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Service animals and emotional support
animals: Should you write that letter?
Understand the ramifications
before advocating for patients
to have such animals
or centuries, animals, especially dogs, have assisted
humans in a variety of ways in their daily lives. Animals
Fthat assist people with disabilities fall into 2 broad cat-
egories: disability service animals, and emotional support
animals (ESAs). Often there is confusion in how these cate-
gories differ because of the animal’s role and the laws related
to them.
This article describes the differences between disability
A / EYEEMservice animals and ESAs, and outlines the forensic and ethi-
ANOV cal concerns you should consider before agreeing to write a
letter for a patient outlining their need for a disability service
animal or ESA. A letter may protect a patient and their ser-
ALIAKSANDRA IVvice animal or ESA in situations where laws and regulations
typically prohibit animals, such as on a flight or when rent-
Kaustubh G. Joshi, MD ing an apartment or house. Note that a description of how to
Associate Professor of Clinical Psychiatry conduct the formal patient evaluation before writing a veri-
Associate Director, Forensic Psychiatry Fellowship fication letter is beyond the scope of this article.
Department of Neuropsychiatry and Behavioral Science
University of South Carolina School of Medicine
Columbia, South Carolina
The differences between disability service
animals and ESAs
Purpose and training. Disability service animals, or service
animals, are dogs of any breed (and in some cases miniature
horses) that are specially trained to perform tasks for an indi-
vidual with a disability (physical, sensory, psychiatric, intel-
1-3
lectual, or other mental disability). These tasks must be
1,2
directly related to the individual’s disability. On the other
Disclosure
The author reports no financial relationships with any companies whose products are mentioned
Current Psychiatry in this article, or with manufacturers of competing products.
16 November 2021 doi: 10.12788/cp.0183
hand, ESAs, which can be any species of Box 1
animal, provide support and minimize the Is it a service dog, or just a pet?
impact of an individual’s emotional or psy-
chological disability based on their presence n the United States, there is no national MDedge.com/psychiatry
alone. Unlike disability service animals, Iservice dog certification program—meaning
ESAs are not trained to perform a specific there is no official test that a dog has to pass
in order to obtain formal recognition as a
2,3 service animal—nor is there a central and
task or duty.
5
There is no legal requirement for service mandatory service dog registry. Instead,
animals to know specific commands, and service dog verification works through an
5
honor system, which can be problematic. In
professional training is not required—indi- many states, misrepresenting one’s dog as a
1 5
viduals can train the animals themselves. service dog is considered a misdemeanor.
Service animals, mainly dogs, can be trained Unfortunately, other than the guidance set
forth by the Americans with Disabilities
4
to perform numerous tasks, including : Act, there are no criteria by which one can
attending to an individual’s mobility recognize a genuine service dog vs one being
5
and activities of daily living passed off as a service dog.
guiding an individual who is deaf or In situations in public settings where it is
not obvious or there’s doubt that the dog Clinical Point
hearing impaired is a service animal (such as when a person
helping to remind an individual to take visits a restaurant or store), employees are Emotional support
their medications not allowed to request documentation for the
dog, require the dog demonstrate its task, animals do not
assisting an individual during and/or or inquire about the nature of the person’s
1 1
after a seizure disability. However, they can ask 2 questions : qualify as service
alerting individuals with diabetes 1. Is the animal required because of a animals under the
disability?
in advance of low or high blood sugar 2. What work or task has the animal been ADA and are not
episodes trained to perform? given the same legal
supporting an individual with autism accommodations
assisting an individual with a psychiat-
ric or mental disability
1-3,6-15
applying sensory commands such as Act. Box 2 (page 18) further discusses
lying on the person or resting their head on these laws and protections.
the individual’s lap to help the individual Evidence. In 1998, Dogs for Good (for-
regain behavioral control. merly Dogs for the Disabled), an organiza-
Service dog verification works via an tion based in the United Kingdom, conducted
honor system, which can be problematic, a survey that assessed the satisfaction of
especially in the case of psychiatric service owners who were provided with trained
16
dogs, whose handlers may not have a vis- assistance dogs. The results suggested
1,5
ible disability (Box 1 ). that service dogs improved their owners’
Legal protections. Under the Americans mobility and helped ease the completion of
with Disabilities Act (ADA), individuals with tasks, thereby helping their owners integrate
disabilities can bring their service animals further on a society level and gain a strong
16
into buildings or facilities where members bond with their animal. Another survey
of the public, program participants, clients, compared quality of life scores of individu-
2
customers, patrons, or invitees are allowed. als who owned a service dog vs individuals
This does not include private clubs, religious who were eligible to receive a dog, but did
17
organizations, or places of worship that are not yet have one. It found that service ani-
6,7
not open to the public. ESAs do not qualify mals were able to help their owners gain a
as service animals under the ADA and are not greater degree of freedom and enhance their Discuss this article at
given the same legal accommodations as ser- ability to participate in everyday outings or www.facebook.com/
1,3 MDedgePsychiatry
vice animals. Although ESAs were initially tasks that may otherwise have been a strug-
covered by the Air Carrier Access Act, they gle, or impossible, if the owner were alone.17
are no longer allowed in aircraft cabins after In addition to boosting confidence, self-
the US Department of Transportation revised esteem, and improving social integration,
this Act’s regulations in December 2020. service dogs have been shown to improve Current Psychiatry
17 Vol. 20, No. 11
ESAs are covered under the Fair Housing their owners’ quality of life. 17
continued
Box 2
Legal protections for service animals and emotional support animals
he Americans with Disabilities Act (ADA) of Access Act (ACAA) of 1986 is the federal law
T1990, as amended by the ADA Amendments that protects the rights of people with disabilities
1,12
Act of 2008, prohibits discrimination on the in air travel. On December 2, 2020, the US
basis of disability in several areas, including Department of Transportation announced that
state and local governments (under Title II of the it was revising its ACAA regulation regarding
Service animal ADA) and places of public accommodations, service animals on aircraft (this final rule will
letters commercial facilities, and private entities (under be effective 30 days after date of publication
6,7 13
Title III of the ADA). Thus, individuals with in the Federal Register). Among the many
disabilities can bring their service animals into revisions, the US Department of Transportation
the building or facility where members of the narrowed the definition of service animals to
public, program participants, clients, customers, only dogs that were individually trained to work
2
patrons, or invitees are allowed. This does not or perform tasks for the benefits of a person
13
include private clubs not open to the public, with a disability. It requires airlines to treat
6,7
religious organizations, or places of worship. psychiatric service animals the same as other
13
Service animals. Although the ADA service animals. Although the US Department
recognizes miniature horses as service animals, of Transportation has chosen to closely align
Clinical Point only dogs are recognized as service animals its ACAA service animal definition with US
in regards to Title II and Title III protections Department of Justice service animal definition
2
under the ADA as of March 15, 2011. Federal under the ADA, the substantive requirements
There is limited 1
agencies do not have to comply with the ADA ; in this final rule differ from US Department
high-quality data however, Section 504 of the Rehabilitation of Justice’s requirements for service animals
Act of 1973 is the federal law that protects the under the ADA in various areas (for example,
pertaining to the rights of people with disabilities to participate in by allowing airlines to require service animal
1,8
potential benefits federal programs and services. It states that documentation and prohibiting the use of voice
13
no qualified individual with a disability shall be control over a service animal).
and risks of emotional excluded from, denied the benefits of, or be Emotional support animals. Regulations
subjected to discrimination under any program regarding ESAs are primarily set by individual
support animals 1,3
or activity that receives federal funding or is states ; however, ESAs may qualify for a waiver
8
conducted by federal agencies. Courts have of a no-pet rule or a pet deposit under the Fair
2,14
strived to interpret the Rehabilitation Act and Housing Amendments Act (FHAA) of 1988.
the ADA in a consistent manner, specifically Under the FHAA, if an individual has a disability,
applying the ADA regulations regarding service as defined by the ADA, that requires the
animals (including its narrow definition regarding presence of an ESA, or if they have symptoms
specifically trained tasks and emotional support) that are ameliorated by the presence of an ESA,
9-11
to the Rehabilitation Act. the landlord must comply with this request and
Similarly, commercial airlines do not have to allow the animal into the facility without charging
1 15
comply with the ADA ; however, the Air Carrier pet fees.
18
Due to the difficulty in reconciling incon- manage symptoms when they arise.” In
sistent definitions for ESAs, there is limited response to a congressional mandate, the US
high-quality data pertaining to the poten- Department of Veterans Affairs launched a
9
tial benefits and risks of ESAs. Currently, multi-site study from December 2014 to June
ESAs are not an evidence-based treatment 2019 to examine how limitations on activity
for psychiatric disorders. To date, a hand- and quality of life in veterans with posttrau-
ful of small studies have focused on ESAs. matic stress disorder are impacted by the
However, data from actual tests of the clini- provision of a service dog vs an emotional
9 19
cal risks and benefits of ESAs do not exist. support dog. As of October 14, 2021, results
19
In practice, ESAs are equivalent to pets. It had not been published.
stands to reason that similar to pets, ESAs
could reduce loneliness, improve life satis-
faction, and provide a sense of well-being.9 What’s in a disability service
A systematic review suggested that pets pro- animal/ESA letter?
vide benefits to patients with mental health If you decide to write a letter advocating
conditions “through the intensity of connec- for your patient to have a service animal or
tivity with their owners and the contribution ESA, the letter should appear on letterhead,
Current Psychiatry they make to emotional support in times be written by a licensed mental health pro-
November 2021 2,20
18 of crises together with their ability to help fessional, and include the following :
statement that the letter is being writ- Related Resources
ten at the patient’s request and is being
given directly to the patient for use as the US Department of Justice. Civil Rights Division. Disability
patient sees fit Rights Section. ADA requirements. Service animals. MDedge.com/psychiatry
Updated February 24, 2020. https://www.ada.gov/service_
confirmation of the patient’s DSM-5 animals_2010.htm
mental health diagnosis American Veterinary Medical Association. Service,
explanation of how the animal helps emotional support and therapy animals. https://www.
avma.org/resources-tools/animal-health-welfare/
alleviate symptoms of the patient’s condi- service-emotional-support-and-therapy-animals
tion, briefly describing any interaction(s) US Department of Transportation. US Department of
between the animal and patient that you Transportation announces final rule on traveling by air with
service animals. https://www.transportation.gov/briefing-
may have observed, and if applicable, a room/us-department-transportation-announces-final-
mention of any training the animal may rule-traveling-air-service-animals
have received from a qualified trainer if
applicable
explanation of the possible negative
effects of the patient not having the animal a patient has for a service animal or ESA.
with him or her How to conduct such evaluations is beyond Clinical Point
statement that you are not vouching the scope of this article. There are meager Be prepared to state
for the animal’s behavior opportunities for formal education and in a legal proceeding
verification of your involvement in your training on how to conduct these evalua-
9 that the presence of
patient’s treatment and your assessment of tions. Online resources may be incomplete
the patient as their licensed mental health or inaccurate, and this information is often a service animal or
professional (including details such as date produced by lay animal enthusiasts and ESA is necessary
and type of license you have and the state/ organizations, which can lead to a biased for your patient
9
other jurisdiction where it was issued). depiction of these animals.
In a letter for a service animal, also indicate If you decide to write a letter for your
that your patient is psychiatrically disabled patient, consider the following forensic and
to the extent that your patient is not able to ethical concerns.
perform at least one major life task without Remain objective. As an advocate for your
2
the daily assistance of a service animal. patient, you may find it difficult to remain
neutral and objective when asked to deter-
mine if your patient has a disability, the
Should you write your patient severity of the disability, the impact of the
a letter? disability on your patient’s life, and the
Writing a letter advocating for a patient to need for a service animal or ESA. Ensure
have a service animal or ESA may appear that your advocacy for your patient does
innocuous, but doing so may have serious not impair your objectivity; if that is dif-
ramifications. Writing a letter certifying ficult, consider referring your patient to a
a dog as a service animal does not make third party who can conduct an objective
that animal a service animal; the dog must evaluation.
be specifically trained for a task or tasks Understand the risks. If you make written
directly related to that individual’s disabil- recommendations for special accommoda-
ity. There are no current standards for con- tions in a letter and those recommendations
ducting evaluations to determine the need are disputed by an agency, that agency could
continued on page 24
Bottom Line
Disability service animals and emotional support animals (ESAs) differ in their roles
and legal protections. Before writing a letter in support of a patient’s request for
a service animal or ESA, take into account the forensic and ethical implications of
Current Psychiatry
doing so. Vol. 20, No. 11 19
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