Navigating Patient Requests for an Emotional Support Animal

Susan Kreimer

March 15, 2022

When Serena-Lian Sakheim-Devine's best friend from childhood died of cancer, she felt sad and lonely while away at college. Wanting something warm to snuggle, she got a guinea pig and named her Basil. Then she got two more and called them Nutmeg and Paprika. The three became her Spice Girls.

"They were of great comfort to me, but also to others at times of need," said Sakheim-Devine, 26, who lived with them in a dormitory at Smith College, an all-women's institution in Northampton, Massachusetts.

Her therapist wrote a letter and sent it to the disability office at Smith, which permitted the guinea pigs as emotional support animals (ESAs). Eventually, though, she wanted a dog to help manage her posttraumatic stress disorder, depression, anxiety, and panic attacks. So, she adopted a beagle from a shelter.

Once again, a therapist provided a letter, and Sakheim-Devine was allowed to keep the beagle, Finnian, then about 13 years old, in her dorm room on the condition that she give up the guinea pigs, which she did.

She and Finnian bonded almost instantly. When she woke up drenched in sweat, unable to move or speak, the dog sensed how tense she was. Finnian licked her hands, got her fingers moving, and helped ground her.

"I didn't really teach her that. She just knew," said Sakheim-Devine, now a safety engineer who lives in New Haven, Connecticut. "It was incredible how well connected we were, even from the get-go."

The Therapeutic Benefits of Four-Legged Friends

Although there is limited scientific literature on the therapeutic use of ESAs, there are well-established benefits of having pets that also apply in these situations. Animals can provide distraction from stress, alleviate loneliness, and instill a sense of responsibility, said Rachel A. Davis, MD, associate professor of psychiatry and neurosurgery at the University of Colorado Anschutz Medical Campus in Aurora, Colorado.

They add structure to a person's day by needing to be fed at specific times, and they can help the human get exercise. "Patients have reported improved sense of meaning in life and purpose," Davis said.

A mental health clinician can recommend an ESA to help mitigate symptoms of a disability related to a mental illness as described in the Diagnostic and Statistical Manual of Mental Disorders. Examples include depression, anxiety, obsessive-compulsive disorder, panic attacks, and posttraumatic stress disorder.

ESAs differ from psychiatric service animals, which are trained to perform specific tasks, such as applying deep pressure that calms the owner. By their mere existence, ESAs provide emotional benefits to a person with a mental health disability.

"Social support, even from an animal, can really help people feel less alone, better about themselves, and safer from unpleasantness or even a physical attack," said David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford University School of Medicine in Palo Alto, California.

Writing a Letter on Your Patient's Behalf

Writing a letter that serves as proof of a person's need for an ESA is a request that mental health professionals sometimes receive from patients. The letter can grant access to housing without additional cost regardless of no-pet polices, and some employers may allow an ESA at work as a reasonable accommodation for a psychological disability. Until recently, an ESA could accompany its owner on a plane, but most airlines no longer permit this, partly because some passengers falsely claim their pets as ESAs.

Before crafting a letter for someone with an ESA, Spiegel asks for the patient's permission to elaborate on the clinical condition that merits professional help and to explain how the animal relieves associated symptoms.

The Fair Housing Act, a federal law, requires a landlord to grant reasonable accommodation involving an emotional support or assistance animal. Such an accommodation honors a request to live on the property despite a no-pets policy. It also waives a pet deposit, fee, or other rules involving animals on the premises.

Landlords are usually supportive of a request to permit an ESA, said Jonathan Betlinski, MD, associate professor and director of the public psychiatry division at Oregon Health and Science University in Portland. None of his patients have experienced any difficulties once they obtained a letter from him.

However, "anytime somebody asks me about a letter for an ESA, that's the time to have a conversation. It's not automatic," Betlinski said. The discussion involves learning about the type of animal a patient has and how it helps his or her emotional state.

Because of privacy concerns, Betlinski doesn't disclose the specific diagnosis in the letter unless the patient signs a release of information. The laws pertaining to ESAs only require his letter to note that an individual has a qualifying diagnosis and that an ESA helps improve symptoms, but it's not necessary to explain how.

"You can see where writing the letter is a fine balancing act," he said. But he finds it helpful to mention any training the animal has completed, such as the Canine Good Citizen course sponsored by the American Kennel Club.

Most of the letters Luis Anez, PsyD, a clinical psychologist and associate professor of psychiatry at Yale University School of Medicine in New Haven, Connecticut, has written for this purpose were in support of ESAs in housing. But he also recalled providing a letter for a patient who was flying to Puerto Rico with an ESA. The letters are generally provided only to established patients with psychiatric diagnoses.

Without a letter, "We've seen people say, 'I'd rather be homeless than part with my dog,' " said Anez, who is also director of Hispanic services at Connecticut Mental Health Center, a partnership between Yale and the Connecticut Department of Mental Health and Addiction Services in Hartford. Before getting an ESA, Anez recommends that individuals become aware of their landlord's policies on possible restrictions relating to dog sizes and breeds.

Additional Considerations

An ESA doesn't necessarily have to be a dog. "It certainly could be a cat. It could be a parrot, too," said Stephen Stern, MD, a psychiatrist in private practice in Mount Kisco, New York. But, "if they say that their emotional support animal is an earthworm, that would make you wonder," he added half-jokingly.

Stern only writes an ESA letter for a patient with whom he has an ongoing professional relationship. For instance, if he's treating someone for depression and that patient tells him how the animal helps relieve symptoms, then that is sufficient justification to write a letter.

"Because you know them, you've assessed that what they're saying is plausible," said Stern, who is also an adjunct professor of psychiatry at the University of Texas Health Science in San Antonio, where he conducted research on companion dogs for veterans with posttraumatic stress disorder and continues to collaborate with colleagues via email and Zoom.

While veterans benefit from ESAs, some live in housing that doesn't permit animals, said Beth Zimmerman, founder and executive director of Pets for Patriots, a nationally operating nonprofit organization in Long Beach, New York, that partners with shelters and animal welfare groups to adopt dogs and cats for companionship and emotional support. She said an ESA can be "a wonderful complement to other forms of therapy that a veteran may undertake.

"Most of the time when the veteran encounters a problem, it's because the landlord is ill-informed of the law," Zimmerman said. "We provide information to the veteran to share with the landlord or building management, and always recommend taking a very amicable approach. In our experience, with very few exceptions, once the landlord understands his or her responsibilities under the law, they will permit the veteran to have that emotional support animal in their dwelling."

For Kristin Lowe, a chocolate Labrador-Weimaraner mix named Lola provided emotional support from her puppy days until her death at age 12 last May. Lowe's psychiatrist provided letters that allowed Lola to live in her apartment and to travel on commercial airline flights.

"She was so connected to me," said Lowe, 34, who lives in Denver and works as an administrative office worker in physical therapy. "She was a part of me. She could read every emotion that I had."

Now, Lowe relies on Henry, an Australian shepherd puppy, to help her cope with obsessive-compulsive disorder, major depressive disorder, and an eating disorder. She described him as "a very happy little guy and a constant tail wagger — and that lights up something in me."

More information, which is provided by the US Department of Housing and Urban Development, can be found here.

Susan Kreimer is a New York–based freelance health journalist.

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