letter for emotional support animal

[deleted1100659]

How do you guys feel about doing letters for patient stating they should have one? I remember one time in residency someone did a letter for an emotional support bird, then the bird pecked another person, lol. Not sure where the liability falls for that.

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[NickNaylor]

I refused to engage in these shenanigans as a resident in clinic. As an inpatient attending, I don't do them. It's not really out of concerns for liability - it's more that I just find the whole concept somewhat ridiculous, and most of the time I feel like there is secondary gain underlying the request (e.g., not wanting to pay a deposit or fees for having a pet in your apartment).

 

[deleted1100659]

I refused to engage in these shenanigans as a resident in clinic. As an inpatient attending, I don't do them. It's not really out of concerns for liability - it's more that I just find the whole concept somewhat ridiculous, and most of the time I feel like there is secondary gain underlying the request (e.g., not wanting to pay a deposit or fees for having a pet in your apartment).

That is essentially how I feel. Ive noticed there is usually some other factor at play. As an attending I surprisingly receive this request quite frequently.

 

[Alemo]

There's a great prior thread on this forum that discusses a lot of these issues in detail. Essentially, the definition of disability is very broad under the ADA, but just because someone might be disabled due to a psychiatric illness (as could be said about many patients), they do not necessarily need an emotional support animal. An emotional support animal is also not a service animal (a legal term that specifies only a few species) because it has not been trained to fulfill a specific role in alleviating one's disability.

I have written letters that state something along the lines of: The patient has a psychiatric condition for which I am treating them, the patient believes that their condition would be helped by having this animal in their (home/apartment/abode/dwelling), I cannot comment on the fitness of this animal for such an arrangement as I do not evaluate animals or residences, but this is what the patient tells me.

I make it clear that I did not "prescribe" the animal, and that I have no knowledge of the actual animal at hand. The letter essentially says, "For what it's worth, the patient has a psychiatric condition, and in the course of treatment they told me that having an animal helps that condition."

I'd be interested to hear other takes.

 

[Sushirolls]

Here is the thread for Emotional Support Animals. Not much more to add here, review this one:

Emotional support animals

Pathologic avoidance? Or healthy coping mechanism? Seems pretty obvious to me that it is the former, and the opposite of the latter.

forums.studentdoctor.net

 

[hamstergang]

I have written letters that state something along the lines of: The patient has a psychiatric condition for which I am treating them, the patient believes that their condition would be helped by having this animal in their (home/apartment/abode/dwelling), I cannot comment on the fitness of this animal for such an arrangement as I do not evaluate animals or residences, but this is what the patient tells me.

I make it clear that I did not "prescribe" the animal, and that I have no knowledge of the actual animal at hand. The letter essentially says, "For what it's worth, the patient has a psychiatric condition, and in the course of treatment they told me that having an animal helps that condition."

I'd be interested to hear other takes.

What I don't like about this approach (which seems to be a somewhat popular approach) is that you seem to be trying to have it both ways. That is, you appear to not want to really recommend an ESA, but you know that the patient getting to have their ESA in their home or on the plane is the outcome from your letter. I'd prefer either to take the step to recommend the ESA for the patient or to not write the letter at all.

Personally, I caved and wrote the letter once for a patient going away to college. I haven't written one since, even when people try to guilt me into it by telling me they already got the pet and just need my letter for their landlord to allow them to keep it.

 

[comp1]

I think Alemo's letter content is fine. It's popular for a reason. It's factual and addresses the patient's request to the extent you are able. What a third party does with the letter is not something that we can control. Most likely, they have as little interest and education in this matter as a given physician. However, arguing with the patient is not really a good use of time for something like this, nor is it particularly therapeutic. If for some reason you have a clinical opinion that an emotional support animal is harmful in some way, then that should go in your letter, but in general, I don't think we have opinions on this matter and the situation is described accurately by Alemo.

 

[FlowRate]

I've more or less stopped doing them for the vast majority of patients. I don't think it's an evidence based practice. I have yet to even find out how this whole concept was brought into the FHA. Some sort of odd specific lobbying group?

A lot of apartment buildings around here have started "requiring" that I attest to the specific animal which I am absolutely not going to do (also not legal per FHA.)

I used to do a generic statement of "I treat this pt for a diagnosis, they think an animal would be helpful." That's also not legal if you take a narrow read of state statutes which prescribe that I must state whether the evidence is that the pt NEEDS the animal due to their disability or that there is not sufficient evidence. And just invites those apt buildings to come back at me with their specific forms.

In my state it's exceptionally easy to find an apt that allows pets, pts just want to not have to pay the pet fee.

 

[erg923]

No one should want to be the physician that tells their their patients that they don't have to live by the current social contracts of society. That's the opposite of being therapeutic. I thought we were supposed to promoting adaptability in the face of adversity/illness? If your patient can't abide by current societal contracts, there is process for adjudicating that. Its called disability.

If you are an adult and feel that your can't get on plane without a live Teddy Bear, my job is to help you not. That's my job/due diligence as a mental health professional, right? And...to therapeutically work with you on discovering why this thought is silly and irrational. Its not my job to enable it.

 

[clausewitz2]

If you are an adult and feel that your can't get on plane without a live Teddy Bear, my job is to help you not. That's my job/due diligence as a mental health professional, right? And...to therapeutically work with you on discovering why this thought is silly and irrational. Its not my job to enable it.

It's funny how much easier it is for people to see that "maybe the fact that you need to slam four shots of tequila to get on an airplane is a problem we should work on" versus when the tequila has a collar and defecates on the upholstery.

 

[sloop]

I disagree with the idea of an ESA and generally try to avoid getting involved with that stuff.

I am actually somewhat open to the idea that people with certain types of mental illness might benefit from having a service animal, and I might consider recommending a patient for a service animal in the right circumstances. If I’m honest, I’m not sure if there is a literature base for such things, but I could imagine a service animal helping an otherwise fairly functional psychotic person maintain reality testing, or something similar.

The core of the problem with the ESA thing, for me, is that they are not service animals. Service animals are selected based on temperament and receive specific training. The process of qualifying one also seems more rigorous. Because of that, I think there is a good case as to why service animals should be exempt from rules about where animals can and can’t be. For instance, a movie theater might not want dogs for some obvious reasons, but a service dog is almost certainly not going to interrupt the movie by barking for no reason. That is not an expectation you can just have of animals generally.

I will also admit that I am not fully literate on the process of obtaining a service animal. It may be that it is practically almost impossible to get one for a mental health diagnosis. If that’s the case, I would support expanding the access to them and training animals to specifically deal with mental illness (to the extent that is feasible). Fundamentally, though, I think that the service animal model is the one to follow if we’re going to be exempting patients from the usual prohibitions on animals.

I think that it is undeniable that many patients would benefit from having an animal. Some might even benefit from having an animal with them most of the time. That said, other stakeholders also have interests in generally prohibiting animals from certain places. Businesses might not want the disruption of animals, workplaces might not want the distraction an animal brings, apartments might not want the risk that a poorly behaved animal will damage things, etc. I think that clear standards for temperament, behavior, and handling (I.e. when the service animal is working, such as when the owner is at work, nobody is allowed to pet or play with the animal, thereby minimizing distraction), serve a critical role in balancing the benefit of animals for certain populations and the concerns of the other stakeholders.

 

[aim-agm]

No one should want to be the physician that tells their their patients that they don't have to live by the current social contracts of society. That's the opposite of being therapeutic. I thought we were supposed to promoting adaptability in the face of adversity/illness? If your patient can't abide by current societal contracts, there is process for adjudicating that. Its called disability.

If you are an adult and feel that your can't get on plane without a live Teddy Bear, my job is to help you not. That's my job/due diligence as a mental health professional, right? And...to therapeutically work with you on discovering why this thought is silly and irrational. Its not my job to enable it.

What's your approach if the patient is engaging in treatment but the animal is useful to mitigate symptoms while treatment progresses?

 

[FlowRate]

I think that it is undeniable that many patients would benefit from having an animal.

TBH I think it's easily deniable when you define animal to be "common, randomly selected pet." What if you have a really hard to train dog that destroys all your stuff? Seems like a lot of added stress.

Lots of people seem to generally feel better from having a friendly thing around to keep them company. For that reason, I agree that there is ample lay suspicion of benefit to justify conducting trials on properly trained service animals for mental health diagnoses.

 

[VA Hopeful Dr]

I disagree with the idea of an ESA and generally try to avoid getting involved with that stuff.

I am actually somewhat open to the idea that people with certain types of mental illness might benefit from having a service animal, and I might consider recommending a patient for a service animal in the right circumstances. If I’m honest, I’m not sure if there is a literature base for such things, but I could imagine a service animal helping an otherwise fairly functional psychotic person maintain reality testing, or something similar.

The core of the problem with the ESA thing, for me, is that they are not service animals. Service animals are selected based on temperament and receive specific training. The process of qualifying one also seems more rigorous. Because of that, I think there is a good case as to why service animals should be exempt from rules about where animals can and can’t be. For instance, a movie theater might not want dogs for some obvious reasons, but a service dog is almost certainly not going to interrupt the movie by barking for no reason. That is not an expectation you can just have of animals generally.

I will also admit that I am not fully literate on the process of obtaining a service animal. It may be that it is practically almost impossible to get one for a mental health diagnosis. If that’s the case, I would support expanding the access to them and training animals to specifically deal with mental illness (to the extent that is feasible). Fundamentally, though, I think that the service animal model is the one to follow if we’re going to be exempting patients from the usual prohibitions on animals.

I think that it is undeniable that many patients would benefit from having an animal. Some might even benefit from having an animal with them most of the time. That said, other stakeholders also have interests in generally prohibiting animals from certain places. Businesses might not want the disruption of animals, workplaces might not want the distraction an animal brings, apartments might not want the risk that a poorly behaved animal will damage things, etc. I think that clear standards for temperament, behavior, and handling (I.e. when the service animal is working, such as when the owner is at work, nobody is allowed to pet or play with the animal, thereby minimizing distraction), serve a critical role in balancing the benefit of animals for certain populations and the concerns of the other stakeholders.

Part of the trouble is even with service animals, you are very limited in what you can ask the person. Its limited to basically "Is this dog trained to perform a task that helps manage an ADA-approved condition". That's it. You can't ask what the task is, what the person has, proof of training, or anything. If a person says that's its a service dog, you more or less have to take them at their word.

That said, you can kick out a service dog if it misbehaves no matter if its a true service dog or just someone lying about it. Since most ESAs aren't that well trained, it makes it easy to not have to deal with them.

 

[sloop]

Part of the trouble is even with service animals, you are very limited in what you can ask the person. Its limited to basically "Is this dog trained to perform a task that helps manage an ADA-approved condition". That's it. You can't ask what the task is, what the person has, proof of training, or anything. If a person says that's its a service dog, you more or less have to take them at their word.

That said, you can kick out a service dog if it misbehaves no matter if its a true service dog or just someone lying about it. Since most ESAs aren't that well trained, it makes it easy to not have to deal with them.

I do think that there should be more standardization of service animals as well. I understand that an individual with a disability has a right not to be interrogated about their disability, but my concerns are more about the dog than the owner.

I am not sure if this has been tried, but I would support some centralized state licensing authority certifying that an animal has met behavioral standards for being a service animal. Such an animal could then display a license on its vest that would signify that it is a certified service animal, and places and establishments that normally prohibit animals could require that an animal have such a license if they are to be exempted from a prohibition on animals. I don’t think that’s too invasive to people with disabilities because such an inquiry is not fundamentally about them or their disability. It is about their dog.

 

[FlowRate]

This prompted me to read more about service animals... I didn't realize that they're not standardized/permitted by any sort of agency or licensing body. All our patients have to do is train their dog to do something specific related to their mental health condition and bam, they're a service animal, no documentation required. Frequently Asked Questions about Service Animals and the ADA

 

[Candidate2017]

It's funny how much easier it is for people to see that "maybe the fact that you need to slam four shots of tequila to get on an airplane is a problem we should work on" versus when the tequila has a collar and defecates on the upholstery.

It's also funny many psychiatrists think Xanax TID, is ok to prescribe for years, for "my panic/anxiety/PTSD." It's even funnier when "therapists" tell me a patient needs to be on long term Xanax TID for "their my panic/anxiety/PTSD."

 

[FlowRate]

Well since the thread was mildly necro'd, I have a specific topic I'd like to discuss on the subject: I still have yet to figure out how the concept of ESA's got introduced into the FHA. My google-fu keeps failing me. Was there a specific lobbying group involved? Someone on the regulation committee's pet (lol) project? It doesn't seem to have arisen from any legitimate mental health entity. Anyone with more background knowledge about how ESA--as a housing/travel "right"--originated?

The level of entitlement in the asks I get from patients regarding ESA letters continues to rise over time. I think the layperson understanding is that they are entitled to having an ESA letter written based on the simple fact that they have a psychiatric diagnosis.

 

[deleted1100659]

Well since the thread was mildly necro'd, I have a specific topic I'd like to discuss on the subject: I still have yet to figure out how the concept of ESA's got introduced into the FHA. My google-fu keeps failing me. Was there a specific lobbying group involved? Someone on the regulation committee's pet (lol) project? It doesn't seem to have arisen from any legitimate mental health entity. Anyone with more background knowledge about how ESA--as a housing/travel "right"--originated?

The level of entitlement in the asks I get from patients regarding ESA letters continues to rise over time. I think the layperson understanding is that they are entitled to having an ESA letter written based on the simple fact that they have a psychiatric diagnosis.

yes there does seem to be an uptick in people requesting this for sure. I think its a generation thing where people #borderlinepersonalitydisorderstruggle and adopted ESAs as the new norm/trendy thing

 

[WisNeuro]

Instead of a letter for an ESA, can one of y'all write me a letter for an Emotional Support Tax Free Paycheck from the govt? That would greatly improve my mental health, way more than a fake support animal.

 

[deleted1100659]

Instead of a letter for an ESA, can one of y'all write me a letter for an Emotional Support Tax Free Paycheck from the govt? That would greatly improve my mental health, way more than a fake support animal.

the billionaires are already doing this when they get paid in stock options/company shares/dividends/etc , lol

 

[Trismegistus4]

This prompted me to read more about service animals... I didn't realize that they're not standardized/permitted by any sort of agency or licensing body. All our patients have to do is train their dog to do something specific related to their mental health condition and bam, they're a service animal, no documentation required. Frequently Asked Questions about Service Animals and the ADA

I realize this thread is a little old but since you posted in it again, as I pointed out in a more recent thread, there's no requirement that they train their dog to do something specific related to their mental health condition. This is because not only are they not required to provide any evidence that they've done so, but also the staff of public accommodations are explicitly barred from asking them for any such evidence.

There's nothing stopping someone from just brazenly lying and claiming that their dog alerts them when they're about to have a seizure. If a store or restaurant manager says "may I please see some proof of this?" they're violating federal law.

 

[neurotic_cow]

At my graduate school, our assessment clinic used to do these evaluations for college students on campus, which I avoided like the plague. Anecdotally, most of the people we saw just wanted to have a pet on campus or get around a landlord telling them they couldn't have a pet. However, in cases where individuals had significant psychiatric symptoms and were approved, typically resulted in destruction of university (or other) property by said animal and/or the person's symptoms were so severe that they could not adequately take care of the animal. Most of the animals approved included large dogs, puppies, cats... and even a few lizards.

These types of animals make it more challenging for those who have actual trained service dogs who can be genuinely helpful for people and I personally wouldn't even entertain writing one of these letters for patients.

 

[FlowRate]

I realize this thread is a little old but since you posted in it again, as I pointed out in a more recent thread, there's no requirement that they train their dog to do something specific related to their mental health condition. This is because not only are they not required to provide any evidence that they've done so, but also the staff of public accommodations are explicitly barred from asking them for any such evidence.

There's nothing stopping someone from just brazenly lying and claiming that their dog alerts them when they're about to have a seizure. If a store or restaurant manager says "may I please see some proof of this?" they're violating federal law.

I'm not really running into public accommodations type patients often. Landlords around here certainly do ask for documentation for ESA's and would likely request some sort of documentation when ADA claims are not self-evident.

 

[CB5T]

Just to invert the question to examine it: What are the risks or side effects of pet companionship? It's not legally binding if there are overruling circumstances, ie public travel is regulated by their own bodies. If a restaurant refuses service to a client with service Great Dane, that's fine, what's that got to do with the letter?

I see it kind of like writing a letter to recommend exercise.

That doesn't mean my letter authorizes an adult to exercise in the math class of their local elementary school.

What am I missing?

 

[90833]

Just to invert the question to examine it: What are the risks or side effects of pet companionship? It's not legally binding if there are overruling circumstances, ie public travel is regulated by their own bodies. If a restaurant refuses service to a client with service Great Dane, that's fine, what's that got to do with the letter?

I see it kind of like writing a letter to recommend exercise.

That doesn't mean my letter authorizes an adult to exercise in the math class of their local elementary school.

What am I missing?

This older thread, linked in an earlier post, goes into the numerous downsides.

Emotional support animals

Pathologic avoidance? Or healthy coping mechanism? Seems pretty obvious to me that it is the former, and the opposite of the latter.

forums.studentdoctor.net

 

[birchswing]

At my graduate school, our assessment clinic used to do these evaluations for college students on campus, which I avoided like the plague. Anecdotally, most of the people we saw just wanted to have a pet on campus or get around a landlord telling them they couldn't have a pet. However, in cases where individuals had significant psychiatric symptoms and were approved, typically resulted in destruction of university (or other) property by said animal and/or the person's symptoms were so severe that they could not adequately take care of the animal. Most of the animals approved included large dogs, puppies, cats... and even a few lizards.

These types of animals make it more challenging for those who have actual trained service dogs who can be genuinely helpful for people and I personally wouldn't even entertain writing one of these letters for patients.

The college I went to brought dogs into the library during exam/reading weeks.

This college had/has a serious, serious mental health crisis issue institutionally. I guess they thought dogs helped make up for policies that worsened students' mental health. Don't want to mention the college but it's been in the national news for this reason multiple times and for multiple aspects of them actively creating or worsening mental health issues.

The dorms I lived were occupied by flying cockroaches, ants, etc.

Not sure you could have harmed the place by adding more flora and fauna.

I was recently on the college's subreddit and freshman are moving in asking which dorms are the worst, and the one I lived in freshman year someone responded to: That place is still standing? It is kind of amazing given that it was subaquatic much of the year. I would have avoided putting a dog in there for the dog's health.

 

[FlowRate]

Just to invert the question to examine it: What are the risks or side effects of pet companionship? It's not legally binding if there are overruling circumstances, ie public travel is regulated by their own bodies. If a restaurant refuses service to a client with service Great Dane, that's fine, what's that got to do with the letter?

I see it kind of like writing a letter to recommend exercise.

That doesn't mean my letter authorizes an adult to exercise in the math class of their local elementary school.

What am I missing?

What's the potential downside to recommending someone get on disability?

 

[littlefred]

What's the potential downside to recommending someone get on disability?

The downside to recommending it is that patient will benefit from this, this or this?

There's a lot on the line for patients to be disabled or pretend to be "disabled". Lends itself to a lot of malingering; and in Psychiatry I argue that it's very hard to assess functionality in a work setting (because we are not at the workplace for example) for most of our disorders (aside from SMI patients with severe cognition deficits, but they wouldn't be employed to begin with).

 

[whopper]

I will write a letter for an ESA if asked. Seriously and I'm backing Erg923, I don't see why a physician or other provider wouldn't want to write one. There's no data (as far as I know) linking malingering with ESAs. (If there's any data show it to me). There's a heck of a lot of data showing ESAs could provide health benefits.

Where I drawn the line is I will only write for the ESA and any animal-related questions I'll tell the patient this ain't my department.

E.g. E.g. I will not write the animal itself is or is not appropriate for something like air-travel (I've been asked this), and I will cite the specific source, a patient of mine was going to Case Western University and wanted an ESA while living on their campus. Case Western wanted the doctor to write a lot of non-medical things that was frankly outside our scope.

e.g. "Have you discussed with your patient the responsibilities that will occur while caring for a pet?"
I told the patient-I don't know the specific responsibilities outside of a laymen so I can't discuss that issue. She became upset telling me if I don't fill it out she can't get the ESA. I told her to see a veterinarian or someone else who can actually detail the responsibilities and that we don't get any ESA qualifications to answer that question.

I even attemped to contact Case Western to tell them they're asking medical professionals to do something outside their scope but the person at Case Western gave me the typical -we don't give a $hit- response. Ironic given that Phil Resnick, one of the foundations of forensic psychiatry, is one of the biggest people telling doctors not to testify outside their box and he worked mostly at Case Western.

I filled out that patient's ESA letter but 3 of the questions I couldn't answer and wrote in the response that Case Western was asking a medical professional to testify on something outside my field so I would not answer it.

 

[whopper]

What's the potential downside to recommending someone get on disability?

You shouldn't go into this area unless it's Medicare, Medicaid or there's just enough information to make this so easily apparent.

The problem is with disability someone could be malingering, or they could be disabled to a degree where they could still work but not full-time. This usually requires forensic level investigation. The reasons why Medicare/Medicaid are exceptions are those institutions have forms to fill out clearly delineating you're not doing a forensic level investigation and to only fill out as a clinician" what you noticed. That's fine.

I've written for disability forensically and clinically. I've been willing to report on disability claims as the clinical treating doctor but only with disclaimers that I did not see this person in a forensic level evaluation and that the arbiter should consider this in my report.

 

[FlowRate]

What's the potential downside to recommending someone get on disability?

The downside to recommending it is that patient will benefit from this, this or this?

There's a lot on the line for patients to be disabled or pretend to be "disabled". Lends itself to a lot of malingering; and in Psychiatry I argue that it's very hard to assess functionality in a work setting (because we are not at the workplace for example) for most of our disorders (aside from SMI patients with severe cognition deficits, but they wouldn't be employed to begin with).

The problem is with disability someone could be malingering, or they could be disabled to a degree where they could still work but not full-time. This usually requires forensic level investigation. The reasons why Medicare/Medicaid are exceptions are those institutions have forms to fill out clearly delineating you're not doing a forensic level investigation and to only fill out as a clinician" what you noticed. That's fine.

I've written for disability forensically and clinically. I've been willing to report on disability claims as the clinical treating doctor but only with disclaimers that I did not see this person in a forensic level evaluation and that the arbiter should consider this in my report.

To be clear, it was a rhetorical question. Thank you for expounding on exactly why.

re: whopper: Is the secondary gain of your patient getting to force a landlord to allow them to have a pet--for free--not compelling enough? That's a $600-$6000/yr benefit. (Average in my area around $1200). Not to mention infringing on the property rights of the landlord.

Also potential downsides of prescribing a security blanket for conditions where they would actually be contraindicated.

There's no data (as far as I know) linking malingering with ESAs. (If there's any data show it to me). There's a heck of a lot of data showing ESAs could provide health benefits.

Only the patients who, when informed I don't write ESA letters, outright state they had to try so they could avoid paying the pet fee.

Very scant evidence for ESA's specifically. There's roundabout possible evidence that having a pet might have wellbeing benefits but the research is poor and insufficient. There's a recent JAAPL article highlighting as such and more or less concluding that ESA evals are forensic evals.

 

[whopper]

Pretty much everyone who asked me for an ESA was an already established patient with me, and not a brand new one, so I was solid in believing they had a psych disorder. Also the data supporting ESAs for mental health problems is solid.

There are downsides to the ESA but not from the doctor's side as far as I can tell. If you're the landlord, for example, pets can be disasters. One incident of cat urine could be thousands of dollars of repair the tenant might refuse to pay. The discount of having an ESA could be happening but this is not in a vacuum. It's within the context that there's solid data ESAs could help.

 

[FlowRate]

Also the data supporting ESAs for mental health problems is solid.

You keep saying this but that doesn't make it true. Extremely limited data regarding "ESAs" specifically and many studies supporting therapeutic potential for animals are not animals owned by patients but rather trained animals in therapeutic settings. Mixed and poor quality evidence of benefit/harm of pet ownership.

Examining Emotional Support Animals and Role Conflicts in Professional Psychology

This article examines the role conflicts that psychologists may face in their practices related to the evaluation and certification of emotional support animals (ESAs). It reviews the legal differences between ESAs and service animals (SAs), outlines ...

www.ncbi.nlm.nih.gov

There are some really old template ESA letters that were suggested by state organizations many years ago that state "ample evidence for benefit" for ESA's but as best I can tell it was a bold-faced lie back then (15-20 years ago) given we're still lacking robust evidence for ESA's.

 

[sloop]

You keep saying this but that doesn't make it true. Extremely limited data regarding "ESAs" specifically and many studies supporting therapeutic potential for animals are not animals owned by patients but rather trained animals in therapeutic settings. Mixed and poor quality evidence of benefit/harm of pet ownership.

Examining Emotional Support Animals and Role Conflicts in Professional Psychology

This article examines the role conflicts that psychologists may face in their practices related to the evaluation and certification of emotional support animals (ESAs). It reviews the legal differences between ESAs and service animals (SAs), outlines ...

www.ncbi.nlm.nih.gov

There are some really old template ESA letters that were suggested by state organizations many years ago that state "ample evidence for benefit" for ESA's but as best I can tell it was a bold-faced lie back then (15-20 years ago) given we're still lacking robust evidence for ESA's.

Also, this type of letter is not just saying that someone would get benefit from an animal. It is saying that they should be exempted from the typical rules people who own animals have to follow.

 

[whopper]

Flowrate-yes you are correct in your details, and that is a valid point in countering my prior posts above. The devil can be in the details!

 

[smalltownpsych]

Also, this type of letter is not just saying that someone would get benefit from an animal. It is saying that they should be exempted from the typical rules people who own animals have to follow.

This is a great point to emphasize. Way too much push to exempt our patients from following rules or being held accountable. I find that it doesn't help my patients because there are certain rules in life that lead to a better quality of life if we follow them. I try to help my patients, regardless of diagnosis or functionality, to learn to apply some of these basic rules so they can have better lives. Show up to work, be on time, get along with people, don't use a lot of mind altering substances, eat healthy, get off the couch and move around occasionally, don't spend all day glued to electronics, have a regular sleep schedule, show up to appointments, pay your bills, tell the truth. I think that about covers the basics.

 

[birchswing]

This is a great point to emphasize. Way too much push to exempt our patients from following rules or being held accountable. I find that it doesn't help my patients because there are certain rules in life that lead to a better quality of life if we follow them. I try to help my patients, regardless of diagnosis or functionality, to learn to apply some of these basic rules so they can have better lives. Show up to work, be on time, get along with people, don't use a lot of mind altering substances, eat healthy, get off the couch and move around occasionally, don't spend all day glued to electronics, have a regular sleep schedule, show up to appointments, pay your bills, tell the truth. I think that about covers the basics.

If you tell them all that, what job left is there for the town priest?

 

[whopper]

Also wanted to add, and Flowrate your post got me breaking my prior paradigm....and I frequently criticize other doctors for this....

Your own situation is not appropriate for others. My own situation ESAs are almost always the right thing to do. Other settings it's not. E.g. every single patient I have on stimulants that have been on them for over a year were vetted. E.g. PDMPs, if need be drug tests, I've gotten to know them very well, but heck no will I prescribe stimulants in an ER setting. I almost don't worry about them, and most of my patients have been with me for years.

So my above posts, now that I think about it was written from the egocentric viewpoint of my private practice and this will not relate to many of you. The malingering factor will have to be considered in several scenarios, just it's hardly an issue in my office.

 

[FlowRate]

Also wanted to add, and Flowrate your post got me breaking my prior paradigm....and I frequently criticize other doctors for this....

Your own situation is not appropriate for others. My own situation ESAs are almost always the right thing to do. Other settings it's not. E.g. every single patient I have on stimulants that have been on them for over a year were vetted. E.g. PDMPs, if need be drug tests, I've gotten to know them very well, but heck no will I prescribe stimulants in an ER setting. I almost don't worry about them, and most of my patients have been with me for years.

So my above posts, now that I think about it was written from the egocentric viewpoint of my private practice and this will not relate to many of you. The malingering factor will have to be considered in several scenarios, just it's hardly an issue in my office.

It's a great point that various aspects of the ESA issue are more or less important depending on your patient population and location. Some have pointed out in the recent threads on ESA's that some cities have very few pet-friendly apartment buildings. I would probably have more flexibility on the issue if that were the case here, but it's not. It's the opposite. Most apartment buildings in the area allow pets. They just require reasonable pet fees. Most of my patients are solidly middle class. They can afford the pet fees but would prefer to not have to pay them. If they think keeping a pet helps their mental health then they should also bear the appropriate responsibilities of pet ownership, including the effect their pet will have on their apartment.

The majority of requests I get for ESA letters are patients with relatively well treated GAD and/or MDD who I haven't even seen in 6 months because they're improved/stable/functioning well. They've had their pet for years with no apparent relation to the best or worst days of their mental health. Hard for me to state that the pet is essential to ameliorating the effects of their mental health disability when they're no longer "disabled" and it's the therapy, meds, and regression to the mean that seemed to actually help resolve the mental health issues.

 

[erg923]

If you are mentally aberrant and impaired, you still have to follow most social rules (especially in regards to property you don't own) and the social contract of behavior. Get help and learn how to live/cope like 99% of the rest of people. This is also like some veteran's complaints about 4th of July fireworks. Get help to learn how to deal/cope with it. Unexpected loud noises is part of living....in the world.

I am also not keen on putting my signature of approval for taking care of an animal to a person who presumably/admittedly is not capable of doing almost anything other than..... feeding, caring/attending, walking (possibly), not abusing due to mental disorder, not neglecting to due mental disorder, paying for immunizations and medical care. etc. If you are disabled and want to do this, that is your right, but I am not going to facilitate it with my signature/attestation that it is "necessary."

For most people asking for this though, I think we need to present a united and strong front of promoting resilience, grit, positive psychology, and frankly... "Buck-up!" Tons of psychological/clinical science literature in this area, too, by the way

 

[mistafab]

ESA’s are not evidenced based medicine. Engaging in this behavior makes psychiatrists look like clowns or quacks. It further makes society “medicalize” bad behavior.

Lose lose all around. I’m interested to see a psychiatrist get sued when a dog tears up an expensive apartment. They put this letter on a slide in front of a court room and say “You said the patient thought a pet would be helpful… thats what you wrote here, isnt it? Without your letter, this apartment would not have been damaged by this animal... There were at least $45000 in repairs needed due to an animal damaging the property. Did you not have a doctor-patient relationship with this patient? Wasnt it your letter that allowed this pet to cause these damages to this property?”

 

[smalltownpsych]

I just broke my own rule today and told a client I would write an ESA letter for her if she needed it. She is trying to get out of an unhealthy situation and be independent for the first time in her life so I weighed the principles and came down on the side of helping a kid out if they need it. What can I say, sort of a softy. Truth is that I will give a little extra for those who are demonstrating a willingness to help themselves. One of those things i learned by helping a client learn when to help others verses when to set boundaries.

 

[littlefred]

Pfft, all these patients are amateurs asking us for letters. A quick google search and you can find a quack to write you a letter for a modest fee.

ESA Letters For Your Pet – Fast, Easy & Legitimate | Pettable

Learn how to receive a legitimate ESA Letter consultation from a trusted Pettable therapist.

pettable.com

Get with the times people!

Business idea for the entrepreneurs out there: disableable.com. Get a certified clinician to sign off of on your disability claim.

 

[Alemo]

Pfft, all these patients are amateurs asking us for letters. A quick google search and you can find a quack to write you a letter for a modest fee.

ESA Letters For Your Pet – Fast, Easy & Legitimate | Pettable

Learn how to receive a legitimate ESA Letter consultation from a trusted Pettable therapist.

pettable.com

Get with the times people!

Business idea for the entrepreneurs out there: disableable.com. Get a certified clinician to sign off of on your disability claim.

How can we disabuse those who abuse the idea of disability and think they’re able to able the able by ableing disability and seeing them as disableable?

 

[littlefred]

How can we disabuse those who abuse the idea of disability and think they’re able to able the able by ableing disability and seeing them as disableable?

disableable is such a great name for the domain, isn't it?

Send royalties my way once it's Done (pun intended).

 

[Trismegistus4]

ESA’s are not evidenced based medicine. Engaging in this behavior makes psychiatrists look like clowns or quacks. It further makes society “medicalize” bad behavior.

When we're on the other side of the desk, it's helpful to remind ourselves of what the lay perception of psychiatry, or medicine in general, is. Just as with controlled substances, the lay perception is that the impetus for these things is coming from the doctors, that we're the ones pushing these things, whereas most of us probably feel that most of the time when we provide these things we are reluctantly caving in to patient requests.

Business idea for the entrepreneurs out there: disableable.com. Get a certified clinician to sign off of on your disability claim.

I see that mycheck.com is not taken. That would fit right in with the "I get my check on the first" mentality.

 

[Candidate2017]

Show up to work, be on time, get along with people, don't use a lot of mind altering substances, eat healthy, get off the couch and move around occasionally, don't spend all day glued to electronics, have a regular sleep schedule, show up to appointments, pay your bills, tell the truth. I think that about covers the basics.

This could be an 11 point self-rated questionaire, with little faces like the Baker-Wong pain scale to which patients can point to and keep track of their progress:

When we're on the other side of the desk, it's helpful to remind ourselves of what the lay perception of psychiatry, or medicine in general, is. Just as with controlled substances, the lay perception is that the impetus from these things is coming from the doctors, that we're the ones pushing these things, whereas most of us probably feel that most of the time when we provide these things we are reluctantly caving in to patient requests.

I once had a patient whose family member who (correctly) believed stimulants were contraindicated. The family member asked why prior doctors kept writing stimulants, and their jaw dropped when I explained doctors find it easier to give in when they get nagged. It never occurred to them.

 

[birchswing]

If you are mentally aberrant and impaired, you still have to follow most social rules (especially in regards to property you don't own) and the social contract of behavior. Get help and learn how to live/cope like 99% of the rest of people. This is also like some veteran's complaints about 4th of July fireworks. Get help to learn how to deal/cope with it. Unexpected loud noises is part of living....in the world.

I am also not keen on putting my signature of approval for taking care of an animal to a person who presumably/admittedly is not capable of doing almost anything other than..... feeding, caring/attending, walking (possibly), not abusing due to mental disorder, not neglecting to due mental disorder, paying for immunizations and medical care. etc. If you are disabled and want to do this, that is your right, but I am not going to facilitate it with my signature/attestation that it is "necessary."

For most people asking for this though, I think we need to present a united and strong front of promoting resilience, grit, positive psychology, and frankly... "Buck-up!" Tons of psychological/clinical science literature in this area, too, by the way

Apropos of nothing, when you watch 101 Dalmations, which character do you believe is the protagonist?

No wrong answers . . .

 

[lockian]

ESA’s are not evidenced based medicine. Engaging in this behavior makes psychiatrists look like clowns or quacks. It further makes society “medicalize” bad behavior.

Lose lose all around. I’m interested to see a psychiatrist get sued when a dog tears up an expensive apartment. They put this letter on a slide in front of a court room and say “You said the patient thought a pet would be helpful… thats what you wrote here, isnt it? Without your letter, this apartment would not have been damaged by this animal... There were at least $45000 in repairs needed due to an animal damaging the property. Did you not have a doctor-patient relationship with this patient? Wasnt it your letter that allowed this pet to cause these damages to this property?”

Apartments like that are few and far between. And the people who can afford to live in them can afford a place that allows pets, a staff to care for a pet or better yet their own home where ESA letters are not needed.

Most of the liability in damages to property are small claims court potatoes, probably not even worth the legal fees.

Not saying providing a letter is appropriate, but people with their claims of damage to property need to stop.