Am Fam Physician. 2020;101(5):302-304
Author disclosure: No relevant financial affiliations.
Case Scenario
A 43-year-old established patient with a history of anxiety requests a letter from her primary care physician to designate her two-year-old, spayed female Labrador retriever mix, adopted from a shelter three months ago, as an emotional support animal. She states that she needs this certification for her dog to accompany her on flights to alleviate her fear of flying. She states she has difficulties meeting with a therapist because of her irregular work schedule.
What steps should physicians take to evaluate and, if appropriate, to provide documentation for a patient's emotional support animal? How does an emotional support animal fit into a patient's therapeutic plan?
Commentary
Companion animals are increasingly viewed as part of the family, and studies show many mental and physical benefits of pet ownership.1 Federal regulations require patients to obtain health care professional documentation for emotional support animals to allow these animals to accompany the owner on air travel or to live in housing that might otherwise restrict pets.2,3 No professional practice guidelines are currently available to guide health care professionals responding to patient requests for emotional support animal documentation.4
Before documenting an emotional support animal as part of a patient's treatment plan, physicians should understand the differences between emotional support animals, service animals, and therapy animals (Table 15); know the potential risks and benefits of emotional support animals; and develop a consistent approach to providing documentation about such animals.
| Emotional support animal | Therapy animal | Service animal | |
|---|---|---|---|
| Access | Housing: allowed even if pets are restricted; landlords cannot charge tenants animal deposit fee Airline travel (Air Carrier Access Act refers to emotional support animals as service animals) No other public access | Only where specifically welcome or invited | All areas where the public is allowed |
| Certifying/documenting professional or organization | Licensed health care professional must document need for emotional support animal; no formally recognized certification process | Registered by nonprofit organizations (e.g., Pet Partners, Therapy Dogs International) | Certified by nonprofit organizations (e.g., National Education for Assistance Dog Services) |
| Governing regulation/policies | Fair Housing Act (42 U.S.C. Part 3604), Air Carrier Access Act CFR part 382.117 | Not applicable | Americans with Disabilities Act, 1990 (Section 35.136) |
| Periodic update of documents | Recent documentation may be required | Some organizations require reregistration | Depends on certifying organization |
| Questions that relevant authorities (airline employees or landlords)* are legally allowed to ask about the animal | Any questions are allowed, but owner's diagnosis may not be questioned | Any questions | Is this a service animal? What is the animal trained to do? |
| Species | Local authorities or carriers may dictate size, generally not wildlife or venomous species | No species restrictions, but registration organizations may dictate affiliative domestic animal species | Only dogs or miniature horses |
| Training | None required | Required per the certifying therapy animal program | Required |
EMOTIONAL SUPPORT ANIMALS
Emotional support animals are intended to support the needs of individuals with disabilities. These animals and their owners are not required to undergo specialized training, socialization, or formal evaluations. There is no formal certifying body or process for establishing that an animal is an emotional support animal. No mainstream medical or veterinary organization sanctions or recommends any of the multiple online registries for emotional support animals or approves use of animal vests and other equipment designed to be worn by emotional support animals; such apparel has no regulatory basis. At least 19 states have passed laws prohibiting misrepresentation of an emotional support animal as a service animal.6,7
Housing covered under the federal Fair Housing Act, even those with no-pet policies, must allow residents to have “an animal that works, provides assistance, or performs tasks for the benefit of a person with a disability, or provides emotional support that alleviates one or more identified symptoms or effects of a person's disability.”2 Although the U.S. Department of Housing and Urban Development does not require that such animals be individually credentialed, a housing provider may request documentation of need for an emotional support animal from a health care professional.
The Air Carrier Access Act prohibits discrimination in airline service against persons with disabilities and requires air carriers to accommodate requests to have animals accompany persons with disabilities on air travel.8 The Department of Transportation requires documentation within the past year on the letterhead of a licensed mental health professional stating that the person has a disability recognized in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5),9 needs the emotional support animal for air travel and activity at the destination, and is under the professional care of the signing mental health care professional.3 Given the increase in companion animal air travel, the Department of Transportation plans to issue an Advance Notice of Proposed Rulemaking on Traveling by Air with Service Animals to protect the health and safety of all travelers.10 Individual air carriers are clarifying policies and procedures, such as limiting species recognized as emotional support animals, and some are requiring that airline-specific forms be completed at least 48 hours before flight, which can include documentation of certain vaccinations for the animal.11
THERAPY ANIMALS
Therapy animals include a wider group of species that are a part of animal-assisted, goal-directed intervention. Animal-assisted therapy includes therapeutic riding programs, physical or occupational therapy, or counseling and psychotherapy.12 Registration for therapy animals and their owners is provided by a number of national and local nonprofit organizations that also mandate the frequency of reevaluation and/or reregistration.
SERVICE ANIMALS
Service animals are defined by the Americans with Disabilities Act as a dog or miniature horse trained to do work or to perform tasks for the benefit of an individual with a disability.13 Service animals receive rigorous training to perform specific tasks such as assisting blind or deaf individuals or alerting people to hypoglycemia or oncoming seizures. Although no national or federal certification protocols or standards for service animals have been developed, several international organizations accredit service dog training facilities in the United States and other countries.5
RISKS AND BENEFITS OF EMOTIONAL SUPPORT ANIMALS
A patient may claim benefit from having an emotional support animal; however, owning the animal is not a substitute for comprehensive appropriate mental health and medical care. In addition, an emotional support animal may present health risks to the owner and others, including zoonotic infectious diseases, allergies, and injury from bites and scratches. Several well-publicized episodes have documented injuries, asthmatic attacks, and allergic responses attributed to emotional support animals during air travel.14–16 The animal's welfare may also be jeopardized by the stress of travel or if the owner's disabilities interfere with the ability to provide adequate care.
Gathering data for an appropriate emotional support animal documentation letter probably requires more than one patient visit. The letter should include the patient's name and date of birth to allow verification of the owner's identity, should state that the patient has a disability recognized in the DSM-5, and should state where the emotional support animal is allowed. Consider including a phrase in the document such as “We recognize that allowing animals in public spaces is not without risk,” if advocating for air travel, and stating that the patient is working with a veterinarian to ensure that the animal's health and vaccination records remain up-to-date. A patient visit should be scheduled to encourage follow-up care and to reassess the role of the emotional support animal.
For the patient in the case scenario, the physician could explore the barriers that the patient has with accessing a therapist. A request from a patient for an emotional support animal documentation letter provides an opportunity to reassess the patient's mental health status, confirm any relevant diagnoses, review current treatment, and discuss why the patient believes that an emotional support animal will be beneficial. Before providing documentation, physicians should determine the role of the emotional support animal in the patient's treatment plan, consider the environments in which the patient could benefit from an emotional support animal, and consult a veterinarian on issues related to the risks of animals in public settings, animal behavior in stressful environments, and any necessary preventive care to protect human and animal health.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the National Pork Board or the U.S. government.
