Emotional Support Animals

[SaraLance]

The National Register had a great talk on this by Jeffrey Younggren, PhD, ABPP.

Role Conflicts and Emotional Support Animal Certifications (Archived) - National Register Continuing Education

Dr. Younggren reviews the laws that apply to the certification of Emotional Support Animals (ESAs). He examines the role conflicts that exist when therapists provide these types of certifications and will review the concept of disability as it applies to these types of assessments. Dr. Younggren...

ce.nationalregister.org

In short, no lol. I decline all requests for ESA letters.


*I do not stand to benefit from posting this talk. If you happen to be a Health Service Psychologist, it's free I believe.

---

Members don't see this ad.

 

[DynamicDidactic]

*I do not stand to benefit from posting this talk. If you happen to be a Health Service Psychologist, it's free I believe.

I think you mean if you are a National Register member (definitely not free otherwise).

 

[AbnormalPsych]

A company called ESAD is recruiting psychologists PA’s, and NP's in my area to provide “Emotional Animal Support letters of recommendation”. The ad has a lot of stuff about complying with HUD guidelines and offers $80-$120/hr compensation. By recruiting locally seems they're avoiding the internet evals but still looks very sketchy to me.

Came across this today, enjoy:

Psychologist (PhD or PsyD) for Emotional Support Animal Assessments

All across America, Canada, and the globe, ESAD Int'l.'s team of licensed health care professionals provide emotional support animal letters and therapy thru online sessions.We've helped thousands of individuals and families achieve their goals. Let us help you.

www.esadoggy.com

 

[AcronymAllergy]

Unfortunately, I don't think they're going to have trouble finding providers willing to sign up. A chunk of psychologists need to really review the idea that giving patients everything they ask for is always a good thing.

 

[WisNeuro]

Unfortunately, I don't think they're going to have trouble finding providers willing to sign up. A chunk of psychologists need to really review the idea that giving patients everything they ask for is always a good thing.

Plenty of diploma millers here from the shuttered diploma factory that are looking for work, I'd have to imagine some of them are doing this.

 

[SportsNeuroPsych]

Came across this today, enjoy:

Psychologist (PhD or PsyD) for Emotional Support Animal Assessments

All across America, Canada, and the globe, ESAD Int'l.'s team of licensed health care professionals provide emotional support animal letters and therapy thru online sessions.We've helped thousands of individuals and families achieve their goals. Let us help you.

www.esadoggy.com

WTF?

My favorite part: "ESADoggy is looking for forward-thinking Psychologists"

 

[WisNeuro]

WTF?

My favorite part: "ESADoggy is looking for forward-thinking ethically ambiguous Psychologists"

FTFY

 

[Fan_of_Meehl]

WTF?

My favorite part: "ESADoggy is looking for forward-thinking Psychologists"

"progress"

 

[Sanman]

You guys missed some of the best stuff on the ESADoggy website about the founder:

Chaz Stevens is an American entrepreneur, journalist, and constitutional activist focused on First Amendment issues. In 2015, Stevens launched the Gay Pride Festivus Pole Generosity Fund, with donations supporting various LGBT youth organizations. Stevens was twice appointed Commissioner to the Deerfield Beach Housing Authority. Stevens is the founder and CEO of ESAD International. Stevens has appeared on Time, Huffington Post, Fox News, Slate, and MTV.

EDIT: Apparently he is famous for this great accomplishment

 

[SportsNeuroPsych]

You guys missed some of the best stuff on the ESADoggy website about the founder:




EDIT: Apparently he is famous for this great accomplishment

Hahaha. I wasn't allowed to proceed through the website to explore more since I'm not a "forward-thinking psychologist."

Again, WTFFFFFF

 

[Fan_of_Meehl]

Hahaha. I wasn't allowed to proceed through the website to explore more since I'm not a "forward-thinking psychologist."

Again, WTFFFFFF

I'm guessing that the primary focus of the founder's 'forward-thinking' is how much he is looking 'forward' to the exponential growth in his bank account by pyramiding and leveraging the actual labor of other providers.

Truly a step forward for our profession (of psychology) which is one of the newer professions in healthcare and society at large. The fact that this progress involves us emulating the ethics, rigor, and motivations of the world's 'oldest profession' is just an added bonus.

 

[AbnormalPsych]

WTF?

My favorite part: "ESADoggy is looking for forward-thinking Psychologists"

This is my favorite part:

"We appreciate the occasional mulligan, so we have a one-time tolerance for a missed event. The second time? There is no second time."

Did I just get threatened by a job ad?

 

[PsyDr]

Florida?- check
PBR?- check
Baseball hat in inappropriate settings?- check
Threatening for no reason?- check

 

[Sanman]

Florida?- check
PBR?- check
Baseball hat in inappropriate settings?- check
Threatening for no reason?- check

So you're saying we found 'Florida Man'

 

[cara susanna]

Ughh that ad tries so hard to be quirky and fun. It's like, we're a FUN job, we're not like those other jobs!

 

[Sanman]

I'm guessing that the primary focus of the founder's 'forward-thinking' is how much he is looking 'forward' to the exponential growth in his bank account by pyramiding and leveraging the actual labor of other providers.

Truly a step forward for our profession (of psychology) which is one of the newer professions in healthcare and society at large. The fact that this progress involves us emulating the ethics, rigor, and motivations of the world's 'oldest profession' is just an added bonus.

Except that their hourly rate can be higher than ours and they manage to get paid cash in hand rather than through insurance. We should be so lucky.

 

[Fan_of_Meehl]

Except that their hourly rate can be higher than ours and they manage to get paid cash in hand rather than through insurance. We should be so lucky.

Good points. However, depending on work setting, we (arguably) get screwed harder and more often.

 

[Fan_of_Meehl]

This is my favorite part:

"We appreciate the occasional mulligan, so we have a one-time tolerance for a missed event. The second time? There is no second time."

Did I just get threatened by a job ad?

And despite the gratuitous use of excessive superlatives to describe his 'most excellent' practice...'impeccable logic' can't be among them.

Either there IS a mulligan (a.k.a. second chance) or there isn't. My guess is the guy is a short skinny dude trying to take the initiative to exhibit preemptive 'alpha' dominance over people he's never even interacted with and who has a cheesy grin wider than his shirt-lapels and limp handshake.

 

[Sanman]

And despite the gratuitous use of excessive superlatives to describe his 'most excellent' practice...'impeccable logic' can't be among them.

Either there IS a mulligan (a.k.a. second chance) or there isn't. My guess is the guy is a short skinny dude trying to take the initiative to exhibit preemptive 'alpha' dominance over people he's never even interacted with and who has a cheesy grin wider than his shirt-lapels and limp handshake.

The person is a offering a part-time contract to an already existing practice. Not sure where they get off telling you anything.

 

[beginner2011]

Good lord. The banner for their website implies that they are offering to write letters for a fee -- "save $60 on your emotional support letter!"

Looks like a great way to risk your license for a few (probably very few) extra bucks.

 

[LadyHalcyon]

What about if the ESA attacks someone? Can the psychologist be held liable? We are supposed to assess the human. What about assessing the animal to make sure they are an appropriate fit? I refuse to write these letters for patients and I think I'm going to refuse to allow them in my building as well.

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[cara susanna]

What about if the ESA attacks someone? Can the psychologist be held liable? We are supposed to assess the human. What about assessing the animal to make sure they are an appropriate fit? I refuse to write these letters for patients and I think I'm going to refuse to allow them in my building as well.

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I have read that, yes, if an ESA attacks someone the therapist who wrote the letter could be held liable.

 

[AcronymAllergy]

I appreciate how "writing letters for a fee" is in quotation marks. As was mentioned above RE: the disclaimer about getting a letter for up to $60 less, I don't know that this all makes a great case for avoiding board sanctions.

And yes, there's the potential liability component. No clue whether or not it'd hold up in court, but is it worth the risk?

 

[Sanman]

I have read that, yes, if an ESA attacks someone the therapist who wrote the letter could be held liable.

Because I am bored, I did a not so deep dive into this. However, ESA status must be renewed annually with an MH professional. Letters must state specifically that the animal is required for travel (does not have to be stated, they can just be at home), and it would behoove any MH professional writing such a letter to first get a sign off from a veterinarian that the animal is safe to travel/ be in public and not a risk to others. Having a copy of such a letter can certainly help to reduce risk in a law suit.

 

[Fan_of_Meehl]

Because I am bored, I did a not so deep dive into this. However, ESA status must be renewed annually with an MH professional. Letters must state specifically that the animal is required for travel (does not have to be stated, they can just be at home), and it would behoove any MH professional writing such a letter to first get a sign off from a veterinarian that the animal is safe to travel/ be in public and not a risk to others. Having a copy of such a letter can certainly help to reduce risk in a law suit.

I've asked this many times and I've looked high and low in the literature but can ANYONE point me to a published (peer reviewed or not) resource (book chapter, review article, assessment manual) that meaningfully operationalizes the process of these so-called 'evaluations' for suitability and medical necessity of an ESA? Like...just at a basic level of what actual procedures the assessor engages in to determine this and what a 'no' determination would look like (and what justifies a 'no')? I know there's a couple of critical articles critiquing the practice from a forensic perspective (Younggren), but is there, like, any kind of exposition of what this entails from the perspective of someone who supposedly practices regularly and semi-ethically/competently in this area? Any accredited/ reputable training programs doing this? Any books by reputable publishers?

 

[Sanman]

I've asked this many times and I've looked high and low in the literature but can ANYONE point me to a published (peer reviewed or not) resource (book chapter, review article, assessment manual) that meaningfully operationalizes the process of these so-called 'evaluations' for suitability and medical necessity of an ESA? Like...just at a basic level of what actual procedures the assessor engages in to determine this and what a 'no' determination would look like (and what justifies a 'no')? I know there's a couple of critical articles critiquing the practice from a forensic perspective (Younggren), but is there, like, any kind of exposition of what this entails from the perspective of someone who supposedly practices regularly and semi-ethically/competently in this area? Any accredited/ reputable training programs doing this? Any books by reputable publishers?

So, I haven't really looked into the literature, but you can be half-legit in these evals. IMO, documentation is asking two assessment questions:

1. Does the person in question have a diagnosable MH disorder? This is bread and butter practice really. You can easily weed out the fakers/outright deniers

2. Will an emotional support animal help in the treatment of said disorder? Not sure what the literature says about this part if anything

 

[Fan_of_Meehl]

So, I haven't really looked into the literature, but you can be half-legit in these evals. IMO, documentation is asking two assessment questions:

1. Does the person in question have a diagnosable MH disorder? This is bread and butter practice really. You can easily weed out the fakers/outright deniers

2. Will an emotional support animal help in the treatment of said disorder? Not sure what the literature says about this part if anything

1. Is no problem doing, as you point out.

2. Is complicated by many factors, not the least of which is the inconvenient fact that the twin evidence-based treatment elements (exposure and cognitive restructuring) effective in treating PTSD/anxiety are fundamentally incompatible with an approach that asserts that prescribing a dog is 'medically necessary' to treat/manage that condition. The dog is clearly functioning as a 'safety behavior' (inimical to exposure therapy) and is also an enacted stuck point ("If I leave my house without my dog, I won't be able to function").

 

[Sanman]

1. Is no problem doing, as you point out.

2. Is complicated by many factors, not the least of which is the inconvenient fact that the twin evidence-based treatment elements (exposure and cognitive restructuring) effective in treating PTSD/anxiety are fundamentally incompatible with an approach that asserts that prescribing a dog is 'medically necessary' to treat/manage that condition. The dog is clearly functioning as a 'safety behavior' (inimical to exposure therapy) and is also an enacted stuck point ("If I leave my house without my dog, I won't be able to function").

Of course, there is a case to be made for those that are treatment resistant or have dropped out of treatment altogether getting some relief and quality of life improvement. That said, we can clearly rule out that that an ESA will help managing your barophobia. So, possibly eligible in some cases and not in others.

 

[Fan_of_Meehl]

Of course, there is a case to be made for those that are treatment resistant or have dropped out of treatment altogether getting some relief and quality of life improvement. That said, we can clearly rule out that that an ESA will help managing your barophobia. So, possibly eligible in some cases and not in others.

I've long opined that the future of the post-deployment clinic involves marijuana plantations and service-dog kennels. Throw in 'whole health drum circles' and we're off to the races.

 

[Sanman]

I've long opined that the future of the post-deployment clinic involves marijuana plantations and service-dog kennels. Throw in 'whole health drum circles' and we're off to the races.

This is why I dislike treating anyone under 65 and prefer 85+

 

[AcronymAllergy]

My cynical side thinks that pretty soon, we'll be writing letters for "emotional support humans." A.k.a., friends.

 

[Fan_of_Meehl]

My cynical side thinks that pretty soon, we'll be writing letters for "emotional support humans." A.k.a., friends.

Or prescribing a fleet of mechanical "cleansing kitty" robots that accompany contamination-based OCD sufferers around enveloping them in a fine mist of mild but potent disinfectant spray. "Medically necessary" to prescribe in such cases, of course.

 

[Sanman]

My cynical side thinks that pretty soon, we'll be writing letters for "emotional support humans." A.k.a., friends.

My cynical side says I am pretty much that already for several of my vets.

 

[Fan_of_Meehl]

My cynical side says I am pretty much that already for several of my vets.

My Rogerian (and even Beckian) side actually thinks that's pretty cool

 

[futureapppsy2]

Important to note here that ESAs are ONLY covered in housing and air travel, NOT hospitals, businesses, etc. They aren't covered by the ADA or other disability laws.

 

[LadyHalcyon]

I've asked this many times and I've looked high and low in the literature but can ANYONE point me to a published (peer reviewed or not) resource (book chapter, review article, assessment manual) that meaningfully operationalizes the process of these so-called 'evaluations' for suitability and medical necessity of an ESA? Like...just at a basic level of what actual procedures the assessor engages in to determine this and what a 'no' determination would look like (and what justifies a 'no')? I know there's a couple of critical articles critiquing the practice from a forensic perspective (Younggren), but is there, like, any kind of exposition of what this entails from the perspective of someone who supposedly practices regularly and semi-ethically/competently in this area? Any accredited/ reputable training programs doing this? Any books by reputable publishers?

This is somewhat helpful

And this:

Younggren, J. N., Boness, C. L., Bryant, L. M., & Koocher, G. P. (2020). Emotional support animal assessments: Toward a standard and comprehensive model for mental health professionals. Professional Psychology: Research and Practice, 51(2), 156–162. https://doi.org/10.1037/pro0000260



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[deleted343839]

"The client's emotional support animal is not a pet."

How does that work?

 

[Fan_of_Meehl]

This is somewhat helpful

And this:

Younggren, J. N., Boness, C. L., Bryant, L. M., & Koocher, G. P. (2020). Emotional support animal assessments: Toward a standard and comprehensive model for mental health professionals. Professional Psychology: Research and Practice, 51(2), 156–162. https://doi.org/10.1037/pro0000260



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"The client's emotional support animal is not a pet."

How does that work?

No cuddling, playing, 'pet-naming,' participation in selfie photos, or use in posting to Reddit. And must sleep in a bed labeled 'Durable Medical Equipment.'

 

[Fan_of_Meehl]

This is somewhat helpful

And this:

Younggren, J. N., Boness, C. L., Bryant, L. M., & Koocher, G. P. (2020). Emotional support animal assessments: Toward a standard and comprehensive model for mental health professionals. Professional Psychology: Research and Practice, 51(2), 156–162. https://doi.org/10.1037/pro0000260



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I wasn't aware of the most recent Younggren article. Thanks!

 

[cara susanna]

Sooo my understanding is that an ESA claim is basically saying that the person is disabled due to a MH condition and the animal improves functioning. Thus, wouldn't a solid assessment have to evaluate for disability?

 

[WisNeuro]

Sooo my understanding is that an ESA claim is basically saying that the person is disabled due to a MH condition and the animal improves functioning. Thus, wouldn't a solid assessment have to evaluate for disability?

And, technically, if you try to bill insurance for a disability assessment, you are committing billing fraud.

 

[WisNeuro]

I think I've told you guys this before; one of my mentors was bored one day and legit got his hyper hot mess of a dog "certified" by a therapist all on line and without ever meeting anyone face to face. He used it to highlight this problematic area in a piece he wrote for a journal.

Considering how ill-behaved and untrained the vast majority of "service" and "ESA" animals I've seen out in public, completely unsurprising. Unfortunately, the worst side effect is that people with legitimate disability and actually trained service animals are now viewed with suspicion.

 

[cara susanna]

And, technically, if you try to bill insurance for a disability assessment, you are committing billing fraud.

Really? I didn't know that! How are they typically billed?

 

[WisNeuro]

Really? I didn't know that! How are they typically billed?

Technically, physicians actually do have some codes that allow for billing of filling out certain kinds of disability-related forms. But, regarding MH codes and evaluations, most explicitly say that you can only bill for clinical services, with disability evals falling within a IME type of framework. Fact is, plenty of people do bill for these types of eval in psychology. It's just not enforced. In general, psychologists are fairly terrible at knowing how billing and coding work, and are even more ignorant of the laws surrounding what they do.

 

[Sanman]

Really? I didn't know that! How are they typically billed?

I would assume cash only as I am not sure this would meet any medical necessity standard. So, once I am financially set for life and no longer need a license, I will be doing as many of these as I can.

 

[PsyDr]

Really? I didn't know that! How are they typically billed?

They should NEVER be billed using insurance. Medical insurance is for healthcare. Disability is a legal issue that is essentially referring to HOW an illness affects X. It has almost nothing to do with the symptoms themselves.


And the Professional guidelines indicate that treating psychologists and psychiatrists should never do disability stuff for their patients. Of course most treatment providers are unaware of the very guidelines in this area in which they choose to practice...something something de facto evidence of negligence....

The proper method for this assessment is for the insurance carrier/ ssa to provide a third party evaluation. Most payers try to avoid this cost by telling the claimant he/she needs to have their treatment provider fill out some forms. Treatment providers just want to help someone and get them out of their office, so they do it. It’s the same way psychologists do an evaluation for a lawsuit using insurance.... they’re leaving a crap ton of money on the table, so legal professionals can make more.

And they are usually unaware that being on disability is correlated, independent of illness, with: increased mortality, lower age of death, more healthcare usage, increased rates of domestic violence, increased rates of children being on disability again independent of illness, etc.

And they never address how this an affective disorder can produce complete inabilty to work in any job, while individuals with severe intellectual disability maintain work.

The proper way to handle it: “it is my understanding that using healthcare insurance for non healthcare purposes constitutes fraud. I’m not willing to risk my license to for you. I would advise you or your attorney to request an independent evaluation. If your attorney wishes to speak with me, he/she can set up an appointment with the front desk at my forensic rate.”.

 

[erg923]

Really? I didn't know that! How are they typically billed?

Health insurance is for healthcare. Same reason health insurance doesn't pay for assessing possible learning disorders or for custody or parenting evaluations, etc.

 

[Fan_of_Meehl]

I would assume cash only as I am not sure this would meet any medical necessity standard. So, once I am financially set for life and no longer need a license, I will be doing as many of these as I can.

And yet, as I understand it, most ESA / service animal "letters" are supposed or expected to include language asserting the "medical necessity" of the "prescribed" animal to address/manage symptoms of the disabling MH condition. Although, strickly speaking, this may only be true of "service animal" letters, in principle the same rationale is used to justify ESA letters (and associated laws). What a clusterbark.

 

[beginner2011]

The proper way to handle it: “it is my understanding that using healthcare insurance for non healthcare purposes constitutes fraud. I’m not willing to risk my license to for you. I would advise you or your attorney to request an independent evaluation. If your attorney wishes to speak with me, he/she can set up an appointment with the front desk at my forensic rate.”.

Out of curiosity, what is a typical forensic rate as compared to therapy? Say 60m therapy = X, what would a forensic rate be?

 

[WisNeuro]

Out of curiosity, what is a typical forensic rate as compared to therapy? Say 60m therapy = X, what would a forensic rate be?

Ranges quite a bit. For a lot of people, anywhere between 150-350. Some can charge 500+/hour, though.