Considerations for the Writing of Certification Letters Endorsing Use of Emotional Support Animals
Abstract
Emotional support animals (ESAs) are different from service animals, therapy animals, and other disability-related assistance animals. Although pet ownership may confer psychological benefits, limited research has supported the use of ESAs to realize such benefits. If clinicians are asked to write a letter of support for use of an ESA, they need to be familiar with relevant federal, state, and local laws that regulate ESAs and with the essential components of an ESA evaluation. This article provides an overview of terminology; federal, state, and local laws related to ESAs; and clinical and ethical considerations for clinicians who decide to write these letters. The authors also review liability issues related to writing these letters, including those related to ESA aggression.
HIGHLIGHTS
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Clinicians should write certification letters endorsing use of an emotional support animal (ESA) only in states where they have a license to practice and only after they have performed an adequate professional evaluation.
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Clinicians writing ESA letters should refer to their state’s laws to determine which information must be included in the letter, while striving to protect patient confidentiality.
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Given the limited evidence supporting the efficacy of ESAs for alleviating psychiatric symptoms, it is ethically permissible to decline to write ESA letters.
Although limited research has substantiated the use of emotional support animals (ESAs) to alleviate psychiatric symptoms, clinicians may be asked to write a certification letter to endorse a patient’s request to designate their pet as an ESA. Federal, state, and local laws that regulate ESAs vary. Because this area of clinical practice and regulation is evolving, psychiatrists who are contemplating whether they should write a letter endorsing use of an ESA must stay up to date with laws in their jurisdiction. This article provides an overview of definitions and terminology; federal, state, and local laws related to ESAs; and clinical, ethical, and liability issues that psychiatrists should consider when they are asked to write an ESA letter for a patient.
Definitions and Terminology
ESAs are different from service animals and other disability-related assistance animals. The terminology describing different categories of animals used in therapy also varies across federal (1, 2) and state laws and in the scientific literature. For the purposes of this article, we define an ESA as an animal of any species that alleviates symptoms of a psychiatric disability through the animal’s companionship or presence (3). Unlike service animals (1, 2), ESAs are not individually trained to perform a specific task. Box 1 provides definitions of ESAs and other animals, and Table 1 describes the intended use of these animals and the legal restrictions governing their use.
BOX 1. Definitions of terms related to emotional support animals
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“Service animals” are protected by the Americans With Disabilities Act (ADA) and are individually trained to work or perform tasks for the benefit of an individual with a disability. Under the ADA, designation as a service animal is limited to dogs, with separate provisions for use of miniature horses.
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“Psychiatric service animals” are a subset of service animals that have been individually trained to perform tasks to alleviate symptoms of a psychiatric disability.
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“Emotional support animals” are animals of any species that alleviate symptoms of a person’s psychiatric disability through their companionship or presence but do not perform a specific task.
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“Therapy animals” accompany trained handlers to provide animal-assisted treatment to improve an individual’s emotional well-being. Animal-assisted therapy is considered a form of complementary or alternative therapy.
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“Pets” offer companionship to their owners but are not used within a treatment setting or to alleviate symptoms related to their owner’s disability.
| Term | Species | Who is helped | Training required | Performs specific task | Mitigates an individual’s disability | Legal right to enter public establishment | Legal right to enter medical settings | Regulations |
|---|---|---|---|---|---|---|---|---|
| Service animal | Dogs or miniature horses only | Individual owner with a disability | Individually trained to assist one person | Yes: related to the owner’s disability | Yes: any disability under the ADA | Yes | Yes, with restrictions | ADA |
| Psychiatric service animal | Dogs or miniature horses only | Individual owner with a psychiatric disability | Individually trained to assist one person | Yes: related to the owner’s psychiatric disability | Yes: disability from a psychiatric illness | Yes | Yes, with restrictions | ADA |
| Emotional support animal | Any | Individual owner with a psychiatric disability | No | No: provides emotional comfort, well-being, support, or companionship | Yes: disability from a psychiatric illness | No | No | FHA, ACAA, IDEA, state and local laws |
| Therapy animal | Any | Various (can be used in large group settings or individual psychotherapy) | Animal and handler trained in obedience and socialization | No: provides emotional comfort, well-being, support, or companionship | No: used to mitigate suffering or illness but not a legal disability | No | Yes | State and local laws |
| Pet | Any | Owner | No | No: provides comfort and companionship to owner | No | No | No | None |
a
ACAA, Air Carrier Access Act; ADA, Americans With Disabilities Act; FHA, Fair Housing Act; IDEA, Individuals With Disabilities Education Act.
Relevant Federal, State, and Local Laws
Federal Laws
Unlike service animals, ESAs are not protected by the Americans With Disabilities Act (ADA). They are regulated by various federal, state, and local laws. Because this area of law is evolving, clinicians should be cognizant of the most current versions of federal, state, and local laws when considering requests for ESA certification letters. Federal laws related to ESAs are summarized in the following sections.
ADA.
The ADA was enacted to prevent discrimination on the basis of disability. Under Titles II and III of the ADA, service animals are limited to dogs (1, 2), and the ADA clearly states, “Dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA” (4). However, if a dog is trained to perform a task related to a person’s disability, it is recognized as a service animal in accordance with the ADA (4). For example, a psychiatric service animal may be trained to recognize or identify early symptoms of a panic attack and then intervene, such as by prompting its owner to take a medication or distracting its owner from symptoms by nudging them or applying pressure. Alternatively, a psychiatric service animal could be trained to alert its owner when the owner is exhibiting warning signs of a nonepileptic seizure. Under the ADA, standardized registration or specific training for service dogs cannot be required, and it is possible that individuals could train their own service animal. Lack of a standardized certification for service animals promotes access for individuals with disabilities but may also generate confusion about whether an animal is a service animal, an ESA, or a pet. Under the ADA, the handler may be asked whether their animal qualifies as a service animal that is required because of a disability, but the handler cannot be asked to produce paperwork or be questioned about their disability. Service animals can also be excluded from premises if they are not housebroken or if they are out of control (5).
Fair Housing Act (FHA).
The FHA prohibits discrimination in housing, including discrimination based on disability. Unlike the ADA, the FHA categorizes both service animals and ESAs as “assistance animals” that “are not pets” and “do work, perform tasks, assist, and/or provide therapeutic emotional support for individuals with disabilities” (6). Therefore, ESAs that are not protected as service animals under the ADA may nevertheless be protected and require reasonable accommodation under the FHA (1, 6, 7).
According to a guiding document by the U.S. Department of Housing and Urban Development (6) that addresses a person’s request to have an animal as a reasonable accommodation under the FHA, an individual with a disability may request to have an assistance animal in their home as a reasonable accommodation to the property owner’s pet policy (7). Examples of reasonable accommodations can include waiving a property’s no-pets policy or pet deposit fee for an assistance animal (7). Housing providers are not entitled to know an individual’s diagnosis or to ask for medical records. However, they can require individuals to provide supporting documentation from a psychiatrist or other licensed health care professional “general to the condition but specific as to the individual with a disability and the assistance or therapeutic emotional support provided by the animal” (6). Psychiatrists can thus be asked to write letters to support the housing of assistance animals.
Air Carrier Access Act (ACAA).
The ACAA prohibits commercial airlines from discriminating against individuals on the basis of their disability. Before 2021, ESAs were allowed on airplanes with a letter from a licensed mental health professional. However, as of January 2021, airlines are no longer required to accommodate ESAs and are allowed to recognize them as pets (8, 9). Of note, service animals are still protected under the ACAA, and the revised rules identify only dogs as service animals. Patients who seek to fly with a psychiatric service animal may be asked to complete Department of Transportation paperwork, depending on the policies of the airline carrier (8, 9).
Individuals With Disabilities Education Act (IDEA).
The IDEA ensures that all individuals with a disability are entitled to “free appropriate public education” that is individualized to them. IDEA applies to primary and secondary school education and protects the use of a service animal but, in accordance with the definitions of these animals provided in the ADA, does not automatically guarantee the use of an ESA. However, if a student may benefit from the presence of an ESA during instruction, this animal may become a part of their individualized education plan (3).
State and Local Laws
State and local policy cannot lessen protections established by federal statute. Although federal statutes set minimum requirements protecting individuals with disabilities, state or local policies can require additional accommodations for people with disabilities. When assessing a patient’s eligibility for an ESA, clinicians must be aware of state and local laws that are constantly evolving and specific to a jurisdiction. For example, in California, effective January 1, 2022, a health care practitioner who writes a letter for an ESA must be licensed in California, have an established relationship with a client for at least 30 days before providing a letter to that client, and have performed a clinical evaluation specific to that individual’s need for an ESA (10). In Florida, effective July 1, 2020, practitioners who provide an ESA letter must have held at least one in-person appointment with the patient requesting the letter, thus preventing the use of online-only letter writing (11). In New York City, certain types of nondomesticated animals prohibited by the public health code (such as raccoons) (12) can be excluded as ESAs by housing providers (13).
Clinical Issues
To date, the evidence base is limited regarding the clinical benefits of ESAs for psychiatric symptoms or disorders (14). One pre-post study of 11 participants with serious mental illness reported significant reductions in loneliness, depression, and anxiety symptoms 12 months after they started living with an ESA. However, the study did not control for other psychiatric treatments received during the study period (15). Another study currently under way is examining the use of ESAs as treatment for veterans with posttraumatic stress disorder (PTSD) (16).
Given the paucity of evidence regarding ESAs for psychiatric symptoms or disorders, inferences may be made from studies that have examined the impact of service and therapy animals, which differ from ESAs in that they must undergo specialized training. These studies show mixed evidence for the utility of service and therapy animals for psychiatric conditions, including PTSD (17, 18), anxiety (19, 20), dementia (21), autism spectrum disorder (22, 23), and schizophrenia (24, 25). In addition, these studies are small, underpowered, and lack a randomized controlled trial design. Further inferences can be made from the effects of pet ownership. Pet ownership may be associated with reduced cardiovascular disease risk (26) and improved general medical and psychological well-being (27). Proposed mechanisms underlying these associations include increased social support (28) and facilitation of social interactions (29–31). Other studies propose that no direct association exists between pet ownership and benefits to human health, but rather that cofactors, including owners’ personality traits, age, economic status, and health status, produce an apparent link between pet ownership and health (32). Qualitative reports suggest that pets may positively contribute to the management of mental health symptoms (3, 32). However, it is also important to consider the practical and emotional burdens of pet ownership and the psychological impact of pet loss (3, 32).
Few formal training opportunities are available for ESA certification, and many of them are produced by “lay animal enthusiasts and organizations, which can lead to bias” (3). This paucity is problematic because 35.7% of mental health providers reported feeling unqualified to make an ESA determination (33). However, several authors have recently proposed practice guidelines for mental health providers to determine whether patients would benefit from an ESA (15, 34).
Younggren et al. (34) assert that clinicians should consider whether an animal has the appropriate temperament, disposition, and training to be an ESA. For example, is a dog able to provide calming effects for its owner when taken into a strange place, such as a crowded airport, or is it going to be scared enough to become aggressive, thereby worsening the patient’s anxiety? Furthermore, they recommend obtaining collateral information from a certification program (e.g., the Canine Good Citizen test), an animal behaviorist, or a veterinarian in order to understand the animal’s temperament (34). They add that clinicians should directly assess the patient-pet interaction to determine whether a pet is able to ameliorate its owner’s mental health impairments (34). In contrast, Hoy-Gerlach et al. (15) state that a clinician does not need to meet an animal or witness patient-animal interactions to make a determination of ESA suitability. They suggest that a clinician may acceptably rely on a patient’s self-report, similar to evaluating standard interventions such as coping strategies or mindfulness practices (15). Because clinicians are not trained to assess an animal’s temperament, evaluating an animal’s suitability as an ESA is outside their area of expertise.
The two recommended components of an ESA evaluation are, first, to determine whether a patient has a chronic mental impairment caused by a psychiatric condition (as defined by the DSM-5-TR) that substantially limits their functioning in one or more domains (i.e., a disability) and, second, to determine whether the ESA will alleviate such an impairment (3, 14).
Definitions of psychiatric disability and impairment alleviation can help clarify these recommendations. The Practice Resource for the Forensic Evaluation of Psychiatric Disability from the American Academy of Psychiatry and the Law (35) indicates that during a disability evaluation, a psychiatrist must link a patient’s chronic mental impairments to a mental disorder. The psychiatrist should also consider explanations for the reported disability other than a mental disorder, including by assessing for malingering, and conduct an evaluation that includes a psychiatric interview, a review of general medical and psychiatric treatment records, and collateral information. Regarding impairment alleviation, Younggren et al. (34) suggest that “disability does not mean the individual has an attachment to the ESA, feels happier in proximity to the ESA, or just wants to accompany the animal, which is usually their pet. It means that the person requires the presence of the animal to function or remain psychologically stable.”
Clinicians should also consider a patient’s ability to care for their animal (15, 34) and the ability of the animal to serve in an ESA role (3, 14). Furthermore, as discussed earlier, clinicians writing ESA certification letters should be aware of variability in state requirements for these evaluations. For example, a clinician must know whether a state requires that the letter writer have an established relationship with a patient or meet with that patient in person or whether it is acceptable to refer a patient for a forensic evaluation to determine the need for an ESA.
In general, minimally necessary clinical information should be included in these letters to protect patient confidentiality. The letter should specify whether the animal is expected to alleviate impairing psychiatric symptoms. Hoy-Gerlach et al. (15) suggest that psychiatrists review all such letters every 6 months and update them as needed to ensure that ESAs are providing continual therapeutic benefits.
Ethical Considerations
Clinicians who are contemplating writing an ESA letter should be aware of several ethical considerations. It is unethical and illegal to engage in disability fraud by writing ESA letters simply to allow patients to bring pets to venues that are not pet friendly, to avoid fees associated with having a pet, or to override restrictions on breeds and species (36). Misusing ESA certifications as legal loopholes “negatively impacts the public’s perception of the disabled” (37), undermining justice for patients who genuinely require an animal’s support. Given the limited evidence supporting the effective use of an ESA—even when a patient has a genuine psychiatric disability—it is ethically permissible to decline to write an ESA letter.
Clinicians can think of an ESA as an unconventional and unproven treatment to target mental health symptoms that cause functional impairment. As with any unproven treatment, clinicians should carefully weigh the relevant risks and benefits of an ESA for each patient, considering the paucity of evidence that supports the use of ESAs. Unlike most conventional treatments, an ESA directly affects not only a patient but also individuals around that patient. Therefore, although a treating clinician’s primary obligation is to their patient, they should also consider their secondary obligations to public health when deciding whether to write an ESA letter (3).
Another ethical consideration is the role conflict that arises when a treating clinician deviates from their traditional role as patient advocate to conduct an ESA evaluation (34). ESA evaluations are essentially disability evaluations. Boness et al. (33) assert that these evaluations should be conducted in the same rigorous manner as other disability evaluations, including assessments of malingering. Others have stated that writing an ESA is “not a stand-alone administrative task like a disability determination, but rather an active intervention based on a clinical rationale” (15). To eliminate the ethical concern about conflict between the roles of clinician and evaluator, some authors argue that, if resources are available, forensic psychiatrists or psychologists are best equipped to conduct these evaluations (3, 34). However, in some jurisdictions, laws require that the letter writer have an established relationship with a patient, and referral to a forensic evaluator is not permitted.
As with any forensic evaluation, whether completed by a treating clinician or a forensic evaluator, the evaluator should assess their own biases and strive for objectivity. If a patient’s treating clinician performs the evaluation, they should consider the effects that an assessment that does not support their patient’s wishes might have on the therapeutic relationship (34). It is also important for clinicians to be aware of the potential harms associated with writing a letter that they do not totally support. If a patient knows that their clinician does not believe what they are writing, then the clinician’s credibility is undermined and the patient may lose trust in the provider (36).
Liability-Related Considerations
Inappropriate ESA Letters
To our knowledge, clinicians who have written letters for patients who are in states in which the clinician has a professional license and have completed an adequate professional evaluation have not been held liable for inappropriate ESA letters or found to be culpable in ESA disputes. However, as described below, prior litigation has occurred in relation to these issues.
In May 2019, the California Board of Behavioral Sciences, Department of Consumer Affairs, ordered the revocation of the license to practice of Carla Jeanne Black, a licensed marriage and family therapist, for practicing out of state without a license to do so and for not performing a “proper assessment” before issuing an ESA letter (38). In this case, a landlord complained after receiving a letter from Ms. Black stating that a tenant needed an ESA. Investigation revealed several problematic findings, including the statement on Ms. Black’s website that she specialized in ESAs and ESA certification letters. Investigators learned that she was providing telehealth evaluations, which lasted from 10 minutes to 1 hour, to individuals across the country who desired ESAs, including in states where she did not have a license to practice.
Similarly, in Riverbrook v Abimbola Fabode (39), the Michigan Court of Appeals accused the district and circuit courts of avoiding their gatekeeper role by not allowing a deeper examination of the reliability and admissibility of the ESA letter written by Anne Venet, a limited licensed professional counselor.
A case decided by the Indiana Court of Appeals, Furbee v Wilson, concerned a tenant who submitted a certification letter for an ESA from Monique Snelson, a licensed marriage and family therapy associate, that did not adequately support the need for an ESA to the satisfaction of the landlord (40). The court found that, even if some of the landlord’s questions regarding the therapist’s recommendation of an ESA were overbroad, questions about the tenant’s disability and the link between the disability and the need for an ESA were not.
The amount of information necessary to make a decision to approve an ESA request was the central issue in another case, Bhogaita v Altamonte Heights Condominium Association (41), which was quoted in Furbee. In that case, which began in 2008, Ajit Bhogaita, a U.S. Air Force veteran diagnosed as having PTSD by his treating psychiatrist, was denied a requested ESA accommodation to allow his dog to live in his residence, despite three supportive letters from his psychiatrist, written over several months. The psychiatrist explained the therapeutic relationship between Bhogaita and his dog and that his condition limited his ability to work directly with other people, such that without the emotional support of his dog, his social interactions would be so overwhelming that he would not be able to perform work of any kind. In 2011, Bhogaita filed suit in the U.S. District Court for the Middle District of Florida, claiming that the Altamonte Heights Condominium Association’s denial of his request for a reasonable accommodation violated federal and Florida fair housing laws. The court granted, in part, Bhogaita’s motion for summary judgment, and the 11th Circuit Court affirmed the ruling, holding that the FHA prevents housing providers from refusing a reasonable accommodation request and that the psychiatrist’s letters, which were provided to the condominium association before it requested additional information, contained all the information needed to make a determination (41, 42). Of note, unlike the cases discussed earlier, the psychiatrist’s opinion was not the subject of inquiry in this case.
Although existing case law pertains to claims of discrimination against individuals who are being denied the companionship of their ESAs in their dwellings and other locations, no evidence suggests that psychiatrists have been implicated in these legal proceedings. Our review of available literature, including of a compilation of lawsuits involving ESAs or service animals from 1931 to 2019 prepared by the Animal Legal and Historical Center of the Michigan State University College of Law (42), did not uncover any lawsuits against psychiatrists or other physicians. Lawsuits were found that involved ESA support letters written by a pediatric neurologist, cardiologists, primary care physicians, and psychiatrists, among others. All letters were written in the context of an established therapeutic relationship with a patient, identified a qualifying disability and the link between the disability and impairment of a major life activity, and described the effect of the recommended ESA on alleviating the patient’s symptoms.
Dog Bites
ESA vs. service animal.
For the purposes of potential liability, as described earlier, it is noteworthy that ESAs are not considered service animals under Titles II and III of the ADA (1) and that service animals and their owners have some protection under this law. A service animal would likely have a well-documented history of training and good behavior. Moreover, most service animals wear a vest that warns bystanders not to bother the animal. This warning helps the animal’s owner in claims that bites or other injuries caused by the service animal were provoked. If an injury occurs because the victim bothered the service animal despite the warning, the owner can argue that they are not at fault for the victim’s injury.
However, a service animal can be excluded from any ADA Title II or III public service or accommodation if the animal is out of control and the handler cannot get the animal under control or if the animal is not housebroken.
Unlike the owners of service animals, the owners of ESAs are not protected by the ADA. Although ESAs generally do not require any kind of training, to distinguish ESAs from pets, some state courts have required training, for example, to ensure that ESAs conform with standards of appropriate behavior (3, 43).
Liability of ESA letter writers.
Liability analysis changes on the basis of the particular circumstances of a case, including the type of animal involved and the situation leading up to an attack by the animal. However, when damages are sustained as a result of an ESA, the liability analysis appears to be the same as it would be when injuries result from a domestic pet with no special therapeutic designation. In other words, if a dog bites an individual—even if that dog is an ESA—its owner would be held responsible, provided that the victim did not provoke the animal. However, because individuals have the right to sue anyone who they think might be liable, clinicians writing an ESA letter should be alert to the possibility of being sued. For example, instead of designating an animal the clinician has never met as an ESA, it would be more appropriate to make a broader statement, such as, “I recommend this patient have an ESA to reduce distress and impairment associated with his mental health disability.”
Our review of the literature did not uncover any cases upholding an award against a provider who had written an ESA letter involving an animal that attacked someone. In addition, psychiatrists have not been held liable for ESA letters. However, psychiatrists should remain alert to the possibility of being sued if they deviate from established standards of professional practice.
Conclusions
The evidence base regarding the clinical benefits of ESAs for psychiatric symptoms or disorders is limited. However, clinicians may be asked to perform ESA evaluations and write letters to support requests for an ESA. We recommend clinicians think about the evidence and considerations presented in this article before determining whether they want to complete an ESA letter for a patient. It is ethical and may be clinically indicated for clinicians to decline to write such letters. However, when clinicians consider writing such a letter, it is essential for them to stay abreast of the laws applicable to these evaluations and to follow standards of professional practice when conducting evaluations.
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Received: 22 September 2022
Revision received: 13 November 2022
Revision received: 8 December 2022
Accepted: 9 December 2022
Published online: 29 March 2023
Published in print: September 01, 2023
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The authors report no financial relationships with commercial interests.
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This article is derived from work done on behalf of the American Psychiatric Association.
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