Could ‘Rx: Pet therapy’ come back to bite you?

Dear Dr. Mossman,

My patient, Ms. A, asked me to write a let­ter to her landlord (who has a “no pets” policy) stating that she needed to keep her dog in her apartment for “therapeutic” pur­poses—to provide comfort and reduce her posttraumatic stress (PTSD) and anxiety. I hesitated. Could my written statement make me liable if her dog bit someone?

Submitted by “Dr. B”

Studies showing that animals can help outpatients manage psychiatric condi­tions have received a lot of publicity lately. As a result, more patients are asking physicians to provide documentation to sup­port having pets in their apartments or letting their pets accompany them on planes and buses and at restaurants and shopping malls.

But sometimes, animals hurt people. The Centers for Disease Control and Prevention reports that dogs bite 4.5 million Americans each year and that one-fifth of dog bites cause injury that requires medical atten­tion; in 2012, more than 27,000 dog-bite vic­tims needed reconstructive surgery.¹ If Dr. B writes a letter to support letting Ms. A keep a dog in her apartment, how likely is Dr. B to incur professional liability?

To answer this question, let’s examine:
   • the history and background of “pet therapy”
   • types of assistance animals
   • potential liability for owners, land­lords, and clinicians.

History and background
Using animals to improve hospitalized patients’ mental well-being dates back to the 18th century.² In the late 1980s, medical pub­lications began to document systematically how service dogs whose primary role was to help physically disabled individuals to navigate independently also provided social and emotional benefits.^3-7 Since the 1990s, accessibility mandates in Title III of the Americans with Disabilities Act (ADA) (Table 1⁸) have led to the gradual acceptance of service animals in public places where their presence was previously frowned upon or prohibited.^9,10

If service dogs help people with physical problems feel better, it only makes sense that dogs and other animals might lessen emo­tional ailments, too.^11-13 Florence Nightingale and Sigmund Freud both recognized that involving pets in treatment reduced patients’ depression and anxiety,¹⁴ but credit for for­mally introducing animals into therapy usu­ally goes to psychologist Boris Levinson, whose 1969 book described how his dog Jingles helped troubled children communi­cate.¹⁵ Over the past decade, using animals— trained and untrained—for psychological assistance has become an increasingly popu­lar therapeutic maneuver for diverse mental disorders, including autism, anxiety, schizo­phrenia, and PTSD.^16-19

Terminology
Because animals can provide many types of assistance and support, a variety of terms are used to refer to them: service animals, com­panion animals, therapy pets, and so on. In certain situations (including the one described by Dr. B), carefully delineating animals’ roles and functions can reduce confusion and mis­interpretation by patients, health care profes­sionals, policy makers, and regulators.

Parenti et al²⁰ have proposed a “taxon­omy” for assistance dogs based on variables that include:
   • performing task related to a disability
   • the skill level required of the dog
   • who uses the dog
   • applicable training standards
   • legal protections for the dog and its handler.

Table 2²⁰ summarizes this classification system and key variables that differentiate types of assistance dogs.

Certification
Health care facilities often require that visit­ing dogs have some form of “certification” that they are well behaved, and the ADA and many state statutes require that service dogs and some other animals be “certified” to perform their roles. Yet no federal or state statutes lay out explicit training standards or requirements for certification. Therapy Dogs International²¹ and Pet Partners²² are 2 orga­nizations that provide certifications accepted by many agencies and organizations.

Assistance Dogs International, an assis­tance animal advocacy group, has proposed “minimum standards” for training and deployment of service dogs. These include responding to basic obedience commands from the client in public and at home, being able to perform at least 3 tasks to mitigate the client’s disability, teaching the client about dog training and health care, and scheduled follow-ups for skill maintenance. Dogs also should be spayed or neutered, properly vac­cinated, nonaggressive, clean, and continent in public places.²³

Liability laws
Most U.S. jurisdictions make owners liable for animal-caused injuries, including inju­ries caused by service dogs.²⁴ In many states (eg, Minnesota²⁵), an owner can be liable for dog-bite injury even if the owner did noth­ing wrong and had no reason to suspect from prior behavior that the dog might bite someone. Other jurisdictions require evi­dence of owner negligence, or they allow liability only when bites occur off the own­er’s premises²⁶ or if the owner let the dog run loose.²⁷ Many homeowners’ insurance policies include liability coverage for dog bites, and a few companies offer a special canine liability policy.

Landlords often try to bar tenants from having a dog, partly to avoid liability for dog bites. Most states have case law stating that, if a tenant’s apparently friendly dog bites someone, the landlord is not liable for the injury^28,29; landlords can be liable only if they know about a dangerous dog and do nothing about it.³⁰ In a recent decision, however, the Kentucky Supreme Court made landlords statutory owners with potential liability for dog bites if they give tenants permission to have dogs “on or about” the rental premises.³¹

Clinicians and liability
Asking tenants to provide documentation about their need for therapeutic pets has become standard operating procedure for landlords in many states, so Ms. A’s request to Dr. B sounds reasonable. But could Dr. B’s written statement lead to liability if Ms. A’s dog bit and injured someone else?

The best answer is, “It’s conceivable, but really unlikely.” Donna Vanderpool, MBA, JD, an author and attorney who develops and implements risk management services for psychiatrists, has not seen any claims or case reports on litigation blaming mental health clinicians for injury caused by emotional support pets after the clinicians had written a letter for housing purposes (oral and written communications, April 7-13, 2014).

Dr. B might wonder whether writing a let­ter for Ms. A would imply that he had evalu­ated the dog and Ms. A’s ability to control it. Psychiatrists don’t usually discuss—let alone evaluate—the temperament or behavior of their patients’ pets; even if they did they aren’t experts on pet training. Recognizing this, Dr. B’s letter could include a statement to the effect that he was not vouching for the dog’s behavior, but only for how the dog would help Ms. A.

Dr. B also might talk with Ms. A about her need for the dog and whether she had obtained appropriate certification, as dis­cussed above. The ADA provisions pertain­ing to use and presence of service animals do not apply to dogs that are merely patients’ pets, notwithstanding the genuine emotional benefits that a dog’s companionship might provide. Stating that a patient needs an ani­mal to treat an illness might be fraud if the doctor knew the pet was just a buddy.

Bottom Line
Psychiatrists can expect that more and more patients will ask them for letters to support having pets accompany them at home or in public. Although liability seems unlikely, cautious psychiatrists can state in such letters that they have not evaluated the animal in question, only the potential benefits that the patient might derive from it.

Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing articles.

Dear Dr. Mossman,

My patient, Ms. A, asked me to write a let­ter to her landlord (who has a “no pets” policy) stating that she needed to keep her dog in her apartment for “therapeutic” pur­poses—to provide comfort and reduce her posttraumatic stress (PTSD) and anxiety. I hesitated. Could my written statement make me liable if her dog bit someone?

Submitted by “Dr. B”

Studies showing that animals can help outpatients manage psychiatric condi­tions have received a lot of publicity lately. As a result, more patients are asking physicians to provide documentation to sup­port having pets in their apartments or letting their pets accompany them on planes and buses and at restaurants and shopping malls.

But sometimes, animals hurt people. The Centers for Disease Control and Prevention reports that dogs bite 4.5 million Americans each year and that one-fifth of dog bites cause injury that requires medical atten­tion; in 2012, more than 27,000 dog-bite vic­tims needed reconstructive surgery.¹ If Dr. B writes a letter to support letting Ms. A keep a dog in her apartment, how likely is Dr. B to incur professional liability?

To answer this question, let’s examine:
   • the history and background of “pet therapy”
   • types of assistance animals
   • potential liability for owners, land­lords, and clinicians.

History and background
Using animals to improve hospitalized patients’ mental well-being dates back to the 18th century.² In the late 1980s, medical pub­lications began to document systematically how service dogs whose primary role was to help physically disabled individuals to navigate independently also provided social and emotional benefits.^3-7 Since the 1990s, accessibility mandates in Title III of the Americans with Disabilities Act (ADA) (Table 1⁸) have led to the gradual acceptance of service animals in public places where their presence was previously frowned upon or prohibited.^9,10

If service dogs help people with physical problems feel better, it only makes sense that dogs and other animals might lessen emo­tional ailments, too.^11-13 Florence Nightingale and Sigmund Freud both recognized that involving pets in treatment reduced patients’ depression and anxiety,¹⁴ but credit for for­mally introducing animals into therapy usu­ally goes to psychologist Boris Levinson, whose 1969 book described how his dog Jingles helped troubled children communi­cate.¹⁵ Over the past decade, using animals— trained and untrained—for psychological assistance has become an increasingly popu­lar therapeutic maneuver for diverse mental disorders, including autism, anxiety, schizo­phrenia, and PTSD.^16-19

Terminology
Because animals can provide many types of assistance and support, a variety of terms are used to refer to them: service animals, com­panion animals, therapy pets, and so on. In certain situations (including the one described by Dr. B), carefully delineating animals’ roles and functions can reduce confusion and mis­interpretation by patients, health care profes­sionals, policy makers, and regulators.

Parenti et al²⁰ have proposed a “taxon­omy” for assistance dogs based on variables that include:
   • performing task related to a disability
   • the skill level required of the dog
   • who uses the dog
   • applicable training standards
   • legal protections for the dog and its handler.

Table 2²⁰ summarizes this classification system and key variables that differentiate types of assistance dogs.

Certification
Health care facilities often require that visit­ing dogs have some form of “certification” that they are well behaved, and the ADA and many state statutes require that service dogs and some other animals be “certified” to perform their roles. Yet no federal or state statutes lay out explicit training standards or requirements for certification. Therapy Dogs International²¹ and Pet Partners²² are 2 orga­nizations that provide certifications accepted by many agencies and organizations.

Assistance Dogs International, an assis­tance animal advocacy group, has proposed “minimum standards” for training and deployment of service dogs. These include responding to basic obedience commands from the client in public and at home, being able to perform at least 3 tasks to mitigate the client’s disability, teaching the client about dog training and health care, and scheduled follow-ups for skill maintenance. Dogs also should be spayed or neutered, properly vac­cinated, nonaggressive, clean, and continent in public places.²³

Liability laws
Most U.S. jurisdictions make owners liable for animal-caused injuries, including inju­ries caused by service dogs.²⁴ In many states (eg, Minnesota²⁵), an owner can be liable for dog-bite injury even if the owner did noth­ing wrong and had no reason to suspect from prior behavior that the dog might bite someone. Other jurisdictions require evi­dence of owner negligence, or they allow liability only when bites occur off the own­er’s premises²⁶ or if the owner let the dog run loose.²⁷ Many homeowners’ insurance policies include liability coverage for dog bites, and a few companies offer a special canine liability policy.

Landlords often try to bar tenants from having a dog, partly to avoid liability for dog bites. Most states have case law stating that, if a tenant’s apparently friendly dog bites someone, the landlord is not liable for the injury^28,29; landlords can be liable only if they know about a dangerous dog and do nothing about it.³⁰ In a recent decision, however, the Kentucky Supreme Court made landlords statutory owners with potential liability for dog bites if they give tenants permission to have dogs “on or about” the rental premises.³¹

Clinicians and liability
Asking tenants to provide documentation about their need for therapeutic pets has become standard operating procedure for landlords in many states, so Ms. A’s request to Dr. B sounds reasonable. But could Dr. B’s written statement lead to liability if Ms. A’s dog bit and injured someone else?

The best answer is, “It’s conceivable, but really unlikely.” Donna Vanderpool, MBA, JD, an author and attorney who develops and implements risk management services for psychiatrists, has not seen any claims or case reports on litigation blaming mental health clinicians for injury caused by emotional support pets after the clinicians had written a letter for housing purposes (oral and written communications, April 7-13, 2014).

Dr. B might wonder whether writing a let­ter for Ms. A would imply that he had evalu­ated the dog and Ms. A’s ability to control it. Psychiatrists don’t usually discuss—let alone evaluate—the temperament or behavior of their patients’ pets; even if they did they aren’t experts on pet training. Recognizing this, Dr. B’s letter could include a statement to the effect that he was not vouching for the dog’s behavior, but only for how the dog would help Ms. A.

Dr. B also might talk with Ms. A about her need for the dog and whether she had obtained appropriate certification, as dis­cussed above. The ADA provisions pertain­ing to use and presence of service animals do not apply to dogs that are merely patients’ pets, notwithstanding the genuine emotional benefits that a dog’s companionship might provide. Stating that a patient needs an ani­mal to treat an illness might be fraud if the doctor knew the pet was just a buddy.

Bottom Line
Psychiatrists can expect that more and more patients will ask them for letters to support having pets accompany them at home or in public. Although liability seems unlikely, cautious psychiatrists can state in such letters that they have not evaluated the animal in question, only the potential benefits that the patient might derive from it.

Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing articles.

Dear Dr. Mossman,

My patient, Ms. A, asked me to write a let­ter to her landlord (who has a “no pets” policy) stating that she needed to keep her dog in her apartment for “therapeutic” pur­poses—to provide comfort and reduce her posttraumatic stress (PTSD) and anxiety. I hesitated. Could my written statement make me liable if her dog bit someone?

Submitted by “Dr. B”

Studies showing that animals can help outpatients manage psychiatric condi­tions have received a lot of publicity lately. As a result, more patients are asking physicians to provide documentation to sup­port having pets in their apartments or letting their pets accompany them on planes and buses and at restaurants and shopping malls.

But sometimes, animals hurt people. The Centers for Disease Control and Prevention reports that dogs bite 4.5 million Americans each year and that one-fifth of dog bites cause injury that requires medical atten­tion; in 2012, more than 27,000 dog-bite vic­tims needed reconstructive surgery.¹ If Dr. B writes a letter to support letting Ms. A keep a dog in her apartment, how likely is Dr. B to incur professional liability?

To answer this question, let’s examine:
   • the history and background of “pet therapy”
   • types of assistance animals
   • potential liability for owners, land­lords, and clinicians.

History and background
Using animals to improve hospitalized patients’ mental well-being dates back to the 18th century.² In the late 1980s, medical pub­lications began to document systematically how service dogs whose primary role was to help physically disabled individuals to navigate independently also provided social and emotional benefits.^3-7 Since the 1990s, accessibility mandates in Title III of the Americans with Disabilities Act (ADA) (Table 1⁸) have led to the gradual acceptance of service animals in public places where their presence was previously frowned upon or prohibited.^9,10

If service dogs help people with physical problems feel better, it only makes sense that dogs and other animals might lessen emo­tional ailments, too.^11-13 Florence Nightingale and Sigmund Freud both recognized that involving pets in treatment reduced patients’ depression and anxiety,¹⁴ but credit for for­mally introducing animals into therapy usu­ally goes to psychologist Boris Levinson, whose 1969 book described how his dog Jingles helped troubled children communi­cate.¹⁵ Over the past decade, using animals— trained and untrained—for psychological assistance has become an increasingly popu­lar therapeutic maneuver for diverse mental disorders, including autism, anxiety, schizo­phrenia, and PTSD.^16-19

Terminology
Because animals can provide many types of assistance and support, a variety of terms are used to refer to them: service animals, com­panion animals, therapy pets, and so on. In certain situations (including the one described by Dr. B), carefully delineating animals’ roles and functions can reduce confusion and mis­interpretation by patients, health care profes­sionals, policy makers, and regulators.

Parenti et al²⁰ have proposed a “taxon­omy” for assistance dogs based on variables that include:
   • performing task related to a disability
   • the skill level required of the dog
   • who uses the dog
   • applicable training standards
   • legal protections for the dog and its handler.

Table 2²⁰ summarizes this classification system and key variables that differentiate types of assistance dogs.

Certification
Health care facilities often require that visit­ing dogs have some form of “certification” that they are well behaved, and the ADA and many state statutes require that service dogs and some other animals be “certified” to perform their roles. Yet no federal or state statutes lay out explicit training standards or requirements for certification. Therapy Dogs International²¹ and Pet Partners²² are 2 orga­nizations that provide certifications accepted by many agencies and organizations.

Assistance Dogs International, an assis­tance animal advocacy group, has proposed “minimum standards” for training and deployment of service dogs. These include responding to basic obedience commands from the client in public and at home, being able to perform at least 3 tasks to mitigate the client’s disability, teaching the client about dog training and health care, and scheduled follow-ups for skill maintenance. Dogs also should be spayed or neutered, properly vac­cinated, nonaggressive, clean, and continent in public places.²³

Liability laws
Most U.S. jurisdictions make owners liable for animal-caused injuries, including inju­ries caused by service dogs.²⁴ In many states (eg, Minnesota²⁵), an owner can be liable for dog-bite injury even if the owner did noth­ing wrong and had no reason to suspect from prior behavior that the dog might bite someone. Other jurisdictions require evi­dence of owner negligence, or they allow liability only when bites occur off the own­er’s premises²⁶ or if the owner let the dog run loose.²⁷ Many homeowners’ insurance policies include liability coverage for dog bites, and a few companies offer a special canine liability policy.

Landlords often try to bar tenants from having a dog, partly to avoid liability for dog bites. Most states have case law stating that, if a tenant’s apparently friendly dog bites someone, the landlord is not liable for the injury^28,29; landlords can be liable only if they know about a dangerous dog and do nothing about it.³⁰ In a recent decision, however, the Kentucky Supreme Court made landlords statutory owners with potential liability for dog bites if they give tenants permission to have dogs “on or about” the rental premises.³¹

Clinicians and liability
Asking tenants to provide documentation about their need for therapeutic pets has become standard operating procedure for landlords in many states, so Ms. A’s request to Dr. B sounds reasonable. But could Dr. B’s written statement lead to liability if Ms. A’s dog bit and injured someone else?

The best answer is, “It’s conceivable, but really unlikely.” Donna Vanderpool, MBA, JD, an author and attorney who develops and implements risk management services for psychiatrists, has not seen any claims or case reports on litigation blaming mental health clinicians for injury caused by emotional support pets after the clinicians had written a letter for housing purposes (oral and written communications, April 7-13, 2014).

Dr. B might wonder whether writing a let­ter for Ms. A would imply that he had evalu­ated the dog and Ms. A’s ability to control it. Psychiatrists don’t usually discuss—let alone evaluate—the temperament or behavior of their patients’ pets; even if they did they aren’t experts on pet training. Recognizing this, Dr. B’s letter could include a statement to the effect that he was not vouching for the dog’s behavior, but only for how the dog would help Ms. A.

Dr. B also might talk with Ms. A about her need for the dog and whether she had obtained appropriate certification, as dis­cussed above. The ADA provisions pertain­ing to use and presence of service animals do not apply to dogs that are merely patients’ pets, notwithstanding the genuine emotional benefits that a dog’s companionship might provide. Stating that a patient needs an ani­mal to treat an illness might be fraud if the doctor knew the pet was just a buddy.

Bottom Line
Psychiatrists can expect that more and more patients will ask them for letters to support having pets accompany them at home or in public. Although liability seems unlikely, cautious psychiatrists can state in such letters that they have not evaluated the animal in question, only the potential benefits that the patient might derive from it.

Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing articles.