was a doctor onboard. Buckles was about to cause a scene when I reminded him he was not a medical doctor and that it was very important he stay in his assigned area.

For me personally, the idea of a dog is pretty ridiculous. Buckles had ten years of training. Some dogs don't even live that long.

I guess my point in all of this is that when it comes to emotional support animals, the species matters.

 

[WisNeuro]

I wouldn't get into this. No one looks at these letters. Just state that you are treating the pt, they have a mental disorder and qualify for an ESA under the Fair Housing Act Amendment. Leave it at that.

I would not recommend stating the pt has a disability and certainly not that they "need" an ESA. I don't think that language is therapeutic and it isn't necessary. This is enshrined in federal law so I wouldn't get too bogged down with what your state laws have to say. HUD also makes it clear that the housing provider is responsible for considering the impact of the animal on the health and safety of others (i.e. the psychiatrist is not responsible and thus cannot be liable for any harm caused by the animal since we are simply attesting to the fact that the pt has a mental disorder not assessing the animal). I don't write these letters for flying, but the same is true there, the airline has a duty to consider the impact of allowing the animal on the plane (the ESA letter is not a carte blanche) NOT the psychiatrist.

I thought the FHA stated that one needed to have a disability to qualify for an ESA under the amendment? If you are saying that they qualify for an ESA and they have not been declared legally disabled, are you not then making a disability decision?

 

[splik]

I thought the FHA stated that one needed to have a disability to qualify for an ESA under the amendment? If you are saying that they qualify for an ESA and they have not been declared legally disabled, are you not then making a disability decision?

you are being deliberately disingenuous here. What does being "declared legally disabled" (whatever that means) have to do with having a disability? Most patients that psychiatrists see have a disability as defined by the ADA and thus would qualify. The ADA definition is quite broad: "To be protected by the ADA, one must have a disability or have a relationship or association with an individual with a disability. An individual with a disability is defined by the ADA as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. The ADA does not specifically name all of the impairments that are covered." This is quite different from making a determination about someone's ability to work (i.e. meeting the SSA definition for disability). The difference as I see it is that a psychiatrist would be making an assessment of whether a patient's symptoms substantially impair or limit some life activity as part of their diagnostic evaluation, whereas they would not normally be assessing their capability to work (hence the latter is more rightly seen as a forensic activity).

 

[WisNeuro]

you are being deliberately disingenuous here. What does being "declared legally disabled" (whatever that means) have to do with having a disability? Most patients that psychiatrists see have a disability as defined by the ADA and thus would qualify. The ADA definition is quite broad: "To be protected by the ADA, one must have a disability or have a relationship or association with an individual with a disability. An individual with a disability is defined by the ADA as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. The ADA does not specifically name all of the impairments that are covered." This is quite different from making a determination about someone's ability to work (i.e. meeting the SSA definition for disability). The difference as I see it is that a psychiatrist would be making an assessment of whether a patient's symptoms substantially impair or limit some life activity as part of their diagnostic evaluation, whereas they would not normally be assessing their capability to work (hence the latter is more rightly seen as a forensic activity).

Not at all, it was an honest question. Perhaps it's because I work in the legal realm, but having undergone a disability evaluation for a mental illness and merely having been diagnosed with a mental illness are two very different things, particularly when it comes to issues surrounding legal statutes. And, also in legal cases, there are objective rules to consider for impairment and disability, usually outlined in jurisdictional statutes. I guess I don't see much difference in filling out a legal document that supersedes certain rules for animal occupancy, than filling out paperwork similarly for SSDI.