ESA letter rejected because I, a licensed psychologist, am not a physician. Is this legal?

[Groupthink]

A client of mine asked me to write a letter in support of having an Emotional Support Animal. They are a renter in a condo. This is a long-standing client of mine who is high functioning and has made great progress. I wrote a letter outlining their diagnosis, their progress in treatment, continuing symptoms, and specifically how the presence of the animal will be of clinical benefit.

The client came back to me and told me that the condo association has rejected the letter. Their reason was, and I quote, "We only accept letters from physicians. Undergoing psychoanalysis or anything like that is not valid. We need a psychiatrist or primary care doctor to write your letter. A psychologist is not a physician and we cannot accept this letter."

This is absolutely ridiculous, and I am furious for my client. We had to work through my client feeling like their diagnosis is invalid, feeling minimized, etc. due to the rejection of this letter. And maybe in a weird identification enactment, I'm feeling the same exact way except with regard to my credentials. My back has really gone up: I am not giving my clients "psychoanalysis" but instead providing evidence-based treatments with targeted and measured symptoms that are tracked using scientifically-validated methods.

How dare this random condo association dismiss the last decade of clinical experience I have worked so hard for. I mean, is this even legal? Under the Fair Housing Act (found at: Assistance Animals):

"Information Confirming Disability-Related Need for an Assistance Animal. . . • Reasonably supporting information often consists of information from a licensed health care professional – e.g., physician, optometrist, psychiatrist, psychologist, physician’s assistant, nurse practitioner, or nurse – general to the condition but specific as to the individual with a disability and the assistance or therapeutic emotional support provided by the animal."

Nowhere in the law written by the US Department of Housing and Urban Development does it say that the person writing the letter must be a physician who can prescribe medication. It specifically states that in order to provide equal opportunity under the Fair Housing Act, the letter must be from "a licensed health care professional", which includes psychologists.

What do I do in this situation? I feel like swooping in as the rescuer by obtaining an ROI for my client's HOA and arguing the case. This feels like utter discrimination and a complete dismissal of everything I have worked for. That's probably why I shouldn't do anything, as that's an overreach of my role clinically. In that case, what should my client do?

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[Sanman]

You mean a condo association made up their own rules around a made up intervention that you have no actual ability to assess?

What do you do? Tell the patient to go to their PCP or psychiatrist. You can forward the letter for copy and paste if you want to be nice?

 

[BuckeyeLove]

I'd treat very lightly here. This whole ESA thing is just RIPE for a blow up. ESA letters are effectively in a sense a psycho-legal opinion. Ergo, treating clinicians should not be proffering evaluative opinions used in a legal/capacity situation. Imagine being on the stand. "So, doctor, is it true that you are the treating psychologist for Mr. So and So. And is it also true that you signed a letter stating that he would be a good candidate for an emotional support animal? Is this analysis meant to be impartial? If so, couldn't we say that your clinical relationship with Mr. So and So has the potential to make you PARTIAL? Yes doctor? I'm waiting? No further questions your honor."

 

[AcronymAllergy]

I would not at all get directly involved in arguing to/with the HOA. An ESA letter is, per APA, a medicolegal document in nature, and by advocating on behalf of the patient, you're already blurring the line. It also sets the stage to have to do this with all future patients. I personally go nowhere near ESA letters, for various reasons.

Some of this may depend on state law. If the patient wants to appeal it, themselves or by retaining an attorney, they can do so. Or, as suggested, they can take your letter to their PCP. But you probably wouldn't (or at least shouldn't) try to directly appeal to a worker's comp company or Social Security Disability for a declined case, so you shouldn't do so here.

And yeah, probably a good idea to get used to being told that your opinion matters less than a physician's sooner rather than later, particularly when it comes to legal matters, and to not taking it personally. It's not always true, and there are definitely ways to argue against it (e.g., if you're deposed), so you don't have to accept it. But you should get used to it. It's an opinion held even by (in my experience) a not-insubstantial portion of the general public, it comes up often in legal cases (e.g., attorneys trying to get under your skin), and in some instances, it's part of legislation. For example, psychologists in many states can't make ultimate determinations about civil competencies, such as to for medical or financial decision making, with occasional exceptions such as for intellectual disability. Heck, some states don't even let (neuro)psychologists diagnose TBI.

 

[R. Matey]

You can write an ESA letter per FHA. The better question is "Why would you?"

 

[Sanman]

I'd treat very lightly here. This whole ESA thing is just RIPE for a blow up. ESA letters are effectively in a sense a psycho-legal opinion. Ergo, treating clinicians should not be proffering evaluative opinions used in a legal/capacity situation. Imagine being on the stand. "So, doctor, is it true that you are the treating psychologist for Mr. So and So. And is it also true that you signed a letter stating that he would be a good candidate for an emotional support animal? Is this analysis meant to be impartial? If so, couldn't we say that your clinical relationship with Mr. So and So has the potential to make you IMPARTIAL? Yes doctor? I'm waiting? No further questions your honor."

That's not even getting into the issue of having no actual ability to assess the impact of said animal on emotional health. If we did, why would this not be a part of treatment recommendations?

 

[Groupthink]

I would not at all get directly involved in arguing to/with the HOA. An ESA letter is, per APA, a medicolegal document in nature, and by advocating on behalf of the patient, you're already blurring the line. It also sets the stage to have to do this with all future patients. I personally go nowhere near ESA letters, for various reasons.

Some of this may depend on state law. If the patient wants to appeal it, themselves or by retaining an attorney, they can do so. Or, as suggested, they can take your letter to their PCP. But you probably wouldn't (or at least shouldn't) try to directly appeal to a worker's comp company or Social Security Disability for a declined case, so you shouldn't do so here.

And yeah, probably a good idea to get used to being told that your opinion matters less than a physician's sooner rather than later, particularly when it comes to legal matters, and to not taking it personally. It's not always true, and there are definitely ways to argue against it (e.g., if you're deposed), so you don't have to accept it. But you should get used to it. It's an opinion held even by (in my experience) a not-insubstantial portion of the general public, it comes up often in legal cases (e.g., attorneys trying to get under your skin), and in some instances, it's part of legislation. For example, psychologists in many states can't make ultimate determinations about civil competencies, such as to for medical or financial decision making, with occasional exceptions such as for intellectual disability. Heck, some states don't even let (neuro)psychologists diagnose TBI.

Thank you. I agree that I should not step forward with regard to patient advocacy in this situation.

However, speaking entirely legalistically here, the actual law of the Fair Housing Act states that psychologists are eligible to provide letters for these accommodations.

Is this condo association not, therefore, breaking the law?

It's very frustrating that with this level of education there is little respect for what I do. I hate this planet sometimes.

 

[ClinicalABA]

I can buy this- no questions asked-and put it on any dog that'll let me. That's why- amongst many other reasons- I don't write ESA letters.

 

[Groupthink]

That's not even getting into the issue of having no actual ability to assess the impact of said animal on emotional health. If we did, why would this not be a part of treatment recommendations?

This conversation is addressing the macro level "should clinicians write ESA letters or not?" That is not my question, and I would appreciate the conversation not going in this direction. The letter is already written, and is a rare case of such occurring in my group practice in which there does happen to be evidence that equine-assisted therapy has had measurable beneficial effect which could likely be generalized to overall livelihood for this client.

For what it's worth, at least I'm not advocating that they keep a horse in their condo. 😀

 

[R. Matey]

However, speaking entirely legalistically here, the actual law of the Fair Housing Act states that psychologists are eligible to provide letters for these accommodations.

Is this condo association not, therefore, breaking the law?

Not a lawyer, but I imagine they have power in determining what kinds of letters they accept.

 

[Groupthink]

You mean a condo association made up their own rules around a made up intervention that you have no actual ability to assess?

What do you do? Tell the patient to go to their PCP or psychiatrist. You can forward the letter for copy and paste if you want to be nice?

This conversation is regarding the LEGAL ability for some random board member to override my recommendation. The US Fair Housing Act specifies that Psychologists are entities who are entitled to providing these recommendations, and that these recommendations cannot be denied due to FHA.

I am being told that my clinical recommendation (note: not intervention) is not acceptable, when the FHA says it absolutely is. Is the condo association in violation of the law?

 

[Groupthink]

Not a lawyer, but I imagine they have power in determining what kinds of letters they accept.

Even though the Fair Housing Act specifies that such letters documenting disability must be accepted, and that Psychologists are grouped within "licensed health care providers" who are qualified to write these letters?

 

[cara susanna]

I hope it's okay if I summon @futureapppsy2 who is very knowledgable in the area of disability rights

 

[Sanman]

This conversation is addressing the macro level "should clinicians write ESA letters or not?" That is not my question, and I would appreciate the conversation not going in this direction. The letter is already written, and is a rare case of such occurring in my group practice in which there does happen to be evidence that equine-assisted therapy has had measurable beneficial effect which could likely be generalized to overall livelihood for this client.

For what it's worth, at least I'm not advocating that they keep a horse in their condo. 😀

Is your client planning on keeping a horse in their condo? Because then you may have some ability to advocate based on treatment outcome. I already addressed what you should do in an earlier comment.

 

[Sanman]

This conversation is regarding the LEGAL ability for some random board member to override my recommendation. The US Fair Housing Act specifies that Psychologists are entities who are entitled to providing these recommendations, and that these recommendations cannot be denied due to FHA.

I am being told that my clinical recommendation (note: not intervention) is not acceptable, when the FHA says it absolutely is. Is the condo association in violation of the law?

Also not a lawyer (and you would get more informed legal opinions on legal board instead of a psychology board), but the fair housing act has nothing to do with condo regulations. They can have additional regulations if they want to as a private entity. They can say it does not meet their condo regs. Does anyone really want to take that to court and pay the required legal bills?

 

[Groupthink]

Also not a lawyer (and you would get more informed legal opinions on legal board instead of a psychology board), but the fair housing act has nothing to do with condo regulations. They can have additional regulations if they want to as a private entity. They can say it does not meet their condo regs. Does anyone really want to take that to court and pay the required legal bills?

From my understanding, any building that has more than 4 dwellings which they take care of is subjected to the Fair Housing Act.

I'm just mad that my credentials are being what I believe to be illegally dismissed for the opinion of...a medical doctor who wouldn't know or have the ability to assess my client anywhere near the extent to which I have been able

It feels wrong.

 

[Sanman]

From my understanding, any building that has more than 4 dwellings which they take care of is subjected to the Fair Housing Act.

I'm just mad that my credentials are being what I believe to be illegally dismissed for the opinion of...a medical doctor who wouldn't know or have the ability to assess my client anywhere near the extent to which I have been able

It feels wrong.

Sure, it also doesn't matter and you have already dedicated too much time and mental energy to something that does not matter. They are not a judge or a court of law. They are a random person on a condo board and their opinion really does not matter. That said, HOA and condo boards tend to draw folks with personality disorders, IMO, who want some power. No real other draw to the position.

Interesting sidebar:

Psychologist defines the HOA Syndrome caused by oppressive HOAs

 

[R. Matey]

From my understanding, any building that has more than 4 dwellings which they take care of is subjected to the Fair Housing Act.

I'm just mad that my credentials are being what I believe to be illegally dismissed for the opinion of...a medical doctor who wouldn't know or have the ability to assess my client anywhere near the extent to which I have been able

It feels wrong.

It's not wrong to be angry about someone questioning your expertise, but as others have pointed out, this person is of little consequence and your client likely has legal options available to them.

 

[AcronymAllergy]

Thank you. I agree that I should not step forward with regard to patient advocacy in this situation.

However, speaking entirely legalistically here, the actual law of the Fair Housing Act states that psychologists are eligible to provide letters for these accommodations.

Is this condo association not, therefore, breaking the law?

It's very frustrating that with this level of education there is little respect for what I do. I hate this planet sometimes.

Personally, I'm not sure it's disrespect for what you do specifically so much as it is a condo association not wanting pets and trying to do all they can to keep them out. Or as has been said, an HOA board on a power trip. Or any other number of things. But even if they are ignorant to your expertise, at the end of the day, IMO, who cares. Let a judge tell them they're being idiots.

As for if the association is breaking the law, I don't know. It'd seem so, but I don't know if there are situations in which state law can supersede or impose additional requirements.

 

[PsyDr]

1) The professional literature and the Trust says we should NOT write these letters. Read Youngren's article.
2) You have done your job. You are treating the person, not trying to be their legal advocate. This is your patient's problem. You are becoming over-involved.
3) A condo might not qualify under the FHA. Those units are individually owned, which likely fall under the exemption. This is one of the reasons that this is not your problem.
4) If you are pissed off, you can always write them a certified letter, saying, " While the Fair Housing Act of 1988 states that "licensed mental health providers" are allowed to write ESA letters, I would like to thank you for taking the time to document your contrary legal opinion. I will forward your written opinion with my complaint to Report Housing Discrimination ."

 

[WisNeuro]

Bottom line, if you don't write pseudoscientific letters for treatment, you don't have to deal with this ****. In other news, if I am ever harmed by an emotional support animal, you better believe that I am naming whomever wrote that letter in a lawsuit, and I will savage them with a dissertation on how their letter is not supported by the empirical literature.,

 

[cara susanna]

Honestly, I'm very much against ESAs letters but I would still be mad that they think I'm not as good as a physician 😆

 

[quickpsych]

1) The professional literature and the Trust says we should NOT write these letters. Read Youngren's article.

The Trust probably says this because it opens possible legal cases which then they have to pay expenses for if a claim is filed against you. Maybe an oversimplification but I'm sure there's an interest there in reducing claim expenses. Do you have a link to this Youngren article, just curious as my assumption is any literature saying not to write these letters is due to a mix of legal risk and blurring the lines of one's professional relationship with the patient.

2) You have done your job. You are treating the person, not trying to be their legal advocate. This is your patient's problem. You are becoming over-involved.

100%

3) A condo might not qualify under the FHA. Those units are individually owned, which likely fall under the exemption. This is one of the reasons that this is not your problem.

I think OP's post said the patient's particular unit is under a HUD contract which would likely qualify under FHA regulations. But we're not lawyers and I wouldn't recommend any psychologist or doctor get involved in trying to prove that.

4) If you are pissed off, you can always write them a certified letter, saying, " While the Fair Housing Act of 1988 states that "licensed mental health providers" are allowed to write ESA letters, I would like to thank you for taking the time to document your contrary legal opinion. I will forward your written opinion with my complaint to Report Housing Discrimination ."

I like this. In fact, I love this.

 

[quickpsych]

To preface all below, I agree, it's frustrating, the HOA person is power tripping and you have a right to feel insulted.

A client of mine asked me to write a letter in support of having an Emotional Support Animal. They are a renter in a condo. This is a long-standing client of mine who is high functioning and has made great progress. I wrote a letter outlining their diagnosis, their progress in treatment, continuing symptoms, and specifically how the presence of the animal will be of clinical benefit.

I wouldn't have written an ESA in this case, but if I even wanted to I would definitely have not included discussion of their progress in treatment, psychoanalysis, or gotten into many if any details about their symptoms (not just from a HIPAA standpoint but also because someone could say "well if they're making great progress they don't need an ESA, they need to keep seeing you. Plus people who don't know things like to draw their own conclusions and unlike you and I, aren't beholden by confidentiality and HIPAA regulations ). This is also probably why most of the replies here say to just not write these things in general. Just my two cents on that one.

The client came back to me and told me that the condo association has rejected the letter. Their reason was, and I quote, "We only accept letters from physicians. Undergoing psychoanalysis or anything like that is not valid. We need a psychiatrist or primary care doctor to write your letter. A psychologist is not a physician and we cannot accept this letter."

I think it's funny, although not surprised given HOA power trips, that whoever this person is thinks they can speak on "undergoing psychoanalysis or anything like that is not valid" or just kind of ignore expertise vs their opinion. That said on a serious note on this particular piece, now the HOA member knows this individual is in "psychoanalysis" and who knows what they'll do with that information or who they'll blab too. I'm not saying that's your problem or there will be a problem but if you get a complaint against you from this client later, talk with your insurance for legal consult before speaking with anyone else. Sticking to diagnostic language and by the book with minimal specifics is generally a good idea. This is also a great example of why some people shouldn't have access to receiving these kind of legal medical documents, it's possible there was a more secure and compliant process: for example if this condo unit is under a HUD contract, I'd imagine the letter would go to HUD, not the HOA because I'd think HUD is authorized to handle sensitive medical and confidential paperwork. Best part about that path is now it’s between HUD and the HOA , not you and the HOA , and if it’s rejected you can comfortably redirect the client to appeal with HUD as I’m sure they’re used to appeals and aren’t going to act out of line as an HOA might.

This is absolutely ridiculous, and I am furious for my client. We had to work through my client feeling like their diagnosis is invalid, feeling minimized, etc. due to the rejection of this letter. And maybe in a weird identification enactment, I'm feeling the same exact way except with regard to my credentials. My back has really gone up: I am not giving my clients "psychoanalysis" but instead providing evidence-based treatments with targeted and measured symptoms that are tracked using scientifically-validated methods.

I agree with you and everyone else here, it's absurd. I'm annoyed just reading about it. The HOA person can pound sand respectively, you know as well as we all do, need to let this stuff roll off our proverbial backs.

How dare this random condo association dismiss the last decade of clinical experience I have worked so hard for. I mean, is this even legal? Under the Fair Housing Act (found at: Assistance Animals):

"Information Confirming Disability-Related Need for an Assistance Animal. . . • Reasonably supporting information often consists of information from a licensed health care professional – e.g., physician, optometrist, psychiatrist, psychologist, physician’s assistant, nurse practitioner, or nurse – general to the condition but specific as to the individual with a disability and the assistance or therapeutic emotional support provided by the animal."

Nowhere in the law written by the US Department of Housing and Urban Development does it say that the person writing the letter must be a physician who can prescribe medication. It specifically states that in order to provide equal opportunity under the Fair Housing Act, the letter must be from "a licensed health care professional", which includes psychologists.

It may be against the law but as others have said this probably isn't worth the headache for you. The client may have legal recourse here but that's something they need to pursue if they feel they're being violated regarding their rights. As others have said if it went to court, a lawyer for the HOA would dismantle any argument you have unfortunately, they could also take the low road and say you violated the patient's confidentiality and creating duress (as absurd as it sounds). The HOA powertripper could also say the same, although they'd be dumb to do so as then it opens them up to liability. There's a whole swamp of crap so to speak you don't want to wade into or a boat you want to rock. It's unlikely and I wouldn't sweat it, but don't push the issue and open yourself up to liability. You wrote the letter to advocate for the client, you did your part.

What do I do in this situation? I feel like swooping in as the rescuer by obtaining an ROI for my client's HOA and arguing the case. This feels like utter discrimination and a complete dismissal of everything I have worked for. That's probably why I shouldn't do anything, as that's an overreach of my role clinically. In that case, what should my client do?

You do and it's understandable. You care about the client, you want them to get the support you have determined they need. But you've also been personally snubbed by some HOA power tripper and unfortunately that also means that this shows you are certainly no longer impartial. If it got into a legal case, the HOA legal side would absolutely go after this and try to show you are too close to the situation and I'm sure a slew of other things to try to weaken your stance further.

On a side note in regards to writing ESA letters , despite the fact that a lot of folks will simply not write them, there are psychologists who do write them. But they are well versed in the nuances of writing them and have weighed the risk/benefits very carefully, know how to use wording and documentation to CYA and follow what it seems psychiatrists do when writing these:

Before I was licensed I did therapy under supervision in settings that had psychiatrists working there where ESA letters and other similar letters were a dime a dozen requests. The psychiatrists would often write them, and obviously not licensed I couldn't. However the psychiatrists would often consult with us if we were seeing the patient for therapy and thus we got to see these letters and how they were worded. They were extremely concise, almost meticulously vague but made the case for the ESA. They stuck to a specific script so to speak. They noted the recommendation (which was often worded as the patient "will require" or "should have access to" or "will need access to", noted the diagnosis (including the DSM/ICD codes) and maybe a brief overview of general symptoms. They specifically noted their role and who they were (i.e. psychiatrist) and specifically noted, sometimes with the full regulation copied in, that they met that state or regulation ( or specific settings) requirements for acceptable professionals to write these letters. One even took and referenced literature that provided evidence of the benefit of an ESA for specific diagnoses when applicable. They definitely did not name specific treatment modalities (i.e. in psychoanalysis), medications, or any details of the course of treatment. In other words if the law or regulations noted that their profession (and license) was accepted to write these, they would state that. They also ensured they had a signed release and documented the client was agreeable to the information being provided. <--- I"m not saying you should go back and write something else in this situation because the boat has left the harbor and isn't coming back so to speak. Now it's up to the client to decide if they want to just get a letter from their PCP or take legal action against the HOA, their choice, not yours.

Ever see the episode of Seinfeld where Jerry gets his dentist friend to write letters for insurance covered massages because "just need a doctor to say you have a medical condition that benefits from massages" then the doctor got investigated. He just wanted to do his friend a favor, help out ya know. ESAs are kind of like that, they're a slippery slope.

 

[PsyDr]

The Trust probably says this because it opens possible legal cases which then they have to pay expenses for if a claim is filed against you. Maybe an oversimplification but I'm sure there's an interest there in reducing claim expenses. Do you have a link to this Youngren article, just curious as my assumption is any literature saying not to write these letters is due to a mix of legal risk and blurring the lines of one's professional relationship with the patient.

1) Having mutual interests does not negate a position. The Trust also doesn't want us to commit insurance fraud, or murder patients in the course of treatment.

2) Emotional Support Animal Assessments: Toward a Standard and Comprehensive Model for Mental Health Professionals

3) IIRC, another issue is the idea that certifying implies that your treatment is not improving your patient, which implies that your treatment is not medically indicated, which implies you are billing insurance for nonmedically necessary services.

 

[msc545]

Thank you. I agree that I should not step forward with regard to patient advocacy in this situation.

However, speaking entirely legalistically here, the actual law of the Fair Housing Act states that psychologists are eligible to provide letters for these accommodations.

Is this condo association not, therefore, breaking the law?

It's very frustrating that with this level of education there is little respect for what I do. I hate this planet sometimes.

Physicians organizations have far better lobbying and a lot more money than Psychologists do. That is why statements like this occur and why an MD Urologist's "Psychological" opinion is considered better than any of ours.

Let it go - costs too much money and time to fight it.

 

[quickpsych]

1) Having mutual interests does not negate a position. The Trust also doesn't want us to commit insurance fraud, or murder patients in the course of treatment.

2) Emotional Support Animal Assessments: Toward a Standard and Comprehensive Model for Mental Health Professionals

Thanks. Interesting read. It also brings up a valid point regarding laws and regulations and the use of the work "disability" as a defining criteria for determining if an ESA would qualify as needed. Also makes a great point about the use of assessment tools to objectively measure the symptoms in the absence of said animal and again in the presence of said animal, and I imagine using a tool for malingering.

3) IIRC, another issue is the idea that certifying implies that your treatment is not improving your patient, which implies that your treatment is not medically indicated, which implies you are billing insurance for nonmedically necessary services.

Thought the same thing when reading the OP of insurance or other third parties questioning it (which is kind of what the HOA power tripper is implying they're doing to OP) . But isn't part of the treatment in cases where an ESA would be of benefit...prescribing or recommending the treatment of having the ESA? The entire basis of many forms of evidence based treatment relies on the patient doing things, or having access to resources, outside the therapy room to improve.

I think there is, in general, confusion and blurred lines between what is an emotional support animal and what is a service animal. Then throw into the mix therapy animals that often come to places (such as places I work at) with their handler and visit residents and patients.

Then again I did a quick google search of "do emotional support animals help anxiety and depression" and a top result was the website of an LPC who apparently regularly "prescribes" the use of ESAs and also encourages clinicians to advocate and fight for their client against landlords which seems like adding fuel to a fire : ESA Primer: A Therapist Explains Emotional Support Animals 🙄 And just like that, a quick google search and finding this link is people run with it and take it too far and just like that I've struck out part of my earlier comment above while editing this reply😒. Now I know why you recommended reading more of Younggren.

 

[quickpsych]

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Physicians organizations have far better lobbying and a lot more money than Psychologists do. That is why statements like this occur and why an MD Urologist's "Psychological" opinion is considered better than any of ours.

Let it go - costs too much money and time to fight it.

Eh at least a urologist can say, a urinary tract infection is causing psychological difficulties with medical data backing it up. A PCP might just go "eh they did a PHQ-2, they need three dogs and a bird to feel better " and probably get approved because MD or DO is after the name. Although I hope there's more discretion then that in doing these things.

Agreed, gotta let this one go.

 

[PsyDr]

Thanks. Interesting read. It also brings up a valid point regarding laws and regulations and the use of the work "disability" as a defining criteria for determining if an ESA would qualify as needed. Also makes a great point about the use of assessment tools to objectively measure the symptoms in the absence of said animal and again in the presence of said animal, and I imagine using a tool for malingering.

Thought the same thing when reading the OP of insurance or other third parties questioning it (which is kind of what the HOA power tripper is implying they're doing to OP) . But isn't part of the treatment in cases where an ESA would be of benefit...prescribing or recommending the treatment of having the ESA? The entire basis of many forms of evidence based treatment relies on the patient doing things, or having access to resources, outside the therapy room to improve.

I think there is, in general, confusion and blurred lines between what is an emotional support animal and what is a service animal. Then throw into the mix therapy animals that often come to places (such as places I work at) with their handler and visit residents and patients.

Then again I did a quick google search of "do emotional support animals help anxiety and depression" and a top result was the website of an LPC who apparently regularly "prescribes" the use of ESAs and also encourages clinicians to advocate and fight for their client against landlords which seems like adding fuel to a fire : ESA Primer: A Therapist Explains Emotional Support Animals 🙄 And just like that, a quick google search and finding this link is people run with it and take it too far and just like that I've struck out part of my earlier comment above while editing this reply😒. Now I know why you recommended reading more of Younggren.

1) The empirical literature does not support for ESAs, aside from physical exercise from dogs. Cats apparently have the reverse effect.
2) I do not care what some master's level person feels like.
3) Everyone recognizes that these positions are great examples of countertransference, right? Countertransference is typically something to work through, not act upon.
4) I don't understand how a treatment provider maintains professional boundaries with advocating.


*I did a dive on the etymology of "guys", it's gender neutral .

 

[quickpsych]

1) The empirical literature does not support for ESAs, aside from physical exercise from dogs. Cats apparently have the reverse effect.
2) I do not care what some master's level person feels like.

They're doing their own research and contributing to their own literature. They're also advocating for it like that link above of some random LPC telling clients they can and should have an ESA and their therapists should fight for them. They're out there like the Amens, Petersons and Phils of the psych world saying these things, growing a public belief in these things, and saying if you don't feel you're getting what you need we'll help you. You might not care, but they do and are marching forward with it:

Social work doing their own research: Study Finds First Scientific Evidence Emotional Support Animals Benefit Those with Chronic Mental Illness | UToledo News

I think some of this is due to the shift from patient/client to "consumer" as they often call clients/patients in more and more settings. You'd not be surprised to hear that plenty of midlevels, and some psychologists, will see if that way and say they expect something so we should provide something. Which is troubling to say the least as it erodes trust in expertise and relies more on expectations of I deserve what I think I should get or what some other "expert" says I should get for paying for your services or treatment.

3) Everyone recognizes that these positions are great examples of countertransference, right? Countertransference is typically something to work through, not act upon.

Everyone? No. See above. Are you correct, yes.

4) I don't understand how a treatment provider maintains professional boundaries with advocating.

You don't, but many see it as something they and we should do. And if you've worked with other health care professionals, they often "feel" the same. Sure advocating could just be talking to another provider in a setting about advocating for a mutual patient, but it could be more according to some social workers and mental health providers:

Social work advocating for psychologists to do more outside of the treatment room for their clients: The Advocate – Society for the Advancement of Psychotherapy

They're also a lot of the same types running agencies and organizations, managing the funding, providing the supervision, analyzing "consumer" satisfaction surveys.

You make great points and I'm in agreement. Reality is that whether you care or not what midlevels do, think or feel, they're going to do it anyway. And some are out there presenting their feeling on these things as beneficial to consumers in easy to understand, emotionally activating, concrete ways: dogs make others happy, they make me happy, therefore an ESA could make you happy.

On a side note, I feel cats are superior to dogs.

 

[futureapppsy2]

I hope it's okay if I summon @futureapppsy2 who is very knowledgable in the area of disability rights

So, the OP is right about psychologists being able to write these letters, and any housing organization/landlord can essentially refuse to accept an ESA letter. The person requesting the ESA can appeal and/or sue, of course, but that takes time and money, so relatively few people do. The exception to this would be college dormitories, where it seems significantly easier to appeal ESA stuff as long as you have a legit letter (and not one from a mill).

As for if psychologists and other clinicians should write these letters, I'm of two minds. On one hand, I 100% get not wanting to put oneself in a place of legal vulnerability (and I'm 100% with you--I'm always very cautious when endorsing something professionally). Otoh, disabled people live in a world were access to legal rights and services is gatekept, and if no one writes these letters because they don't want to attest to disability status, people who legitimately do need and qualify for reasonable accommodations and other protections won't get them. I've had to get physician letters numerous times in my life attesting to my lifelong, static, and very visible disability, and if my PCPs refused to write them because they aren't, say, in PM&R, or just don't want to say if I'm disabled, I'd be in a world of hurt for no logical reason when it comes to some basic things (e.g., putting up grab bars in an apartment). Also, I think psychologists in general don't always do a good job of recognizing that a lot of our patients are disabled (ADA/Rehab Act definition) by virtue of their mental illnesses alone and that mental illness are often disabling in both a legal and practical sense.

 

[WisNeuro]

So, the OP is right about psychologists being able to write these letters, and any housing organization/landlord can essentially refuse to accept an ESA letter. The person requesting the ESA can appeal and/or sue, of course, but that takes time and money, so relatively few people do. The exception to this would be college dormitories, where it seems significantly easier to appeal ESA stuff as long as you have a legit letter (and not one from a mill).

As for if psychologists and other clinicians should write these letters, I'm of two minds. On one hand, I 100% get not wanting to put oneself in a place of legal vulnerability (and I'm 100% with you--I'm always very cautious when endorsing something professionally). Otoh, disabled people live in a world were access to legal rights and services is gatekept, and if no one writes these letters because they don't want to attest to disability status, people who legitimately do need and qualify for reasonable accommodations and other protections won't get them. I've had to get physician letters numerous times in my life attesting to my lifelong, static, and very visible disability, and if my PCPs refused to write them because they aren't, say, in PM&R, or just don't want to say if I'm disabled, I'd be in a world of hurt for no logical reason when it comes to some basic things (e.g., putting up grab bars in an apartment). Also, I think psychologists in general don't always do a good job of recognizing that a lot of our patients are disabled (ADA/Rehab Act definition) by virtue of their mental illnesses alone and that mental illness are often disabling in both a legal and practical sense.

I don't know many, if any, people who refuse to write ESA letters who won't recognize disability from their mental illness. Though, doing an actual evaluation that establishes disability status legally is a different story. Rather, that emotional support animals are not a "treatment" for that mental illness. They receive the same benefits, and challenges, from pet ownership as anyone else. Pets, no matter who the owner is, should not receive preferential treatment in any case aside from legitimate service animals.

As to personal experience, in the handful of times I've been asked to write an ESA letters, the individuals were not disabled in any legal sense. Mild sx, fully independent i/ADLs, no sig impairment in social/occupational fx. They simply wanted an override for the rules of the place they were moving to. That being said, even with more impairing sx, I still wouldn't write that ESA letter even though I am fairly well versed in disability evals and the law for the reasons mentioned above.

 

[futureapppsy2]

I don't know many, if any, people who refuse to write ESA letters who won't recognize disability from their mental illness. Though, doing an actual evaluation that establishes disability status legally is a different story. Rather, that emotional support animals are not a "treatment" for that mental illness. They receive the same benefits, and challenges, from pet ownership as anyone else. Pets, no matter who the owner is, should not receive preferential treatment in any case aside from legitimate service animals.

As to personal experience, in the handful of times I've been asked to write an ESA letters, the individuals were not disabled in any legal sense. Mild sx, fully independent i/ADLs, no sig impairment in social/occupational fx. They simply wanted an override for the rules of the place they were moving to. That being said, even with more impairing sx, I still wouldn't write that ESA letter even though I am fairly well versed in disability evals and the law for the reasons mentioned above.

I’ve met a lot of psychologists who said that they don’t need to know about disability law because they aren’t in rehab/neuro/health psych and therefore don’t treat any patients with disabilities.

I agree that a lot of (most) ESA requests are literally just people wanting to have a pet in a place that doesn’t allow pets but also that there’s a (small?) minority of patients for whom having a pet really is a reasonable accommodation that reduces barriers. The ESA loophole is massively abused by a lot of people and that creates a lot of issues. On the other hand, the systems that are obsessed with trying to catch fakers can sometimes get absurd—I once went to a paratransit evaluation where they tried to push me over to see if I would actually fall down despite me literally using mobility aids my entire life and having documentation to that effect—and paratransit isn’t even a good service that anyone with any other options would use. So, it’s a balance, I guess. 🤷‍♀️

(Also I’m curious as to why patients with no impairment in functioning have an active psych diagnosis, unless they’re trying to get accommodations for an in-remission diagnosis with little to no residual symptoms, which is just fraud)

 

[smalltownpsych]

My biggest problem with writing these is the blurring of lines of treatment vs. advocate. That being said, I have decided that it made sense to do it for a few cases. When I have written them, I have used the following language:
To whom it may concern:

This letter is provided at the request of patient. Patient has been seeing myself for individual psychotherapy for a mental health condition that meets the criteria for a disability as delineated in the American with Disabilities Act. It is clear that she benefits both physiologically and psychologically from the therapeutic effects of her ESA and it is reasonable to allow her to have this ESA to help her with her mental health disability.

 

[Therapist4Chnge]

I think some of this is due to the shift from patient/client to "consumer" as they often call clients/patients in more and more settings. You'd not be surprised to hear that plenty of midlevels, and some psychologists, will see if that way and say they expect something so we should provide something.

I loathe the use of “consumer” or “customer”. A patient doesn’t go to a surgeon, oncologist, podiatrist, dentist, psychologist, et al. like they go to a florist or Home Depot.

You don't, but many see it as something they and we should do. And if you've worked with other health care professionals, they often "feel" the same. Sure advocating could just be talking to another provider in a setting about advocating for a mutual patient, but it could be more according to some social workers and mental health providers:

I’d argue “advocating” for interventions in line with the literature is our ethical responsibility. When I was in the VA, ESA’s were contraindicated for PTSD & axis-II diagnoses, which were the primary psych dx’s I treated. Use of service animals for folks with SCI, epilepsy/seizure disorders, and similar are obviously not the same category as the “tell my landlord I can have an emotional support ostrich Emmanuel!” The average ESA with a “service” harness from Amazon would act about the same as a wild ostrich.

You make great points and I'm in agreement. Reality is that whether you care or not what midlevels do, think or feel, they're going to do it anyway. And some are out there presenting their feeling on these things as beneficial to consumers in easy to understand, emotionally activating, concrete ways: dogs make others happy, they make me happy, therefore an ESA could make you happy.

Just like life coaches and reiki “experts”, if midlevels are promoting a bogus (& sometimes harmful) “intervention(s)”, we as a profession should speak out against them.

 

[Fan_of_Meehl]

A client of mine asked me to write a letter in support of having an Emotional Support Animal. They are a renter in a condo. This is a long-standing client of mine who is high functioning and has made great progress. I wrote a letter outlining their diagnosis, their progress in treatment, continuing symptoms, and specifically how the presence of the animal will be of clinical benefit.

The client came back to me and told me that the condo association has rejected the letter. Their reason was, and I quote, "We only accept letters from physicians. Undergoing psychoanalysis or anything like that is not valid. We need a psychiatrist or primary care doctor to write your letter. A psychologist is not a physician and we cannot accept this letter."

This is absolutely ridiculous, and I am furious for my client. We had to work through my client feeling like their diagnosis is invalid, feeling minimized, etc. due to the rejection of this letter. And maybe in a weird identification enactment, I'm feeling the same exact way except with regard to my credentials. My back has really gone up: I am not giving my clients "psychoanalysis" but instead providing evidence-based treatments with targeted and measured symptoms that are tracked using scientifically-validated methods.

How dare this random condo association dismiss the last decade of clinical experience I have worked so hard for. I mean, is this even legal? Under the Fair Housing Act (found at: Assistance Animals):

"Information Confirming Disability-Related Need for an Assistance Animal. . . • Reasonably supporting information often consists of information from a licensed health care professional – e.g., physician, optometrist, psychiatrist, psychologist, physician’s assistant, nurse practitioner, or nurse – general to the condition but specific as to the individual with a disability and the assistance or therapeutic emotional support provided by the animal."

Nowhere in the law written by the US Department of Housing and Urban Development does it say that the person writing the letter must be a physician who can prescribe medication. It specifically states that in order to provide equal opportunity under the Fair Housing Act, the letter must be from "a licensed health care professional", which includes psychologists.

What do I do in this situation? I feel like swooping in as the rescuer by obtaining an ROI for my client's HOA and arguing the case. This feels like utter discrimination and a complete dismissal of everything I have worked for. That's probably why I shouldn't do anything, as that's an overreach of my role clinically. In that case, what should my client do?

"Is this legal?"

I mean, ultimately these things are decided by juries in actual trials. Not personally aware of any case law or precedents in this area. May want to consider, what is it, the Daubert standard in relation to ESAs as evidenced-based treatment? That could get interesting. At this historical juncture, I think the case law is WAY behind the times/fads regarding ESAs and 'service animals.'

Also, it always pays to think twice about 'swooping in' as 'rescuer' for a psychotherapy client. You may be participating a quite dysfunctional 'oppressor--victim--savior' dynamic constituting the root of your client's pathology.

 

[Fan_of_Meehl]

My biggest problem with writing these is the blurring of lines of treatment vs. advocate. That being said, I have decided that it made sense to do it for a few cases. When I have written them, I have used the following language:
To whom it may concern:

This letter is provided at the request of patient. Patient has been seeing myself for individual psychotherapy for a mental health condition that meets the criteria for a disability as delineated in the American with Disabilities Act. It is clear that she benefits both physiologically and psychologically from the therapeutic effects of her ESA and it is reasonable to allow her to have this ESA to help her with her mental health disability.

Serious question:

What if a client suffers from the MH disability of clinical depression and--as part of their unique personal and MH history--you discover that them engaging in daily gardening (at their 'old' property, years ago) was vital in helping them recover from a past major depressive episode but at their current residence HOA regulations forbid having a garden. Wouldn't a letter in support of allowing their case to be an exception to the HOA proscription against gardening be following the same logic? There is a very plausible argument that the behavioral activation/ Vitamin D / exercise / self-efficacy associated with gardening for this patient would be 'antidepressant' and mitigate their disability of major depressive d/o.

I see it as the exact same argument and I agree that it blurs the line between psychotherapy and advocacy and, further, it is about putting MH professionals out there as sort of a quasi-priesthood or judges deciding matters of public policy and law.

 

[futureapppsy2]

Serious question:

What if a client suffers from the MH disability of clinical depression and--as part of their unique personal and MH history--you discover that them engaging in daily gardening (at their 'old' property, years ago) was vital in helping them recover from a past major depressive episode but at their current residence HOA regulations forbid having a garden. Wouldn't a letter in support of allowing their case to be an exception to the HOA proscription against gardening be following the same logic? There is a very plausible argument that the behavioral activation/ Vitamin D / exercise / self-efficacy associated with gardening for this patient would be 'antidepressant' and mitigate their disability of major depressive d/o.

I see it as the exact same argument and I agree that it blurs the line between psychotherapy and advocacy and, further, it is about putting MH professionals out there as sort of a quasi-priesthood or judges deciding matters of public policy and law.

For one thing, there’s no laws defining and granting access to emotional support gardening. There is, for better or worse, for ESAs. That doesn’t mean you have to write a letter, of course, either for a particular patient or in the general, because that’s your professional call. The law does give you the right to, but it doesn’t require you to.

That said, there’s a real venom towards disability rights among a lot of people. In my work of disabled psychology trainees, I’ve gotten some questions about how faculty and training directors could essentially get around the law, because they didn’t want to accommodate disabled trainees and simply wanted to know how to kick them out without getting sued. Same with a lot of landlords, employers, etc.

 

[quickpsych]

Serious question:

What if a client suffers from the MH disability of clinical depression and--as part of their unique personal and MH history--you discover that them engaging in daily gardening (at their 'old' property, years ago) was vital in helping them recover from a past major depressive episode but at their current residence HOA regulations forbid having a garden. Wouldn't a letter in support of allowing their case to be an exception to the HOA proscription against gardening be following the same logic? There is a very plausible argument that the behavioral activation/ Vitamin D / exercise / self-efficacy associated with gardening for this patient would be 'antidepressant' and mitigate their disability of major depressive d/o.

I imagine some would ask why they can't just find a similar activity like a window garden or keeping potted plants in a window and caring for them. Especially in older populations, there's a lot of "I used to do xyz which made me happy and can't do xyz anymore" and thus begins exploring what's a way to modify that activity or find a similar activity to do.

 

[Sanman]

For one thing, there’s no laws defining and granting access to emotional support gardening. There is, for better or worse, for ESAs. That doesn’t mean you have to write a letter, of course, either for a particular patient or in the general, because that’s your professional call. The law does give you the right to, but it doesn’t require you to.

That said, there’s a real venom towards disability rights among a lot of people. In my work of disabled psychology trainees, I’ve gotten some questions about how faculty and training directors could essentially get around the law, because they didn’t want to accommodate disabled trainees and simply wanted to know how to kick them out without getting sued. Same with a lot of landlords, employers, etc.

I definitely agree that there is a rights issue there. That said, in this particular case there is a question of how one can objectively evaluate whether an animal would actually benefit their mental health condition. Most clinicians are not setup to make such an assessment nor would it really be appropriate for pets to be brought into most offices. The issue here is this "law" was a political football that got kicked to us without any real world guidelines or procedures. This is similar to how the state of Virginia attempted to make treating mental health clinicians the ones to decide if gun owners were allowed to keep their firearms. There is an ethical conflict there and one that may affect the treatment relationship as well. If someone wants to open up a real ESA assessment clinic (not a mill), go for it.

 

[ClinicalABA]

... That said, in this particular case there is a question of how one can objectively evaluate whether an animal would actually benefit their mental health condition...

The issue I have is more related to the inability to determine the specific animal that would be beneficial. I work with toddlers with ASD, and get asked for these letters several times per year. I have seen many young children with ASD who have great relationships with their pets (it's usually a dog). While that's the modal situation, it's not 100%. A lot can go wrong if the dog is not a good match for the environment. While there is certainly some risk aversion in my company policy about not writing these letters, It really comes down to it not being within the scope of my traiing and practice to do so.

Most of my families do not have a lot of money, thus they are unlikely to own their own home and more likely to live in an apartment with limited access to outdoor space, so there is the issue of it maybe not being the best setting for specific breeds. I really wish there was a specific, standardized training program that certified dogs (or other animals), so that I could just write a letter in support of the family having an appropriately trained dog that is matched to family/child needs by an appropriately credentialed individual. Instead, families are left on their own to either identify and vet an ESA training program, or just adopt any old dog they want. It all kinda sucks, honestly, and I have had to tell many families that I can't help them.

In regards to physicians writing those letters, I'm finding that most of the pediatricians in my area have a similar policy and instead refer the client to me for that letter.

 

[Fan_of_Meehl]

I think it's fair to say that the legislation is way out ahead of the science on ESA's and service animals. That's one reason it's so frustrating for many psychologists when they get these requests.

It's hard for many to feel comfortable putting in writing that the animal is 'medically necessary' to mitigate a psychiatric disability when:

(a) the research literature, at present, fails to offer strong support that the animal is 'medically-indicated,' let alone 'medically necessary' to treat or manage the condition--in fact, in the case of anxiety disorders, it may even be contra-indicated and interfere with recovery
(b) as some (including Younggren) point out, diagnosis does not necessarily mean disability (this needs to be separately assessed/addressed) such that any ESA letters necessarily assert disability status, arguably a forensic issue with associated role conflicts for the therapist, etc.

If you're a VA psychologist, you get a double-helping of these headaches (legislators passing laws before the science is in) in the form of requests for documentation arguing the need for a 'full-time caregiver (caregiver support)' due to a MH diagnosis (e.g., PTSD).

 

[futureapppsy2]

I think it's fair to say that the legislation is way out ahead of the science on ESA's and service animals. That's one reason it's so frustrating for many psychologists when they get these requests.

It's hard for many to feel comfortable putting in writing that the animal is 'medically necessary' to mitigate a psychiatric disability when:

(a) the research literature, at present, fails to offer strong support that the animal is 'medically-indicated,' let alone 'medically necessary' to treat or manage the condition--in fact, in the case of anxiety disorders, it may even be contra-indicated and interfere with recovery
(b) as some (including Younggren) point out, diagnosis does not necessarily mean disability (this needs to be separately assessed/addressed) such that any ESA letters necessarily assert disability status, arguably a forensic issue with associated role conflicts for the therapist, etc.

If you're a VA psychologist, you get a double-helping of these headaches (legislators passing laws before the science is in) in the form of requests for documentation arguing the need for a 'full-time caregiver (caregiver support)' due to a MH diagnosis (e.g., PTSD).

I agree with the research re: ESAs. With actual service dogs, they are tool (albeit a living one) and provide access in a similar way to a wheelchair or other mobility/access aid (or something like blood glucose monitor, etc) might. That said, I agree that the usefulness of psychiatric service dogs specifically is very iffy in a lot of cases and the lines between them and ESAs is often blurry.

I’ve also seen what @ClinicalABA mentioned about people assuming an animal will be therapeutic when it very well might not be. Lots of people seem to think a dog will automatically be great for their autistic kid when it could be quite the opposite.

I like the Younggren article overall but do find it odd that they cite the SSA definition of disability when that’s a much, much higher bar than those not tied to financial compensation (like the ADA definition) and those definitions are pretty much never used outside of compensation systems. Odd choice.

 

[msc545]

The apparent coldness in my colleagues is sometimes quite appalling and very disgusting.

What happens to a person who has depression and is forced to get rid of (or euthanize) a beloved dog because some landlord is worried about some extra cleaning when that person moves out and won't allow the dog? What if that is the only apartment the person can afford?

Do you suppose, just maybe, that the person's depression might be a little bit exacerbated as a result?

 

[PsyDr]

The apparent coldness in my colleagues is sometimes quite appalling and very disgusting.

What happens to a person who has depression and is forced to get rid of (or euthanize) a beloved dog because some landlord is worried about some extra cleaning when that person moves out and won't allow the dog? What if that is the only apartment the person can afford?

Do you suppose, just maybe, that the person's depression might be a little bit exacerbated as a result?

Which property rights change due to psychiatric illness?

What if the landlord has an anxiety disorder which would be worsened by the prescience of a dog? What if their rental property is their only source of income?

What if someone with a depressive disorder gets more depressed when they pay taxes? Does everyone else have to pay more to make up for this shortage, limiting everyone else’s property rights? What if the person is extremely rich but depressed? Or is this about wealth and not psychiatric illness?

What about criminal charges?

What if a depressed offending pedophile will get more depressed by incarceration? Do you ignore the states rights and the victims rights?

 

[smalltownpsych]

Serious question:

What if a client suffers from the MH disability of clinical depression and--as part of their unique personal and MH history--you discover that them engaging in daily gardening (at their 'old' property, years ago) was vital in helping them recover from a past major depressive episode but at their current residence HOA regulations forbid having a garden. Wouldn't a letter in support of allowing their case to be an exception to the HOA proscription against gardening be following the same logic? There is a very plausible argument that the behavioral activation/ Vitamin D / exercise / self-efficacy associated with gardening for this patient would be 'antidepressant' and mitigate their disability of major depressive d/o.

I see it as the exact same argument and I agree that it blurs the line between psychotherapy and advocacy and, further, it is about putting MH professionals out there as sort of a quasi-priesthood or judges deciding matters of public policy and law.

I haven’t written a letter for anyone who is trying to circumvent an HOA. Typically it’s for lower cost rentals and the property manager has told them they need to get the letter in order to keep their pet so it’s not really that adversarial. As far as gardening goes, I had an HOA remove a rose bush I planted in front of my condo. I would not recommend ever fighting an HOA to anyone unless they have lots of attorneys. 😁

 

[Sanman]

Which property rights change due to psychiatric illness?

What if the landlord has an anxiety disorder which would be worsened by the prescience of a dog? What if their rental property is their only source of income?

What if someone with a depressive disorder gets more depressed when they pay taxes? Does everyone else have to pay more to make up for this shortage, limiting everyone else’s property rights? What if the person is extremely rich but depressed? Or is this about wealth and not psychiatric illness?

What about criminal charges?

What if a depressed offending pedophile will get more depressed by incarceration? Do you ignore the states rights and the victims rights?

Studies show low SES increases the likelihood of depression. Stimulus checks for everyone! Better yet, SSDI.

 

[cara susanna]

My doctor won't even fill out a form so I can use a heating pad at work to manage my endometriosis pain 😕

 

[WisNeuro]

My doctor won't even fill out a form so I can use a heating pad at work to manage my endometriosis pain 😕

Is this because of the VA's strict rules on not being able to plug in anything with a heating element?

 

[cara susanna]

Is this because of the VA's strict rules on not being able to plug in anything with a heating element?

Correct, I would need official accommodations which would require a form signed by my doctor.

I KNEW I should have started out by asking for opioids first...