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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 ...

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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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...Service animals and emotional support should you write that letter understand the ramifications before advocating for patients to have such or centuries especially dogs assisted humans in a variety of ways their daily lives fthat assist people with disabilities fall into broad cat egories disability esas often there is confusion how these cate gories differ because animal s role laws related them this article describes differences between eyeemservice outlines forensic ethi anov cal concerns consider agreeing patient outlining need esa may protect ser aliaksandra ivvice situations where regulations typically prohibit as on flight when rent kaustubh g joshi md ing an apartment house note description associate professor clinical psychiatry conduct formal evaluation writing veri director fellowship fication beyond scope department neuropsychiatry behavioral science university south carolina school medicine columbia purpose training are any breed some cases miniature horses specially train...

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