Curbside Consultation - Emotional Support Animals

302 American Family Physician www.aafp.org/afp Volume 101, Number 5

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March 1, 2020

Curbside Consultation

Emotional Support Animals:

Considerations for Documentation

Commentary by Alice H. Tin, MD, MPH, Swedish Cherry Hill Family Medicine Residency, Seattle,

Washington; Peter Rabinowitz, MD, MPH, University of Washington Departments of Environmental/

Occupational Health Sciences, Family Medicine, Global Health and UW Center for One Health Research, Seattle,

Washington; and Heather Fowler, VMD, PhD, MPH, DACVPM, National Pork Board, Clive, Iowa

Case Scenario

A 43-year-old established patient with a history of anxiety

requests a letter from her primary care physician to desig-

nate 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 certication

for her dog to accompany her on ights to alleviate her fear

of ying. She states she has diculties meeting with a ther-

apist because of her irregular work schedule.

What steps should physicians take to evaluate and, if

appropriate, to provide documentation for a patient’s emo-

tional support animal? How does an emotional support ani-

mal t into a patient’s therapeutic plan?

Commentary

Companion animals are increasingly viewed as part of the

family, and studies show many mental and physical bene-

ts of pet ownership.

Federal regulations require patients

to obtain health care professional documentation for emo-

tional support animals to allow these animals to accompany

the owner on air travel or to live in housing that might oth-

erwise restrict pets.

2,3

No professional practice guidelines

are currently available to guide health care professionals

responding to patient requests for emotional support ani-

mal documentation.

Before documenting an emotional support animal as part

of a patient’s treatment plan, physicians should understand

the dierences between emotional support animals, service

animals, and therapy animals (Table 1

); know the poten-

tial risks and benets of emotional support animals; and

develop a consistent approach to providing documentation

about such animals.

EMOTIONAL SUPPORT ANIMALS

Emotional support animals are intended to support the

needs of individuals with disabilities. ese animals and

their owners are not required to undergo specialized train-

ing, socialization, or formal evaluations. ere is no formal

certifying body or process for establishing that an animal

is an emotional support animal. No mainstream medi-

cal or veterinary organization sanctions or recommends

any of the multiple online registries for emotional support

animals or approves use of animal vests and other equip-

ment 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 benet of a person with a disability, or provides emo-

tional support that alleviates one or more identied symp-

toms or eects of a person’s disability.”

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.

e 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.

e

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 Men-

tal Disorders, 5th ed. (DSM-5),

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.

Given the increase in companion animal

air travel, the Department of Transportation plans to issue

an Advance Notice of Proposed Rulemaking on Traveling

Case scenarios are written to express typical situations that

family physicians may encounter; authors remain anony-

mous. Send scenarios to afpjournal@ aafp.org. Materials are

edited to retain conﬁdentiality.

This series is coordinated by Caroline Wellbery, MD, associ-

ate deputy editor.

A collection of Curbside Consultation published in AFP is

available at https:// www.aafp.org/afp/curbside.

Author disclosure: No relevant ﬁnancial aliations.

mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

March 1, 2020

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Volume 101, Number 5 www.aafp.org/afp American Family Physician 303

CURBSIDE CONSULTATION

by Air with Service Animals to protect the health and safety

of all travelers.

Individual air carriers are clarifying pol-

icies and procedures, such as limiting species recognized

as emotional support animals, and some are requiring that

airline-specic forms be completed at least 48 hours before

ight, which can include documentation of certain vaccina-

tions for the animal.

THERAPY ANIMALS

erapy animals include a wider group of species that

are a part of animal-assisted, goal-directed intervention.

Animal-assisted therapy includes therapeutic riding pro-

grams, physical or occupational therapy, or counseling

and psychotherapy.

Registration for therapy animals and

their owners is provided by a number of national and local

nonprot organizations that also mandate the frequency of

reevaluation and/or reregistration.

SERVICE ANIMALS

Service animals are dened by the Americans with Dis-

abilities Act as a dog or miniature horse trained to do work

or to perform tasks for the benet of an individual with

a disability.

Service animals receive rigorous training to

perform specic tasks such as assisting blind or deaf indi-

viduals or alerting people to hypoglycemia or oncoming

seizures. Although no national or federal certication

protocols or standards for service animals have been

developed, several international organizations accredit

service dog training facilities in the United States and

other countries.

TABLE 1

Emotional Support, Therapy, and Service 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 pub-

lic is allowed

Certifying/documenting pro-

fessional or organization

Licensed health care professional

must document need for emo-

tional 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 Disabil-

ities 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 author-

ities (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 organiza-

tions may dictate aliative

domestic animal species

Only dogs or miniature

horses

Training None required Required per the cer-

tifying therapy animal

program

Required

*—For service animals, this applies to shop owners, bus drivers, etc.

Information from reference 5.

mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

304 American Family Physician www.aafp.org/afp Volume 101, Number 5

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March 1, 2020

CURBSIDE CONSULTATION

RISKS AND BENEFITS OF EMOTIONAL

SUPPORT ANIMALS

A patient may claim benet from having an emotional

support animal; however, owning the animal is not a sub-

stitute for comprehensive appropriate mental health and

medical care. In addition, an emotional support animal

may present health risks to the owner and others, includ-

ing 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

e 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. e letter should include the patient’s

name and date of birth to allow verication of the owner’s

identity, should state that the patient has a disability recog-

nized 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 veter-

inarian to ensure that the animal’s health and vaccination

records remain up-to-date. A patient visit should be sched-

uled 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, conrm any rel-

evant diagnoses, review current treatment, and discuss why

the patient believes that an emotional support animal will

be benecial. 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 benet from an emotional sup-

port 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 ocial or

as reﬂecting the views of the National Pork Board or the U.S.

government.

Address correspondence to Peter Rabinowitz, MD, MPH, at

peter r7@ uw.edu. Reprints are not available from the authors.

References

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