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For centuries, animals, especially dogs, have assisted humans in a variety of ways in their daily lives. Animals that assist people with disabilities fall into 2 broad categories: disability service animals, and emotional support animals (ESAs). Often there is confusion in how these categories differ because of the animal’s role and the laws related to them.
This article describes the differences between disability service animals and ESAs, and outlines the forensic and ethical 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 service animal or ESA in situations where laws and regulations typically prohibit animals, such as on a flight or when renting an apartment or house. Note that a description of how to conduct the formal patient evaluation before writing a verification letter is beyond the scope of this article.
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 individual with a disability (physical, sensory, psychiatric, intellectual, or other mental disability).1-3 These tasks must be directly related to the individual’s disability.1,2 On the other hand, ESAs, which can be any species of animal, provide support and minimize the impact of an individual’s emotional or psychological disability based on their presence alone. Unlike disability service animals, ESAs are not trained to perform a specific task or duty.2,3
There is no legal requirement for service animals to know specific commands, and professional training is not required—individuals can train the animals themselves.1 Service animals, mainly dogs, can be trained to perform numerous tasks, including4:
- attending to an individual’s mobility and activities of daily living
- guiding an individual who is deaf or hearing impaired
- helping to remind an individual to take their medications
- assisting an individual during and/or after a seizure
- alerting individuals with diabetes in advance of low or high blood sugar episodes
- supporting an individual with autism
- assisting an individual with a psychiatric or mental disability
- applying sensory commands such as lying on the person or resting their head on the individual’s lap to help the individual regain behavioral control.
Service dog verification works via an honor system, which can be problematic, especially in the case of psychiatric service dogs, whose handlers may not have a visible disability (Box 11,5).
Box 1
In the United States, there is no national service dog certification program—meaning there is no official test that a dog has to pass in order to obtain formal recognition as a service animal—nor is there a central and mandatory service dog registry.5 Instead, service dog verification works through an honor system, which can be problematic.5 In many states, misrepresenting one’s dog as a service dog is considered a misdemeanor.5 Unfortunately, other than the guidance set forth by the Americans with Disabilities Act, there are no criteria by which one can recognize a genuine service dog vs one being passed off as a service dog.5
In situations in public settings where it is not obvious or there’s doubt that the dog is a service animal (such as when a person visits a restaurant or store), employees are not allowed to request documentation for the dog, require the dog demonstrate its task, or inquire about the nature of the person’s disability.1
However, they can ask 2 questions1:
1. Is the animal required because of a disability?
2. What work or task has the animal been trained to perform?
Legal protections. Under the Americans with Disabilities Act (ADA), individuals with disabilities can bring their service animals into buildings or facilities where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs, religious organizations, or places of worship that are not open to the public.6,7 ESAs do not qualify as service animals under the ADA and are not given the same legal accommodations as service animals.1,3 Although ESAs were initially covered by the Air Carrier Access Act, they are no longer allowed in aircraft cabins after the US Department of Transportation revised this Act’s regulations in December 2020. ESAs are covered under the Fair Housing Act. Box 21-3,6-15 further discusses these laws and protections.
Evidence.
Due to the difficulty in reconciling inconsistent definitions for ESAs, there is limited high-quality data pertaining to the potential benefits and risks of ESAs.9 Currently, ESAs are not an evidence-based treatment for psychiatric disorders. To date, a handful of small studies have focused on ESAs. However, data from actual tests of the clinical risks and benefits of ESAs do not exist.9 In practice, ESAs are equivalent to pets. It stands to reason that similar to pets, ESAs could reduce loneliness, improve life satisfaction, and provide a sense of well-being.9 A systematic review suggested that pets provide benefits to patients with mental health conditions “through the intensity of connectivity with their owners and the contribution they make to emotional support in times of crises together with their ability to help manage symptoms when they arise.”18 In response to a congressional mandate, the US Department of Veterans Affairs launched a multi-site study from December 2014 to June 2019 to examine how limitations on activity and quality of life in veterans with posttraumatic stress disorder are impacted by the provision of a service dog vs an emotional support dog.19 As of October 14, 2021, results had not been published.19
Continue to: What’s in a disability service animal/ESA letter?
What’s in a disability service animal/ESA letter?
If you decide to write a letter advocating for your patient to have a service animal or ESA, the letter should appear on letterhead, be written by a licensed mental health professional, and include the following2,20:
- statement that the letter is being written at the patient’s request and is being given directly to the patient for use as the patient sees fit
- confirmation of the patient’s DSM-5 mental health diagnosis
- explanation of how the animal helps alleviate symptoms of the patient’s condition, briefly describing any interaction(s) between the animal and patient that you may have observed, and if applicable, a mention of any training the animal may have received from a qualified trainer if applicable
- explanation of the possible negative effects of the patient not having the animal with him or her
- statement that you are not vouching for the animal’s behavior
- verification of your involvement in your patient’s treatment and your assessment of the patient as their licensed mental health professional (including details such as date and type of license you have and the state/other jurisdiction where it was issued).
In a letter for a service animal, also indicate that your patient is psychiatrically disabled to the extent that your patient is not able to perform at least one major life task without the daily assistance of a service animal.2Should you write your patient a letter?
Writing a letter advocating for a patient to have a service animal or ESA may appear innocuous, but doing so may have serious ramifications. Writing a letter certifying a dog as a service animal does not make that animal a service animal; the dog must be specifically trained for a task or tasks directly related to that individual’s disability. There are no current standards for conducting evaluations to determine the need a patient has for a service animal or ESA. How to conduct such evaluations is beyond the scope of this article. There are meager opportunities for formal education and training on how to conduct these evaluations.9 Online resources may be incomplete or inaccurate, and this information is often produced by lay animal enthusiasts and organizations, which can lead to a biased depiction of these animals.9
If you decide to write a letter for your patient, consider the following forensic and ethical concerns.
Remain objective. As an advocate for your patient, you may find it difficult to remain neutral and objective when asked to determine if your patient has a disability, the severity of the disability, the impact of the disability on your patient’s life, and the need for a service animal or ESA. Ensure that your advocacy for your patient does not impair your objectivity; if that is difficult, consider referring your patient to a third party who can conduct an objective evaluation.
Understand the risks. If you make written recommendations for special accommodations in a letter and those recommendations are disputed by an agency, that agency could initiate legal action and you may be called to justify your recommendations in a deposition or open court.9,21 Before writing the letter, ask yourself, “Can I defend my determination that my patient is disabled by a DSM-5 disorder and that this disability requires the presence of an animal in exception to existing policy?”21 Be prepared to state in a legal proceeding that the presence of a service animal or ESA is necessary. If you are unwilling to risk exposure to a legal action, then you should likely refrain from writing the letter. It is a crime to fraudulently certify an animal as a service animal in some jurisdictions, and such conduct could result in disciplinary action by your licensing board.21
Conduct a systematic examination. When you write a letter for your patient, you are explicitly declaring your patient has a disability or condition. Comprehensive disability determinations are complex and are best conducted by assessing for objective evidence of psychiatric disorders and impairment through the use of standard, systematic examination methods.22 Unstandardized measures (eg, asking patients open-ended questions and then relying on your clinical judgement and interpretation in arriving at conclusions) are not as effective.22 In addition, consider the possibility that your patient may malinger their symptoms in an effort to obtain a letter supporting a service animal or ESA. Assessing for malingering is essential to making a disability determination, especially if a disability claim is based primarily on self-report.22
Anticipate pushback. Problems can arise when a patient wants a letter that you cannot or will not provide due to your scope of practice. Consider how you would resolve the situation when you do not believe your patient has a disability that requires the presence of a service animal or ESA—or you believe that your patient no longer needs a service animal or ESA—and the patient disagrees.21 Disagreeing with your patient’s assessment could result in a conflict of interest that could damage the therapeutic relationship.21
Box 2
The Americans with Disabilities Act (ADA) of 1990, as amended by the ADA Amendments Act of 2008, prohibits discrimination on the basis of disability in several areas, including state and local governments (under Title II of the ADA) and places of public accommodations, commercial facilities, and private entities (under Title III of the ADA).6,7 Thus, individuals with disabilities can bring their service animals into the building or facility where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs not open to the public, religious organizations, or places of worship.6,7
Service animals. Although the ADA recognizes miniature horses as service animals, only dogs are recognized as service animals in regards to Title II and Title III protections under the ADA as of March 15, 2011.2 Federal agencies do not have to comply with the ADA1; however, Section 504 of the Rehabilitation Act of 1973 is the federal law that protects the rights of people with disabilities to participate in federal programs and services.1,8 It states that no qualified individual with a disability shall be excluded from, denied the benefits of, or be subjected to discrimination under any program or activity that receives federal funding or is conducted by federal agencies.8 Courts have strived to interpret the Rehabilitation Act and the ADA in a consistent manner, specifically applying the ADA regulations regarding service animals (including its narrow definition regarding specifically trained tasks and emotional support) to the Rehabilitation Act.9-11
Similarly, commercial airlines do not have to comply with the ADA1 ; however, the Air Carrier Access Act (ACAA) of 1986 is the federal law that protects the rights of people with disabilities in air travel.1,12 On December 2, 2020, the US Department of Transportation announced that it was revising its ACAA regulation regarding service animals on aircraft (this final rule will be effective 30 days after date of publication in the Federal Register).13 Among the many revisions, the US Department of Transportation narrowed the definition of service animals to only dogs that were individually trained to work or perform tasks for the benefits of a person with a disability.13 It requires airlines to treat psychiatric service animals the same as other service animals.13 Although the US Department of Transportation has chosen to closely align its ACAA service animal definition with US Department of Justice service animal definition under the ADA, the substantive requirements in this final rule differ from US Department of Justice’s requirements for service animals under the ADA in various areas (for example, by allowing airlines to require service animal documentation and prohibiting the use of voice control over a service animal).13
Emotional support animals. Regulations regarding ESAs are primarily set by individual states1,3; however, ESAs may qualify for a waiver of a no-pet rule or a pet deposit under the Fair Housing Amendments Act (FHAA) of 1988.2,14 Under the FHAA, if an individual has a disability, as defined by the ADA, that requires the presence of an ESA, or if they have symptoms that are ameliorated by the presence of an ESA, the landlord must comply with this request and allow the animal into the facility without charging pet fees.15
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 doing so.
Related Resources
- US Department of Justice. Civil Rights Division. Disability Rights Section. ADA requirements. Service animals. Updated February 24, 2020. https://www.ada.gov/service_ animals_2010.htm
American Veterinary Medical Association. Service, emotional support and therapy animals. https://www. avma.org/resources-tools/animal-health-welfare/ service-emotional-support-and-therapy-animals
US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. https://www.transportation.gov/briefingroom/us-department-transportation-announces-finalrule-traveling-air-service-animals
1. US Department of Justice. Frequently asked questions about service animals and the ADA. Published July 20, 2015. Accessed on July 28, 2021. https://www.ada.gov/regs2010/service_animal_qa.pdf
2. ADA National Network. Service animals and emotional support animals: where are they allowed and under what conditions? Published 2014. Accessed July 28, 2021. https://adata.org/sites/adata.org/files/files/Service_Animal_Booklet_2014(2).pdf
3. Huben-Kearney A. What to do if patients want service or emotional support animals. Psychiatric News. Published September 28, 2020. Accessed July 28, 2021. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.10a24
4. Fine AH. The role of therapy and service animals in the lives of persons with disabilities. Rev Sci Tech. 2018;37(1):141-149.
5. Wlodarczyk J. When pigs fly: emotional support animals, service dogs and the politics of legitimacy across species boundaries. Med Humanit. 2019;45(1):82-91.
6. Americans with Disabilities Act of 1990. Pub L. 101-336, 104 Stat. 327.
7. ADA Amendments Act of 2008. Pub L. 110-325.
8. Rehabilitation Act of 1973. Pub L. 93-112, 87 Stat 355.
9. Carroll JD, Mohlenhoff BS, Kersten CM, et al. Laws and ethics related to emotional support animals. J Am Acad Psychiatry Law. 2020;48(4):509-518.
10. Sanchez v US Dept of Energy. 870 F3d 1185 (10th Circuit 2017).
11. Berardelli v Allied Services Inst. of Rehab. Med., 900 F3d 104 (3rd Circuit 2018).
12. Air Carrier Access Act of 1986. 49 USC §41705.
13. US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. Published December 2, 2020. Accessed July 28, 2021. https://www.transportation.gov/briefing-room/us-department-transportation-announces-final-rule-traveling-air-service-animals
14. Fair Housing Amendments Act of 1988. Pub. L. 100-430. https://www.govinfo.gov/content/pkg/STATUTE-102/pdf/STATUTE-102-Pg1619.pdf
15. Boness CL, Younggren JN, Frumkin IB. The certification of emotional support animals: difference between clinical and forensic mental health practitioners. Professional Psychology: Research and Practice. 2017;48(3):216-223.
16. Lane DR, McNicholas J, Collis GM. Dogs for the disabled: benefits to recipients and welfare of the dog. Applied Animal Behaviour Science. 1998;59(1-3):49-60.
17. Hall SS, MacMichael J, Turner A, et al. A survey of the impact of owning a service dog on quality of life for individuals with physical and hearing disability: a pilot study. Health Qual Life Outcomes. 2017;15(1):59. doi:10.1186/s12955-017-0640-x
18. Brooks HL, Rushton K, Lovell K, et al. The power of support from companion animals for people living with mental health problems: a systematic review and narrative synthesis of the evidence. BMC Psychiatry. 2018;18(1):31. doi: 10.1186/s12888-018-1613-2
19. US National Library of Medicine: ClinicalTrials.gov. Can service dogs improve activity and quality of life in veterans with PTSD? (SDPTSD). Updated August 15, 2019. Accessed October 14, 2021. https://clinicaltrials.gov/ct2/show/study/NCT02039843
20. Clay RA. Is that a pet or therapeutic aid? American Psychological Association. 2016;47(8):38. https://www.apa.org/monitor/2016/09/pet-aid
21. Younggren JN, Boisvert JA, Boness CL. Examining emotional support animals and role conflicts in professional psychology. Prof Psychol Res Pr. 2016;47(4):255-260.
22. Gold LH, Anfang SA, Drukteinis AM, et al. AAPL practice guideline for the forensic evaluation of psychiatric disability. J Am Acad Psychiatry Law. 2008;36(4 Suppl):S3-S50. https://www.aapl.org/docs/pdf/Evaluation%20of%20Psychiatric%20Disability.pdf
For centuries, animals, especially dogs, have assisted humans in a variety of ways in their daily lives. Animals that assist people with disabilities fall into 2 broad categories: disability service animals, and emotional support animals (ESAs). Often there is confusion in how these categories differ because of the animal’s role and the laws related to them.
This article describes the differences between disability service animals and ESAs, and outlines the forensic and ethical 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 service animal or ESA in situations where laws and regulations typically prohibit animals, such as on a flight or when renting an apartment or house. Note that a description of how to conduct the formal patient evaluation before writing a verification letter is beyond the scope of this article.
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 individual with a disability (physical, sensory, psychiatric, intellectual, or other mental disability).1-3 These tasks must be directly related to the individual’s disability.1,2 On the other hand, ESAs, which can be any species of animal, provide support and minimize the impact of an individual’s emotional or psychological disability based on their presence alone. Unlike disability service animals, ESAs are not trained to perform a specific task or duty.2,3
There is no legal requirement for service animals to know specific commands, and professional training is not required—individuals can train the animals themselves.1 Service animals, mainly dogs, can be trained to perform numerous tasks, including4:
- attending to an individual’s mobility and activities of daily living
- guiding an individual who is deaf or hearing impaired
- helping to remind an individual to take their medications
- assisting an individual during and/or after a seizure
- alerting individuals with diabetes in advance of low or high blood sugar episodes
- supporting an individual with autism
- assisting an individual with a psychiatric or mental disability
- applying sensory commands such as lying on the person or resting their head on the individual’s lap to help the individual regain behavioral control.
Service dog verification works via an honor system, which can be problematic, especially in the case of psychiatric service dogs, whose handlers may not have a visible disability (Box 11,5).
Box 1
In the United States, there is no national service dog certification program—meaning there is no official test that a dog has to pass in order to obtain formal recognition as a service animal—nor is there a central and mandatory service dog registry.5 Instead, service dog verification works through an honor system, which can be problematic.5 In many states, misrepresenting one’s dog as a service dog is considered a misdemeanor.5 Unfortunately, other than the guidance set forth by the Americans with Disabilities Act, there are no criteria by which one can recognize a genuine service dog vs one being passed off as a service dog.5
In situations in public settings where it is not obvious or there’s doubt that the dog is a service animal (such as when a person visits a restaurant or store), employees are not allowed to request documentation for the dog, require the dog demonstrate its task, or inquire about the nature of the person’s disability.1
However, they can ask 2 questions1:
1. Is the animal required because of a disability?
2. What work or task has the animal been trained to perform?
Legal protections. Under the Americans with Disabilities Act (ADA), individuals with disabilities can bring their service animals into buildings or facilities where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs, religious organizations, or places of worship that are not open to the public.6,7 ESAs do not qualify as service animals under the ADA and are not given the same legal accommodations as service animals.1,3 Although ESAs were initially covered by the Air Carrier Access Act, they are no longer allowed in aircraft cabins after the US Department of Transportation revised this Act’s regulations in December 2020. ESAs are covered under the Fair Housing Act. Box 21-3,6-15 further discusses these laws and protections.
Evidence.
Due to the difficulty in reconciling inconsistent definitions for ESAs, there is limited high-quality data pertaining to the potential benefits and risks of ESAs.9 Currently, ESAs are not an evidence-based treatment for psychiatric disorders. To date, a handful of small studies have focused on ESAs. However, data from actual tests of the clinical risks and benefits of ESAs do not exist.9 In practice, ESAs are equivalent to pets. It stands to reason that similar to pets, ESAs could reduce loneliness, improve life satisfaction, and provide a sense of well-being.9 A systematic review suggested that pets provide benefits to patients with mental health conditions “through the intensity of connectivity with their owners and the contribution they make to emotional support in times of crises together with their ability to help manage symptoms when they arise.”18 In response to a congressional mandate, the US Department of Veterans Affairs launched a multi-site study from December 2014 to June 2019 to examine how limitations on activity and quality of life in veterans with posttraumatic stress disorder are impacted by the provision of a service dog vs an emotional support dog.19 As of October 14, 2021, results had not been published.19
Continue to: What’s in a disability service animal/ESA letter?
What’s in a disability service animal/ESA letter?
If you decide to write a letter advocating for your patient to have a service animal or ESA, the letter should appear on letterhead, be written by a licensed mental health professional, and include the following2,20:
- statement that the letter is being written at the patient’s request and is being given directly to the patient for use as the patient sees fit
- confirmation of the patient’s DSM-5 mental health diagnosis
- explanation of how the animal helps alleviate symptoms of the patient’s condition, briefly describing any interaction(s) between the animal and patient that you may have observed, and if applicable, a mention of any training the animal may have received from a qualified trainer if applicable
- explanation of the possible negative effects of the patient not having the animal with him or her
- statement that you are not vouching for the animal’s behavior
- verification of your involvement in your patient’s treatment and your assessment of the patient as their licensed mental health professional (including details such as date and type of license you have and the state/other jurisdiction where it was issued).
In a letter for a service animal, also indicate that your patient is psychiatrically disabled to the extent that your patient is not able to perform at least one major life task without the daily assistance of a service animal.2Should you write your patient a letter?
Writing a letter advocating for a patient to have a service animal or ESA may appear innocuous, but doing so may have serious ramifications. Writing a letter certifying a dog as a service animal does not make that animal a service animal; the dog must be specifically trained for a task or tasks directly related to that individual’s disability. There are no current standards for conducting evaluations to determine the need a patient has for a service animal or ESA. How to conduct such evaluations is beyond the scope of this article. There are meager opportunities for formal education and training on how to conduct these evaluations.9 Online resources may be incomplete or inaccurate, and this information is often produced by lay animal enthusiasts and organizations, which can lead to a biased depiction of these animals.9
If you decide to write a letter for your patient, consider the following forensic and ethical concerns.
Remain objective. As an advocate for your patient, you may find it difficult to remain neutral and objective when asked to determine if your patient has a disability, the severity of the disability, the impact of the disability on your patient’s life, and the need for a service animal or ESA. Ensure that your advocacy for your patient does not impair your objectivity; if that is difficult, consider referring your patient to a third party who can conduct an objective evaluation.
Understand the risks. If you make written recommendations for special accommodations in a letter and those recommendations are disputed by an agency, that agency could initiate legal action and you may be called to justify your recommendations in a deposition or open court.9,21 Before writing the letter, ask yourself, “Can I defend my determination that my patient is disabled by a DSM-5 disorder and that this disability requires the presence of an animal in exception to existing policy?”21 Be prepared to state in a legal proceeding that the presence of a service animal or ESA is necessary. If you are unwilling to risk exposure to a legal action, then you should likely refrain from writing the letter. It is a crime to fraudulently certify an animal as a service animal in some jurisdictions, and such conduct could result in disciplinary action by your licensing board.21
Conduct a systematic examination. When you write a letter for your patient, you are explicitly declaring your patient has a disability or condition. Comprehensive disability determinations are complex and are best conducted by assessing for objective evidence of psychiatric disorders and impairment through the use of standard, systematic examination methods.22 Unstandardized measures (eg, asking patients open-ended questions and then relying on your clinical judgement and interpretation in arriving at conclusions) are not as effective.22 In addition, consider the possibility that your patient may malinger their symptoms in an effort to obtain a letter supporting a service animal or ESA. Assessing for malingering is essential to making a disability determination, especially if a disability claim is based primarily on self-report.22
Anticipate pushback. Problems can arise when a patient wants a letter that you cannot or will not provide due to your scope of practice. Consider how you would resolve the situation when you do not believe your patient has a disability that requires the presence of a service animal or ESA—or you believe that your patient no longer needs a service animal or ESA—and the patient disagrees.21 Disagreeing with your patient’s assessment could result in a conflict of interest that could damage the therapeutic relationship.21
Box 2
The Americans with Disabilities Act (ADA) of 1990, as amended by the ADA Amendments Act of 2008, prohibits discrimination on the basis of disability in several areas, including state and local governments (under Title II of the ADA) and places of public accommodations, commercial facilities, and private entities (under Title III of the ADA).6,7 Thus, individuals with disabilities can bring their service animals into the building or facility where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs not open to the public, religious organizations, or places of worship.6,7
Service animals. Although the ADA recognizes miniature horses as service animals, only dogs are recognized as service animals in regards to Title II and Title III protections under the ADA as of March 15, 2011.2 Federal agencies do not have to comply with the ADA1; however, Section 504 of the Rehabilitation Act of 1973 is the federal law that protects the rights of people with disabilities to participate in federal programs and services.1,8 It states that no qualified individual with a disability shall be excluded from, denied the benefits of, or be subjected to discrimination under any program or activity that receives federal funding or is conducted by federal agencies.8 Courts have strived to interpret the Rehabilitation Act and the ADA in a consistent manner, specifically applying the ADA regulations regarding service animals (including its narrow definition regarding specifically trained tasks and emotional support) to the Rehabilitation Act.9-11
Similarly, commercial airlines do not have to comply with the ADA1 ; however, the Air Carrier Access Act (ACAA) of 1986 is the federal law that protects the rights of people with disabilities in air travel.1,12 On December 2, 2020, the US Department of Transportation announced that it was revising its ACAA regulation regarding service animals on aircraft (this final rule will be effective 30 days after date of publication in the Federal Register).13 Among the many revisions, the US Department of Transportation narrowed the definition of service animals to only dogs that were individually trained to work or perform tasks for the benefits of a person with a disability.13 It requires airlines to treat psychiatric service animals the same as other service animals.13 Although the US Department of Transportation has chosen to closely align its ACAA service animal definition with US Department of Justice service animal definition under the ADA, the substantive requirements in this final rule differ from US Department of Justice’s requirements for service animals under the ADA in various areas (for example, by allowing airlines to require service animal documentation and prohibiting the use of voice control over a service animal).13
Emotional support animals. Regulations regarding ESAs are primarily set by individual states1,3; however, ESAs may qualify for a waiver of a no-pet rule or a pet deposit under the Fair Housing Amendments Act (FHAA) of 1988.2,14 Under the FHAA, if an individual has a disability, as defined by the ADA, that requires the presence of an ESA, or if they have symptoms that are ameliorated by the presence of an ESA, the landlord must comply with this request and allow the animal into the facility without charging pet fees.15
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 doing so.
Related Resources
- US Department of Justice. Civil Rights Division. Disability Rights Section. ADA requirements. Service animals. Updated February 24, 2020. https://www.ada.gov/service_ animals_2010.htm
American Veterinary Medical Association. Service, emotional support and therapy animals. https://www. avma.org/resources-tools/animal-health-welfare/ service-emotional-support-and-therapy-animals
US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. https://www.transportation.gov/briefingroom/us-department-transportation-announces-finalrule-traveling-air-service-animals
For centuries, animals, especially dogs, have assisted humans in a variety of ways in their daily lives. Animals that assist people with disabilities fall into 2 broad categories: disability service animals, and emotional support animals (ESAs). Often there is confusion in how these categories differ because of the animal’s role and the laws related to them.
This article describes the differences between disability service animals and ESAs, and outlines the forensic and ethical 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 service animal or ESA in situations where laws and regulations typically prohibit animals, such as on a flight or when renting an apartment or house. Note that a description of how to conduct the formal patient evaluation before writing a verification letter is beyond the scope of this article.
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 individual with a disability (physical, sensory, psychiatric, intellectual, or other mental disability).1-3 These tasks must be directly related to the individual’s disability.1,2 On the other hand, ESAs, which can be any species of animal, provide support and minimize the impact of an individual’s emotional or psychological disability based on their presence alone. Unlike disability service animals, ESAs are not trained to perform a specific task or duty.2,3
There is no legal requirement for service animals to know specific commands, and professional training is not required—individuals can train the animals themselves.1 Service animals, mainly dogs, can be trained to perform numerous tasks, including4:
- attending to an individual’s mobility and activities of daily living
- guiding an individual who is deaf or hearing impaired
- helping to remind an individual to take their medications
- assisting an individual during and/or after a seizure
- alerting individuals with diabetes in advance of low or high blood sugar episodes
- supporting an individual with autism
- assisting an individual with a psychiatric or mental disability
- applying sensory commands such as lying on the person or resting their head on the individual’s lap to help the individual regain behavioral control.
Service dog verification works via an honor system, which can be problematic, especially in the case of psychiatric service dogs, whose handlers may not have a visible disability (Box 11,5).
Box 1
In the United States, there is no national service dog certification program—meaning there is no official test that a dog has to pass in order to obtain formal recognition as a service animal—nor is there a central and mandatory service dog registry.5 Instead, service dog verification works through an honor system, which can be problematic.5 In many states, misrepresenting one’s dog as a service dog is considered a misdemeanor.5 Unfortunately, other than the guidance set forth by the Americans with Disabilities Act, there are no criteria by which one can recognize a genuine service dog vs one being passed off as a service dog.5
In situations in public settings where it is not obvious or there’s doubt that the dog is a service animal (such as when a person visits a restaurant or store), employees are not allowed to request documentation for the dog, require the dog demonstrate its task, or inquire about the nature of the person’s disability.1
However, they can ask 2 questions1:
1. Is the animal required because of a disability?
2. What work or task has the animal been trained to perform?
Legal protections. Under the Americans with Disabilities Act (ADA), individuals with disabilities can bring their service animals into buildings or facilities where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs, religious organizations, or places of worship that are not open to the public.6,7 ESAs do not qualify as service animals under the ADA and are not given the same legal accommodations as service animals.1,3 Although ESAs were initially covered by the Air Carrier Access Act, they are no longer allowed in aircraft cabins after the US Department of Transportation revised this Act’s regulations in December 2020. ESAs are covered under the Fair Housing Act. Box 21-3,6-15 further discusses these laws and protections.
Evidence.
Due to the difficulty in reconciling inconsistent definitions for ESAs, there is limited high-quality data pertaining to the potential benefits and risks of ESAs.9 Currently, ESAs are not an evidence-based treatment for psychiatric disorders. To date, a handful of small studies have focused on ESAs. However, data from actual tests of the clinical risks and benefits of ESAs do not exist.9 In practice, ESAs are equivalent to pets. It stands to reason that similar to pets, ESAs could reduce loneliness, improve life satisfaction, and provide a sense of well-being.9 A systematic review suggested that pets provide benefits to patients with mental health conditions “through the intensity of connectivity with their owners and the contribution they make to emotional support in times of crises together with their ability to help manage symptoms when they arise.”18 In response to a congressional mandate, the US Department of Veterans Affairs launched a multi-site study from December 2014 to June 2019 to examine how limitations on activity and quality of life in veterans with posttraumatic stress disorder are impacted by the provision of a service dog vs an emotional support dog.19 As of October 14, 2021, results had not been published.19
Continue to: What’s in a disability service animal/ESA letter?
What’s in a disability service animal/ESA letter?
If you decide to write a letter advocating for your patient to have a service animal or ESA, the letter should appear on letterhead, be written by a licensed mental health professional, and include the following2,20:
- statement that the letter is being written at the patient’s request and is being given directly to the patient for use as the patient sees fit
- confirmation of the patient’s DSM-5 mental health diagnosis
- explanation of how the animal helps alleviate symptoms of the patient’s condition, briefly describing any interaction(s) between the animal and patient that you may have observed, and if applicable, a mention of any training the animal may have received from a qualified trainer if applicable
- explanation of the possible negative effects of the patient not having the animal with him or her
- statement that you are not vouching for the animal’s behavior
- verification of your involvement in your patient’s treatment and your assessment of the patient as their licensed mental health professional (including details such as date and type of license you have and the state/other jurisdiction where it was issued).
In a letter for a service animal, also indicate that your patient is psychiatrically disabled to the extent that your patient is not able to perform at least one major life task without the daily assistance of a service animal.2Should you write your patient a letter?
Writing a letter advocating for a patient to have a service animal or ESA may appear innocuous, but doing so may have serious ramifications. Writing a letter certifying a dog as a service animal does not make that animal a service animal; the dog must be specifically trained for a task or tasks directly related to that individual’s disability. There are no current standards for conducting evaluations to determine the need a patient has for a service animal or ESA. How to conduct such evaluations is beyond the scope of this article. There are meager opportunities for formal education and training on how to conduct these evaluations.9 Online resources may be incomplete or inaccurate, and this information is often produced by lay animal enthusiasts and organizations, which can lead to a biased depiction of these animals.9
If you decide to write a letter for your patient, consider the following forensic and ethical concerns.
Remain objective. As an advocate for your patient, you may find it difficult to remain neutral and objective when asked to determine if your patient has a disability, the severity of the disability, the impact of the disability on your patient’s life, and the need for a service animal or ESA. Ensure that your advocacy for your patient does not impair your objectivity; if that is difficult, consider referring your patient to a third party who can conduct an objective evaluation.
Understand the risks. If you make written recommendations for special accommodations in a letter and those recommendations are disputed by an agency, that agency could initiate legal action and you may be called to justify your recommendations in a deposition or open court.9,21 Before writing the letter, ask yourself, “Can I defend my determination that my patient is disabled by a DSM-5 disorder and that this disability requires the presence of an animal in exception to existing policy?”21 Be prepared to state in a legal proceeding that the presence of a service animal or ESA is necessary. If you are unwilling to risk exposure to a legal action, then you should likely refrain from writing the letter. It is a crime to fraudulently certify an animal as a service animal in some jurisdictions, and such conduct could result in disciplinary action by your licensing board.21
Conduct a systematic examination. When you write a letter for your patient, you are explicitly declaring your patient has a disability or condition. Comprehensive disability determinations are complex and are best conducted by assessing for objective evidence of psychiatric disorders and impairment through the use of standard, systematic examination methods.22 Unstandardized measures (eg, asking patients open-ended questions and then relying on your clinical judgement and interpretation in arriving at conclusions) are not as effective.22 In addition, consider the possibility that your patient may malinger their symptoms in an effort to obtain a letter supporting a service animal or ESA. Assessing for malingering is essential to making a disability determination, especially if a disability claim is based primarily on self-report.22
Anticipate pushback. Problems can arise when a patient wants a letter that you cannot or will not provide due to your scope of practice. Consider how you would resolve the situation when you do not believe your patient has a disability that requires the presence of a service animal or ESA—or you believe that your patient no longer needs a service animal or ESA—and the patient disagrees.21 Disagreeing with your patient’s assessment could result in a conflict of interest that could damage the therapeutic relationship.21
Box 2
The Americans with Disabilities Act (ADA) of 1990, as amended by the ADA Amendments Act of 2008, prohibits discrimination on the basis of disability in several areas, including state and local governments (under Title II of the ADA) and places of public accommodations, commercial facilities, and private entities (under Title III of the ADA).6,7 Thus, individuals with disabilities can bring their service animals into the building or facility where members of the public, program participants, clients, customers, patrons, or invitees are allowed.2 This does not include private clubs not open to the public, religious organizations, or places of worship.6,7
Service animals. Although the ADA recognizes miniature horses as service animals, only dogs are recognized as service animals in regards to Title II and Title III protections under the ADA as of March 15, 2011.2 Federal agencies do not have to comply with the ADA1; however, Section 504 of the Rehabilitation Act of 1973 is the federal law that protects the rights of people with disabilities to participate in federal programs and services.1,8 It states that no qualified individual with a disability shall be excluded from, denied the benefits of, or be subjected to discrimination under any program or activity that receives federal funding or is conducted by federal agencies.8 Courts have strived to interpret the Rehabilitation Act and the ADA in a consistent manner, specifically applying the ADA regulations regarding service animals (including its narrow definition regarding specifically trained tasks and emotional support) to the Rehabilitation Act.9-11
Similarly, commercial airlines do not have to comply with the ADA1 ; however, the Air Carrier Access Act (ACAA) of 1986 is the federal law that protects the rights of people with disabilities in air travel.1,12 On December 2, 2020, the US Department of Transportation announced that it was revising its ACAA regulation regarding service animals on aircraft (this final rule will be effective 30 days after date of publication in the Federal Register).13 Among the many revisions, the US Department of Transportation narrowed the definition of service animals to only dogs that were individually trained to work or perform tasks for the benefits of a person with a disability.13 It requires airlines to treat psychiatric service animals the same as other service animals.13 Although the US Department of Transportation has chosen to closely align its ACAA service animal definition with US Department of Justice service animal definition under the ADA, the substantive requirements in this final rule differ from US Department of Justice’s requirements for service animals under the ADA in various areas (for example, by allowing airlines to require service animal documentation and prohibiting the use of voice control over a service animal).13
Emotional support animals. Regulations regarding ESAs are primarily set by individual states1,3; however, ESAs may qualify for a waiver of a no-pet rule or a pet deposit under the Fair Housing Amendments Act (FHAA) of 1988.2,14 Under the FHAA, if an individual has a disability, as defined by the ADA, that requires the presence of an ESA, or if they have symptoms that are ameliorated by the presence of an ESA, the landlord must comply with this request and allow the animal into the facility without charging pet fees.15
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 doing so.
Related Resources
- US Department of Justice. Civil Rights Division. Disability Rights Section. ADA requirements. Service animals. Updated February 24, 2020. https://www.ada.gov/service_ animals_2010.htm
American Veterinary Medical Association. Service, emotional support and therapy animals. https://www. avma.org/resources-tools/animal-health-welfare/ service-emotional-support-and-therapy-animals
US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. https://www.transportation.gov/briefingroom/us-department-transportation-announces-finalrule-traveling-air-service-animals
1. US Department of Justice. Frequently asked questions about service animals and the ADA. Published July 20, 2015. Accessed on July 28, 2021. https://www.ada.gov/regs2010/service_animal_qa.pdf
2. ADA National Network. Service animals and emotional support animals: where are they allowed and under what conditions? Published 2014. Accessed July 28, 2021. https://adata.org/sites/adata.org/files/files/Service_Animal_Booklet_2014(2).pdf
3. Huben-Kearney A. What to do if patients want service or emotional support animals. Psychiatric News. Published September 28, 2020. Accessed July 28, 2021. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.10a24
4. Fine AH. The role of therapy and service animals in the lives of persons with disabilities. Rev Sci Tech. 2018;37(1):141-149.
5. Wlodarczyk J. When pigs fly: emotional support animals, service dogs and the politics of legitimacy across species boundaries. Med Humanit. 2019;45(1):82-91.
6. Americans with Disabilities Act of 1990. Pub L. 101-336, 104 Stat. 327.
7. ADA Amendments Act of 2008. Pub L. 110-325.
8. Rehabilitation Act of 1973. Pub L. 93-112, 87 Stat 355.
9. Carroll JD, Mohlenhoff BS, Kersten CM, et al. Laws and ethics related to emotional support animals. J Am Acad Psychiatry Law. 2020;48(4):509-518.
10. Sanchez v US Dept of Energy. 870 F3d 1185 (10th Circuit 2017).
11. Berardelli v Allied Services Inst. of Rehab. Med., 900 F3d 104 (3rd Circuit 2018).
12. Air Carrier Access Act of 1986. 49 USC §41705.
13. US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. Published December 2, 2020. Accessed July 28, 2021. https://www.transportation.gov/briefing-room/us-department-transportation-announces-final-rule-traveling-air-service-animals
14. Fair Housing Amendments Act of 1988. Pub. L. 100-430. https://www.govinfo.gov/content/pkg/STATUTE-102/pdf/STATUTE-102-Pg1619.pdf
15. Boness CL, Younggren JN, Frumkin IB. The certification of emotional support animals: difference between clinical and forensic mental health practitioners. Professional Psychology: Research and Practice. 2017;48(3):216-223.
16. Lane DR, McNicholas J, Collis GM. Dogs for the disabled: benefits to recipients and welfare of the dog. Applied Animal Behaviour Science. 1998;59(1-3):49-60.
17. Hall SS, MacMichael J, Turner A, et al. A survey of the impact of owning a service dog on quality of life for individuals with physical and hearing disability: a pilot study. Health Qual Life Outcomes. 2017;15(1):59. doi:10.1186/s12955-017-0640-x
18. Brooks HL, Rushton K, Lovell K, et al. The power of support from companion animals for people living with mental health problems: a systematic review and narrative synthesis of the evidence. BMC Psychiatry. 2018;18(1):31. doi: 10.1186/s12888-018-1613-2
19. US National Library of Medicine: ClinicalTrials.gov. Can service dogs improve activity and quality of life in veterans with PTSD? (SDPTSD). Updated August 15, 2019. Accessed October 14, 2021. https://clinicaltrials.gov/ct2/show/study/NCT02039843
20. Clay RA. Is that a pet or therapeutic aid? American Psychological Association. 2016;47(8):38. https://www.apa.org/monitor/2016/09/pet-aid
21. Younggren JN, Boisvert JA, Boness CL. Examining emotional support animals and role conflicts in professional psychology. Prof Psychol Res Pr. 2016;47(4):255-260.
22. Gold LH, Anfang SA, Drukteinis AM, et al. AAPL practice guideline for the forensic evaluation of psychiatric disability. J Am Acad Psychiatry Law. 2008;36(4 Suppl):S3-S50. https://www.aapl.org/docs/pdf/Evaluation%20of%20Psychiatric%20Disability.pdf
1. US Department of Justice. Frequently asked questions about service animals and the ADA. Published July 20, 2015. Accessed on July 28, 2021. https://www.ada.gov/regs2010/service_animal_qa.pdf
2. ADA National Network. Service animals and emotional support animals: where are they allowed and under what conditions? Published 2014. Accessed July 28, 2021. https://adata.org/sites/adata.org/files/files/Service_Animal_Booklet_2014(2).pdf
3. Huben-Kearney A. What to do if patients want service or emotional support animals. Psychiatric News. Published September 28, 2020. Accessed July 28, 2021. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.10a24
4. Fine AH. The role of therapy and service animals in the lives of persons with disabilities. Rev Sci Tech. 2018;37(1):141-149.
5. Wlodarczyk J. When pigs fly: emotional support animals, service dogs and the politics of legitimacy across species boundaries. Med Humanit. 2019;45(1):82-91.
6. Americans with Disabilities Act of 1990. Pub L. 101-336, 104 Stat. 327.
7. ADA Amendments Act of 2008. Pub L. 110-325.
8. Rehabilitation Act of 1973. Pub L. 93-112, 87 Stat 355.
9. Carroll JD, Mohlenhoff BS, Kersten CM, et al. Laws and ethics related to emotional support animals. J Am Acad Psychiatry Law. 2020;48(4):509-518.
10. Sanchez v US Dept of Energy. 870 F3d 1185 (10th Circuit 2017).
11. Berardelli v Allied Services Inst. of Rehab. Med., 900 F3d 104 (3rd Circuit 2018).
12. Air Carrier Access Act of 1986. 49 USC §41705.
13. US Department of Transportation. US Department of Transportation announces final rule on traveling by air with service animals. Published December 2, 2020. Accessed July 28, 2021. https://www.transportation.gov/briefing-room/us-department-transportation-announces-final-rule-traveling-air-service-animals
14. Fair Housing Amendments Act of 1988. Pub. L. 100-430. https://www.govinfo.gov/content/pkg/STATUTE-102/pdf/STATUTE-102-Pg1619.pdf
15. Boness CL, Younggren JN, Frumkin IB. The certification of emotional support animals: difference between clinical and forensic mental health practitioners. Professional Psychology: Research and Practice. 2017;48(3):216-223.
16. Lane DR, McNicholas J, Collis GM. Dogs for the disabled: benefits to recipients and welfare of the dog. Applied Animal Behaviour Science. 1998;59(1-3):49-60.
17. Hall SS, MacMichael J, Turner A, et al. A survey of the impact of owning a service dog on quality of life for individuals with physical and hearing disability: a pilot study. Health Qual Life Outcomes. 2017;15(1):59. doi:10.1186/s12955-017-0640-x
18. Brooks HL, Rushton K, Lovell K, et al. The power of support from companion animals for people living with mental health problems: a systematic review and narrative synthesis of the evidence. BMC Psychiatry. 2018;18(1):31. doi: 10.1186/s12888-018-1613-2
19. US National Library of Medicine: ClinicalTrials.gov. Can service dogs improve activity and quality of life in veterans with PTSD? (SDPTSD). Updated August 15, 2019. Accessed October 14, 2021. https://clinicaltrials.gov/ct2/show/study/NCT02039843
20. Clay RA. Is that a pet or therapeutic aid? American Psychological Association. 2016;47(8):38. https://www.apa.org/monitor/2016/09/pet-aid
21. Younggren JN, Boisvert JA, Boness CL. Examining emotional support animals and role conflicts in professional psychology. Prof Psychol Res Pr. 2016;47(4):255-260.
22. Gold LH, Anfang SA, Drukteinis AM, et al. AAPL practice guideline for the forensic evaluation of psychiatric disability. J Am Acad Psychiatry Law. 2008;36(4 Suppl):S3-S50. https://www.aapl.org/docs/pdf/Evaluation%20of%20Psychiatric%20Disability.pdf
