Points to Consider When Asked to Write Emotional Support Animal Advocacy Letter
Abstract
As in any clinical situation, psychiatrists should proceed with care when patients ask them to write an emotional support animal advocacy letter.
Psychiatric training prepares us to serve in many capacities. We evaluate patients, teach, practice psychotherapy and psychopharmacology, engage in research, have administrative responsibilities, and collaborate with other medical professionals. One shortcoming in psychiatric training and education is documentation for patients who are pursuing disability entitlements. This includes letters advocating for patients to have emotional support animals (ESAs).
The request for ESA advocacy letters increased precipitously in the last decade, along with the range of reactions from people who have been told by psychiatrists that they do not meet criteria for an ESA. Psychiatrists should not feel obligated to write such letters. On one occasion, an angry patient refused to leave my office after I chose not to write the letter. Eventually, law enforcement officers escorted the person from the building and cited the person for trespassing. Psychiatrists need to feel comfortable when assessing patients for ESA eligibility.
Service Animals vs. ESAs
The Americans With Disabilities Act (ADA) classifies assistance animals, including service animals and ESAs. Service animals are dogs and, in some cases, miniature horses and have specific training to perform one or more tasks that alleviates a person’s disability. A familiar example is a guide dog that assists a person who has a visual impairment. Other service dogs are trained to identify early indicators of hypoglycemia, seizures, and other illnesses and to alleviate symptoms of mental illness such as anxiety attacks, nightmares, and anger.
With rare exceptions, service animals are afforded full protections under the ADA. They can accompany their owners in restaurants, classrooms, dormitories, grocery stores, trains, buses, and other places that traditionally don’t accommodate pets. Also, service animals may travel by air in the main cabin at no cost to the owner as long as airlines’ guidelines are followed.
All assistance animals, including ESAs, have protections under the Fair Housing Act, which applies to public and private long-term housing. For example, assistance animals can live with their owners in domiciles that do not permit residents to have pets.
Although ESAs are not trained, they mitigate psychiatric symptoms by providing companionship. Unlike service animals, ESAs can be any type of animal, including cats, hamsters, monkeys, and other animals. The media frenzy about airline passengers bringing on board a variety of animals that allegedly were classified as ESAs resulted in a surge of requests for health care professionals to classify pets as ESAs. The excitement was quenched by the Air Carrier Access Act Amendment of 2021, which empowered airlines to treat ESAs as pets and require a fee for them to board planes.
Generally speaking, protections for ESAs require the owner to have the capacity to responsibly select and care for the animal. The animal must have an appropriate temperament, and the owner must meet the animal’s health, hygienic, emotional, and other needs.
Accommodations may be denied or rescinded by the property owner, airline, etc., if an animal poses a direct threat to the health or safety of others, misbehaves, or is disruptive (excessive noise, attacks on children, poor bowel or bladder control, etc.). Owners should be given the opportunity to address or ameliorate the problem before being asked to remove the animal from the building or area.
Patient Evaluation for ESAs
Psychiatrists should be familiar with the classification of assistance animals in the ADA. An assistance animal must serve a therapeutic purpose that mitigates a person’s disability. This includes service animals, ESAs, and therapy animals. All other domesticated animals are considered pets.
It is recommended that the psychiatrist use a systematic approach when interviewing patients for ESA advocacy letters. It is easier to start with what we know as clinicians. First, the psychiatrist should determine if the patient has a “psychiatric disability.” The ADA defines a person with a psychiatric disability as one who has mental impairment that substantially limits one or more major life activities. This includes people who have a history of a mental disorder even if it is in remission. Also, the ADA’s definition of psychiatric disability includes individuals who have not been diagnosed with a psychiatric disability but who are regarded or treated as if they do.
The patient’s temperament may contribute to or detract from his or her capacity to care for a domesticated animal. It may take several sessions to ascertain this. The psychiatrist should determine, to the extent possible, if the patient is rational, flexible, can follow a routine, engages in self-care, and functions at home and in the community. However, some patients who may benefit from an ESA may not be good candidates, including those who are easily agitated and are aggressive toward people, property, and/or animals. Also, patients who say that they have never fed or cleaned up after a pet or believe that animals should be allowed to roam free and depend on the kindness of strangers may not be suited to having an ESA.
The psychiatrist should ask the patient how the animal mitigates the the patient’s psychiatric disorder. If the patient states that the ESA alleviates symptoms of a nonpsychiatric condition, the psychiatrist should refer the patient to a health care professional with expertise in that disorder.
Considerations When Writing Letters
Each patient should collaborate with his or her psychiatrist on crafting an individualized psychiatric treatment plan that is predicated on evidence-based psychiatry and is subject to periodic review. Presently, ESAs are not an evidence-based treatment for mental disorders, but they can be an ancillary therapeutic modality. ESAs should not be the sole component of the treatment plan unless the psychiatrist and patient or guardian agree that this is the best course of action. The psychiatrist is not obligated to write a letter for ESA advocacy if the patient is refusing to participate in treatment.
If the psychiatrist is concerned that the patient will end treatment after the letter is submitted, the letter should be effective for a shorter time frame, for example, six months instead of one year. Also, the time frame can be briefer for patients who have a pattern of destabilizing and engaging in disruptive, dangerous, or bizarre behavior, since the patient may put the animal and community at risk.
When composing the ESA advocacy letter, the psychiatrist should not list the diagnosis or symptoms. A statement indicating that the person has a disability and the ESA alleviates the disability should suffice. Also, a disclaimer that the psychiatrist lacks expertise in matters pertaining to animals makes it clear that the psychiatrist is not exceeding the scope of psychiatric practice. Animal temperament, health, and related matters are best left to a veterinarian.
ESAs can benefit many patients and may serve as a motivator for some to adhere to treatment. Knowing how to approach the assessment and documentation process empowers psychiatrists to employ their skillsets in a novel way. ■
Cheryl D. Wills, M.D., is a forensic psychiatrist and an associate professor of psychiatry at Case Western Reserve University and vice chair for equity, diversity, and inclusion and chief of child psychiatry at Case Western’s Metrohealth System. She is also APA’s Area 4 trustee and received APA’s Special Presidential Commendation for her work as chair of APA's Presidential Task Force on Structural Racism Throughout Psychiatry and service to the Joint Reference Committee as Area 4 Trustee.
