Good morning, everybody. How is the sound? Is it too loud or okay? Okay. So thank you for coming to our session this morning. My name is Lee White. I am a college psychiatrist, a member of the APA College Mental Health Caucus, and one of the APA representatives to the Higher Education Mental Health Alliance, as is Mira, who's going to introduce herself in a little bit. And first, I want to welcome all of you today. This is going to be a pretty interactive session, and we're going to have some cases to go through. I wish it was a smaller room because it feels like a huge room with a lot of emptiness in it, but I think we can make it work. The session is being recorded today. So if you have comments, please speak into the microphone. If you're not comfortable speaking into the microphone, we can just repeat what you said so that the audience at home can hear. Mira, would you like to introduce yourself? Hi, everyone. Good morning. My name is Mira Menon. It's nice to see or meet everyone. I'm a psychiatrist at The Ohio State University where I practice young adult mental health. I'm also chair of the College Mental Health Caucus. So if you're interested in being a part of our online community or listeners related to college mental health, please catch me after this and I'll get your email so I can send you directions about how to do that. I am also one of the representatives to the Higher Education Mental Health Alliance. It's great to see everyone. Yeah. And Mira and I are going to be just switching back a little bit during the presentation. So today we're going to be talking about HEMA's latest work product, which was just published in January. And we will have a QR code at the end so you can pull up the guide for yourself if you'd like to do that. If you wanted to pull it up earlier, it's just you can go to HEMA.org and find it. But I'd recommend waiting to the end. And it's called the Animals on Campus Guide Informing Ethical, Legal, and Best Practices. So disclosures. This presentation is a designated work product of the APA College Mental Health Caucus. And our speakers have no disclosures, no financial or non-financial disclosures. Okay. So the learning outcomes for today include evaluating the role and purpose of HEMA, or the Higher Education Mental Health Alliance, and identifying how its free resources can be helpful in clinical practice. Examining the logistical and ethical dilemmas related to animals on campus, considering interest of various campus stakeholders. Knowing the difference or differentiating between therapy animals, service animals, and emotional support animals, and the regulations related to each. And then beginning to formulate strategies for creating institution-wide policies on assistance animals. Okay. So this is the famous HEMA cube. HEMA is an organization that was, or a partnership of organization, that was formed 15 years ago at the American College Health Association. And for those of you who are in college psychiatry, you probably realize that it seems like there's a very small number of us. And it's the same, you know, when you go to psychologists or primary care physicians. And we really wanted to have a way to effectively advocate for college student mental health, and to move the field forward. So the brainstorm at the time was why not bring relevant organizations together, and we could work together, bring our numbers, our funding, our voices, and our ideas together to further student mental health. If we look at the cube, I think the cube's a little too busy to go into detail today. The real reason it's up there is just to think about that we talked about, we thought about as a group, you know, what does the mental health continuum mean to us when we think about students? And as you see, the top row goes everywhere from education, prevention, intervention, treatment, to aftercare. How would we like to make higher education better? If you look over on the right side of the cube, we look at things like learning outcomes, retention of students, recruitment, recruitment of students and of faculty staff to care about mental health, student mental health. And then our focus areas, I think the front of the cube is really important, which are at HEMA, we focus on how can we use our power for advocacy for student mental health. So when we have opportunities to have each of our organizations sign off on a letter to Congress or a letter to other places that will help advocate, we do that. Sometimes it's hard because a partnership of nine organizations is not nimble at all, as you might imagine. We look at policy, practice, and research as well. Okay, so I've gone through the first couple of bullets on here. Again, the mission is to provide leadership through the partnership of organizations to advance college mental health. How does this practically work? Well, there are nine organizations. We meet monthly through Zoom conference calls. We have an annual in-person business meeting, which is going to be just in a couple of weeks at the American College Health Association meeting in Boston. We work with group consensus. So we really try to get buy-in from every group that's there when we decide what we're going to do next, what we're going to advocate for, how we move forward. And similar with this conference presentation, so the presentation that Mira and I are doing today is being presented at organizations across our membership. So it will be presented at the American College Health Association, the American Psychological Association, NASPA, several conferences across the nation this year. Who are our members? The American Academy of Child and Adolescent Psychiatry, the American College Counseling Association, the American College Health Association, ACPA, the American Psychiatric Association and Psychological Associations, the Association for University Counseling Center Directors, NASPA, which are the Student Affairs Administrators, and the Jed Foundation, which probably most of you know, but it's an advocacy organization for colleges and students and provides a lot of resources. So what have we done over the 15 years? One of the things, so being not very nimble, at first we thought we would do a lot of policy and legislative kind of things. And as we figured out how hard it was to be nimble with nine organizations, we figured out what we could do well was to look at areas that colleges were struggling with and to come up with guides for the colleges on how do you approach this. And to think about it from lots of different perspectives, from the perspective of everybody in the room, including students. The first one that came out was early, and it was balancing safety and support on campuses, which was a big issue then and continues to be one now. Our second guide, which is used a lot, and is probably one of the most used guides, is called Postvention. And that is a guide for universities and colleges on what do you do after an event has occurred at your university. And it's really designed to be read before there's an emergency, because the biggest recommendation is you put a postvention committee together and who should be on it, how do you form it and think about it. The third one was one before COVID on tele-mental health and using it for students who were at a distance. And our most recent one, which was just released in January, is what we're talking about today. So now I'm interested. I wonder if I can get some ideas of what brought each of you to the conference today and what you're hoping to learn more about. And if you're able to speak up to the microphone, that would be great. I'm a psychiatrist in Boston and I see a lot of college students and this issue of the emotional support animal has blossomed. It's a real problem for the colleges. I have some ideas that help them, but the requests have been numerous and if you don't comply, it really creates an alliance issue with your students that you're treating. Yeah, so that if you are at a university where as a practitioner you are allowed to write ESAs, or emotional support animal letters, which not all are allowing this, there are a lot of risks involved. And one of them is the therapeutic alliance if you do not agree that an animal is necessary for emotional support. That's a hard one. Yeah. Hi, I'm a psychiatrist that practices here at the VA in San Francisco and not a college mental health psychiatrist, but this topic of service animals, ESAs, and therapy animals are highly prevalent among my veterans. So it's good to have a framework to talk about this. Yeah, I think there's similarities between different settings, definitely. And really the age group we're working with is really similar between the two in many cases too. I'm a military psychiatrist, and so of course I take care of young, healthy people, and so there's interest, and I have my opinions on what war fighters need, and so I have interest in other people's point of view, but still think that war fighters are different than the civilian population. Thank you. So looking at the applications to young people in the military. I think one nice thing about the HEMA guides especially is that we know that all institutions of higher education have different student populations and sizes and are in different areas, and so the nice thing about these guides is that, like Lee has been talking about, it gives you a good framework. And with that in mind, I do think that it is nicely applicable to other settings where you're in a large institutional institution and you're trying to figure out how to apply some of these concepts to create policy at your institution. I'm actually an occupational therapist. I have some, I've done hippotherapy and things like that, but what I see a lot, my father is a psychiatrist, and I get a lot of people that are like, oh, you know, we're going into a different, we're moving into here and they don't allow pets, so I just need the letter to manipulate my landlord, you know, and I'm like, oh, well, do you see the ethics behind that? So I see that a lot, and he saw that a lot where they didn't they just wanted it after they had entered into the contract with the landlord to get an animal in. I think that's one issue that we struggle with tremendously. Yeah. Tremendously. Marcia? I'm interested in learning about some of the legal aspects of this issue because, as you said, some schools will not write the letters, but is that legal? And one other thing I just wanted to point out, I went to the positive psychiatry talk yesterday, and they talked about the importance of social support, including animals. So that puts another aspect, is this, you know, are we, we want to help our students as much as possible, should we be writing these letters? Yeah, thank you. Thank you. So it's funny, is that kind of pulling the room just a little bit, I, with psychiatrists and people in other, like, allied professions, the different viewpoints that come, even as we all think about this, it's very similar to our HEMA meetings, is, you know, the person from student affairs is saying, well, this is what bothers me about it, or this is what I struggle with, and the psychiatrist may have a very different point of view. And so, it's very, very rich. Okay. So, our current HEMA project, the Animals on Campus Guide, the purposes of it, one is to provide educational information, so it includes background information, definitions of terms, types of animals on campus, and it reviews the current literature on the topic. I think the guide is about, I'm forgetting now, I think it's almost 80 pages long. It's easy to read, though it's in kind of big print and good pictures, but it really does, it's educational to start with. And then the next purpose is to engage mental health professionals and campus administrators in discussions about medical, legal, and ethical aspects of this topic in order to help develop appropriate policies and procedures on campuses. The third one is to outline several areas to consider regarding animals on campuses. And the fourth purpose is to connect readers to resources that go further than the guide can. Some of the limits on this guide scope, it's not intended to serve as a best practice guideline. It will link you to some things that we may consider best practices, but we don't include those in there because we feel those shift over the years. It's not intended to instruct or advise a campus on this topic, but rather to help guide them through their own discussions of what they need. The scope is educational, it's meant to encourage further dialogue among campus stakeholders, and to inform stakeholders so that every campus can develop policies that are appropriate to their own setting, their mission, and their own student population. And so this always amazes me, when you put a policy together at a university, the length of the list of collaborators. And if you've ever been in a room where you're writing policy, which I have at the university, it's amazing how many offices you need to involve and run it through to make a really good policy. There are 16 offices listed here. I'm not gonna go through all of them, but I'll highlight a few. So legal counsel, disability services, housing, housing has to be involved, student conduct, the care services, so counseling, health, psychiatry, DEI offices, in states where those are still allowed to exist, campus police, and facilities management, among many other offices come together to really think about what do we need in these policies. A little bit about what the guide covers, the benefits of the human-animal bond, definitions of animal categories, animal welfare, risks associated with ESAs on campus, institutional considerations for policy development, which I think is one of the most valuable pieces, diagnostic and counseling considerations, legal and ethical considerations, summaries of relevant laws and legal cases to be aware of, practical considerations, and then lots of case studies and activities spread throughout the guide to help facilitate conversation and to make all of us active learners, so that we're really making sure we're digesting the material the right way, and then links to relevant resources. And what Mira and I will be going through is a selection of this today, because obviously we can't go through all of everything that's on that guide. Okay, I'm gonna turn it over to Mira at this point. Great, so I'm gonna get us started with going into the meat of the guide, first starting with differentiating different types of animals. And I know the first one, it will seem obvious, but I'll kind of, I think it's useful to talk about pets as well in context of the other types of assistance animals that are out there. So pets are domesticated or tamed animals that are kept for companionship, kept for pleasure. On, in a legal sense, and in terms of, yeah, I guess in a legal sense, they are not granted special access. You know, we see on a lot of different buildings that no pets allowed. And also, there's no specific requirement for training as opposed to other types of assistance animals. Now, state to state, I know that there are requirements in terms of vaccinations and things along those lines, but in terms of assistance animals, there's no unique laws that are requiring training for pets. So therapy animals, so therapy animals, actually, show of hands, who has therapy animals coming into their workspaces right now? I know I do. Whether it be hospital-based or one-on-one, maybe sometimes, yeah, mm-hmm. Yeah, so I think we're all kind of familiar with this to a certain extent. So therapy animals, and sometimes we call it animal-assisted activities, so when I think of this, I kind of think about it in two senses. One are the animal-assisted activities where you might bring the animal, where the animal's owner will bring that animal into a space, and people will come to that animal and provide comfort. So, for example, in a college setting, during finals week, the student union might have a group of dogs there with their owners, and students are welcome to stop by if they wanna have that additional comfort and stress relief leading up to the final exam season. Another way to think about therapy animals is the use of a therapy animal one-on-one in a therapeutic setting. So, for example, the owner, who might be a clinician within the clinic of a college counseling center, might use the therapy dog to, for example, if a student patient is having difficulty with assertiveness, kind of talk through what's it like to assertively call out to the dog and ask the dog to sit on your lap, and how do you navigate the blow if the dog decides not to do that? So, for this, obedience training may indeed be required. However, there's no legal special right to special access for these dogs. And we'll talk about this a little bit more later, but when it comes to a therapy animal, if an animal is designated as such, like I said, they don't have special legal rights of access to every single location. If you are going into a setting with your therapy animal, you do need to figure out who you need to ask permission of within that center, and also get specific permission for the building in which you're going to be as well. Okay, emotional support animals. So, emotional support animals do not require any specific training. They may have some special access, but they are not granted all rights of access to spaces. And these animals are, they do not necessarily, they're for individuals who have specifically mental health concerns that rise to the level of a disability. However, they do not provide, the animal does not have specific training necessarily, and is not meant to perform a specific task. This isn't, and I'll kind of go back to this slide, but this is kind of in contrast to a service animal, where the person might have a medical or a mental health disability, and the animal, which is typically a service dog, in some cases, it can be a tiny horse, which is very cute, I know, but that animal would be specifically performing a task. So the stuff that I think about the most is, for example, if someone struggles with non-epileptic seizures, the service dog that is able to detect that up front, and notify the owner, and help that owner get into a safe space. Or the service mini horse, who helps grab the owner's medication, brings them to them, so that they can remember to take it. So let me go back here, just so I can kind of distinguish that. So the individual with the emotional support animal does have a psychiatric disability. However, the purpose of the animal, which can be of any species, is meant for comfort, not necessarily to provide a specific task. Another thing I'd say about that, so if, even if someone has an emotional support animal, or really any assistance animal, if they're unable to properly care for this animal, or neglecting the service or emotional support animal, it does rise to the level where the animal is endangered, and it could become a criminal matter. So that is something important to keep in mind if we're writing these letters for individuals, the consideration of whether or not the person is even able to take care of that animal. So service and emotional support animals, they are not exempt from any state or national animal neglect laws that are out there. And local law enforcement and animal control might intervene. So I practice, and I live in Ohio, and within the state of Ohio, licensed social workers and clinical counselors are mandated reporters when it comes to animal abuse and animal neglect. And that might be the case in other states as well. So these are all different things that we need to kind of keep in mind when we're discussing these things with our patients. Other things to add with emotional support animals. So the emotional support animal is typically, when we're writing these letters, is to provide provisions in housing and to kind of overcome reasonable accommodations within a housing setting. However, the tenant is also subject to other areas of the lease. So they need to, even if they have an emotional support animal, they're still supposed to keep the environment sanitary, and they could be subjected to eviction or cleaning fees if they are indeed not keeping the area sanitary. So in summary, I feel like a lot of times when my patients ask me for these letters, they think it's kind of like a blanket, like get out of jail free card when it comes to having a pet. But there's a lot of nuance to it. So going back to service animals. So they're really, according to the Americans with Disabilities Act, there's only two questions that one is allowed to ask an individual with a service animal. Now, when I'm talking about this, I'm not talking about if I'm sitting one-on-one with a patient, you're still allowed to ask all the questions that you might ask for your clinical examination. But if I have front desk staff, or if we are talking about campus police or housing administrators, they're really only able to ask these two questions. So is that dog a service animal that is required because of a disability? And what work or task has that dog been trained to perform? So individuals in those other positions, or even if you happen to be in a position where you are kind of more in that administrative role and not in that clinical role, you can't ask things like, hey, can you demonstrate for me? Or tell me more details about what your disability is and when it started and how it impacts you and this and that. You can only ask these two questions. So this would be useful to remember and pass along to any staff that works at your center. And it's kind of hard because if you see a sweet dog, you immediately want to kind of go up to it, ask people, sometimes it invites people to have these additional conversations, but we really cannot. So, let's see. I think this might still be a small enough group that I'll just have people kind of. So we have some clinical cases. So, is this animal allowed on campus? And then think about it and I'll kind of pose these questions to the audience and I would love for you to come up to the microphone and tell me kind of like what you think and what you would do in some of these scenarios. So, Fluffy is a seven year old cat and her owner, Calista, got her as a kitten when her parents divorced when she was 13. Fluffy has been a constant comforting presence. When leaving for college, neither parent was willing to take custody of Fluffy and Calista felt that she would need Fluffy's support at school. She found an online therapist and was able to get Fluffy designated as an emotional support animal. They live in a co-ed residence hall in a suite style situation. Where on campus can Fluffy go with Calista? Any ideas? Okay. Places that explicitly allow pets or don't say that they don't allow pets as well as her housing situation? Yeah, no, that's great. So, when we're getting the letter for the emotional support animal specifically, it's typically written for housing and right now with the Fair Housing Act that Lee will talk a little bit about later, that's really one of the few laws out there that really has provisions for emotional support animals. So, in this case, Fluffy can only be in the residence hall at this time. So, going on to the next question. Calista's thinking about moving off campus next semester but most places do not allow pets. So, does Fluffy's ESA status offer any workaround for these policies? Does anyone know the answer to this? Yes, what Diane's saying is you might need to write another letter, but yes, you know, there are different workarounds. So the ESA letter, it really, if an off-campus apartment does not permit pets, the ESA letter can overcome that barrier, and if there's any sort of pet fees, the ESA letter can eliminate those additional pet fees, just so that there's not any additional barriers to having this emotional support animal for the individual with a psychiatric disability. Yeah. One of the big problems I have with this is, what animal is not an emotional support animal? Who gets a dog or a cat? And I've really changed my views over the years. I love animals, and I think everyone who wants an animal should have one, and that if schools want to allow emotional support animals, they should have dorms where animals are allowed, and avoid this entire problem, because I think, to me, it's almost 95% an abuse of a term for mental health. Maybe I'm wrong. I wonder what you guys think. Also, the liability, I don't know this animal. This animal bites the next-door neighbor, my patient's on a plane and gets bitten. I'm an MD with a license and a very good malpractice coverage. Why are we exposing ourselves to these kind of risks? So I'm very cynical, and if the rule is no animals, there's no animals, and you really, it's almost pretentious to insist your animal come where you're living when animals aren't allowed. There are people who are allergic in the area, and so it's really mushroomed, to me, into a huge problem, whereas initially it was one or two cases here and there. But every animal, to me, is an emotional support animal now. Yeah. No, I definitely hear where you're coming from. I think one of the unique things is these animals, and really any pet, are for comfort. It's the psychiatric disability piece, but I think because of the lack of just education out there, and a lot of educational programs that do exist online to train clinicians in how to write letters for ESAs, kind of already have a bias in support of animals and just having more animals out there. So I think a lot of the ESA letters that can be written, especially some of those online companies, are ones where they're kind of fudging the psychiatric disability piece, and we'll talk about definitions of disability here in a little bit. But yeah, you're completely right, and it is a struggle. So at Ohio State a few years ago, and so my knowledge, just disclaimer, my knowledge of this is, I was not involved in this, my knowledge is based on reading news articles about it, and so we had a situation where one individual in a sorority had an emotional support animal. Another person in the sorority had allergies to dogs that triggered their irritable bowel disease. What the university had been doing in terms of deciding who gets to stay was who signed their housing contract first, and in this situation it was the person with irritable bowel disease, so the person with the ESA brought up a big lawsuit, and it was found in favor of the person with the ESA because of discrimination against this individual psychiatric disability. So these are really extraordinary complexities that we were facing with this, and I know what you mean, it really does bring up a lot of liability, it's a big conundrum, and it's hard to know what the right thing to do is. What some universities are doing, I mean, there's a lot of talk about, you know, making animal-free buildings and, you know, do we just get around it that way, there's many positives to that, and as you might imagine, a lot of complexity to that. The other thing that some universities are doing is when people apply for housing, is asking every single person, you know, do they have animal allergies or phobias, so that when they are getting ready to place people with emotional support animals or service animals, they can really do it thoughtfully, and they're going to doing this in a blanket way just so that they're not identifying people who might have a disability, I guess is one way to say it. Yeah, that's it. Yeah, that would be a good approach when you're developing your policy, certainly. Okay, so here's another case. So Bella is a six-year-old golden retriever therapy dog. She has been certified through pet partners and frequently volunteers at local elementary schools, nursing homes, and hospitals. She loves to socialize with people. She's been invited to the student union for a final exam de-stress event hosted by the counseling center. So this question, is Bella allowed on campus, and if yes, who, if anyone has, let me start over. Is Bella allowed on campus? And if so, who had to grant her permission to come to campus? Any thoughts on this? I'm going to give it a shot. Great. In this case, yes, because she's been invited to the student union, and the person who runs the student union would give her that permission. Yeah, most likely. I think this is kind of the scenario where you need to know who are the people who need to grant permission, and so it might be multiple places on campus. Like the person who runs the student union, it might be a larger office on campus. But Bella is really only permitted to be in this one place, which kind of gives us, it's a good segue in the second part of this. So Bella's handler, Melanie, is a parent of a student on campus. Melanie knows that her son, Kyle, is in the chemistry building at the same time she'll be leaving the event, and knows that Kyle would love to see Bella. Melanie walks over to the chemistry building and hangs out inside the foyer to wait for Kyle. Is Bella allowed in the chemistry building? Why or why not? And we kind of discussed the answer to this already. So the answer to this is no, because they haven't, I've lost track of who's who, because there's a lot of names. The owner didn't get that extra permission to have the therapy dog, Bella, in the additional space. Yeah. This makes me think of that each building may also have very different policies around what type of therapy animals can come in. So for example, at the health center I worked at, we had therapy dogs come into the psychiatry waiting room. And we had really strict policy around it, so we had to know that they'd had the appropriate training and designation, that they were up to date on all of their shots. There were additional rules about the animal being cleaned and groomed, freshly groomed, just because of people with allergies and things, and that the animal behaved at all times like a therapy animal should. So that we had the freedom, if there is a therapy animal that was brought in and was not interacting in appropriate ways, that we could take that animal out right away and we could point to our policy and say, here's what's going on with it. I think we also had limitations on how long the emotional support, or the therapy animal could work, because we didn't want to exhaust them, so I think they would come in for about an hour into the waiting room, and that was about what they could take before they would start to get fatigued from being on duty. Yeah, I'm doing, plug, I'm doing another talk tomorrow on therapy animals. It's also, I think it's around the 10 o'clock hour, so if you're interested in that, you should definitely come. Diane. Diane asked, in that case, how would you make sure there's no patients with allergies, and I'll extend that to say, with phobias. And so what we did is we had an unusually large waiting room, because it was an old building and that's all there was, and it served the purpose well, so the therapy dog was off on one side. We made it really predictable, so Wednesday afternoons from 2 to 3, the therapy dog was there. That soon became our favorite patient slot, the waiting room would fill up with people who wanted their appointments 2 to 3 on Wednesday afternoon. I had a man who had a dog phobia, and originally he was scheduling all of his appointments when the dog was not there, and then he actually had to schedule when the dog was there a few times, and so he sat on the edge of the waiting room, and then he kept moving closer and closer to the dog, and I think at the time the year was done, he liked the dog, and he said his phobia was a little bit better. Oh, perfect. But I do think, especially in the medical center, if there was a complaint, we never got one, but if there was a complaint about someone who had a severe allergy, we would probably, we had a way to remove the dog, and a way to make sure that that person in the future would never be exposed to it. I think maybe new patients were told about the hour as well when they came in, but we were very thoughtful about it. I loved that. It was a bonus. At Ohio State's medical center, for the therapy animals that kind of go room to room to visit patients, they're not permitted to go into rooms of people who have not yet had a physical exam, so the purpose of that is kind of to avoid some liability so that there can be documented no dog bites, kind of like whether or not the person has something that seems like a dog scratch or bite kind of leading up to the interaction, or an allergy. All right, so this is going to be the last one, last case for a little bit. Dan is an 18-year-old freshman at USA University who has a seizure disorder. Luke is Dan's seven-year-old black lab seizure alert service dog who can alert him prior to a seizure. Dan's parents felt more comfortable sending him to campus with Luke because sometimes Dan forgets to take his medications, and having Luke around reminds him. Question number one, is Luke allowed to go to class with Dan? I'm seeing some nods, thumbs up, yes, yes, because Luke is a service animal, so Luke has granted that additional special access. The next question, is Luke required to wear a service dog vest? I'm seeing a lot of nods, so technically the answer here is it can be recommended, but not required. And this would be something also to look at your local laws as well, because there might be some variations within that state to state, or city to city. So that one was a tough one. I actually, when I was preparing for this, I got it wrong, and then I checked with someone else, and they were like, no, this is why. Okay, so number three, what, if any question, can faculty staff ask Dan about his dog and his disability? So this kind of goes back to that previous slide, where you can ask the person, is this dog a service dog required for a disability, which is a yes or no question. And then the second one, which is, what task has this dog been trained to perform? So in this case, it would be, you know, to alert me to my seizure disorder, help me take my medication. Is a seizure disorder necessarily a disability? I mean, I think if it gets in the way of day-to-day activities, and, you know, has like a meaningful impact. Yeah, I know, it's a good question. I've known people who've had service dogs for the seizure disorder, and they can be useful in a lot of ways, including with taking medicine, but I also think there are safety things they can do around when someone is having a seizure as well. So I think there are a number of people with seizure disorders who do end up with service dogs. And I don't know the specifics, but I remember that they almost can sense the aura with the person before it happens and kind of alert them to, yeah. Yeah, it's a good question, because a person with seizure is not necessarily on disability, but it can be a disability too, so it's difficult. These are tough questions. So the last question on this slide, is Dan required to document his need for Luke with Disability Services Office on campus? People nodding their heads. So actually, this is a tough question, another one that I had gotten wrong initially. So you can encourage people to do this, but you technically can't require this, because it could be seen as discrimination. So one example I tend to think of is if someone was blind and they used, well, actually, let me use this. If someone used a wheelchair or a cane for mobility, you're not required to have them file that in the office on campus in order to allow them to use that. So you need to think of the service animal in the same way as a wheelchair, for example. And I'm going to add a twist to this case. So let's say that Dan is at my university, Michigan State University, and he's a vet student. And he's in his third year of vet school, so he is doing clinics. So is Dan allowed to bring his service animal to clinics? And how do we think about that question? Because maybe it's not a yes-no answer. And this is a real situation I had. Yeah. So the clarification is the clinics mean that Dan, as a vet student, is going in to see animals. I think the answer is that he's still allowed to, legally protected, to bring his service animal to his clinical duties, with the exception that he may have to be more mindful and have some accommodations made to not interact with animals that might be aggressive toward his dog, or his dog aggressive toward them, or other kind of interactions that, you know, if I'm trying to think of an analogy for humans, if we have in our own hospital settings a human that is infected with MRSA, won't be going room to room to other patients' rooms. So you have to be mindful of that. Yeah. You got it. So the considerations we had to think about included risks to the service animal, because service animals are taught to not be really aggressive. And so if another animal attacked, it's quite likely that a service animal would not defend themselves well. So the service animal might be in danger from that. They might be in danger from illnesses, infectious illnesses that other animals are coming in with. Conversely, in that situation, you know, somebody coming in with a cat that's very scared of dogs, even if it's a very nice dog, it might not be comfortable for the patient, for the animal and their owner. And so in this case, it was worked out that the service animal would be in the back room. This was a student who had really terrible PTSD and would dissociate. And so the dog was extraordinarily helpful on a, you know, hour by hour basis for this person. And the service animal was given a room in the back, but not allowed to come into the animal room. And that was very acceptable to the student. And especially as she thought about going into her profession and how she was going to handle this as she worked into the professional world, but that was a really tricky one. Right. I think you're doing this part right, yeah. Okay, I'm back. So we're going to go through the next few slides kind of quickly just to kind of think about things. So what are some of the ethical issues that come up and what are some of the concerns that come up with animals on campus? So the risk to the welfare of other humans, animals, and the campus community. For campus faculty and staff, concerns about what they're allowed to ask, so what kind of training do you give to everybody who works at the university so we're in compliance? Does this cause conflicts between roommates and others and how does the university deal with that? Here's the big one for us, right? Whole conflicts for mental health professionals who write letters and I will say just a little bit more about that is that I definitely have had students that I feel like emotional support animals keep them alive. I mean I feel like they have severe illness and this animal is an amazing treatment and really necessary and helpful. I have a lot of other times that I'm approached by students who may see me two or three times a year for a milder anxiety disorder who show up and said, I got a cat last week, I need a letter. And it really puts you in a spot, doesn't it? And that's where we benefit I think sometimes if we work at a university or within an institution of having strong policies about what we do and do not do and what are the criteria and it helps support the individual practitioner in kind of putting things together. Other things that come up is who's competent to write a letter? Do we as a university when we're sitting on these committees or a disability office, do we accept the letter from this place that we know is a mill, that we know they haven't seen them in person? Back to is there a risk to the therapeutic alliance if you're telling somebody that you don't believe the anxiety disorder rises to a level of a disability and that you're not comfortable writing a letter for this? Can you be objective, of course, and is there vicarious liability? So I struggled with this dot point actually, so I'm going to explain what I found out. So vicarious liability means that you are, the legal definition is that you are liable for the actions of something else. So one way of looking at it is as a pet owner or a dog owner, you're liable if you are not taking, you know, if your dog bites someone else or attacks someone else. And then that can extend to a university. So if the university has made a policy and they've, you know, checked the boxes and said, yes, we're going to bring this emotional support animal into the dorm, and Susie, you're going to be the roommate of the person with this emotional support animal, there may be vicarious liability for the university around that. Another example that's here was animals in labs where maybe the animal could get hurt or breathe in some things that's not good for it, or an animal in a vet clinic, right? So some of the things. So students may have a legitimate need and desire to have an animal on campus, but what if they don't have financial resources to adequately care for the animal? If neglect is determined, difficult decisions lie ahead for the individual and the institution of higher education regarding whether the student can keep the animal. And so some things to think about when you're developing policies and procedures. One is what responsibility do universities have to determine the student's ability to provide adequate care for the animal? How do you put that in your policy? What are the consequences if a student is determined to have neglected or abused an animal? What might the consequences be if there's an increase in separations of animals from owners due to policy violations, abuse, or neglect? And then even looking at the bigger picture, what consequences might this have on campus and community relations if animals are ending up in local shelters? So some of the considerations for writing ESA letters. One is that our policies have to balance the need of students with the impacts that ESAs may have on the general public or providers assessing students or the animals themselves. So there's a lot of impacted parties. Practitioners writing letters of support must fully understand how it may alter their role as a provider and set clear expectations for students prior to undergoing any examination to determine whether evaluation and research is substantial enough to justify this letter of support they're asking for. Clients must be informed that evaluation may not support the request for an ESA and any letter may not supersede laws or policies pertaining to animals on campus. As someone else brought up, unlike service animals, ESAs are not trained to assist individuals and were not selected based on temperament. As a result, ESAs may be in situations where they could interfere with the duties of a trained service animal, they could cause distress for the members of the public, or be exposed to detrimental stressors. Last is there may be confusion or concerns among the general public who are unfamiliar with having ESAs in their public presence so that policies and guidelines must be clear and ensure public safety and animal well-being. Some of the laws that are relevant to consider within your policy, the American with Disabilities Act, a Rehab Act of 1973, Fair Housing Act, and state and local laws which are ever-changing. The ADA protects rights to have a service animal and protects against, the Rehab Act protects against discrimination. The Fair Housing Act allows for assistance animals and that fees can be waived. We're going to go through some examples of these here. One example, a legal precedent from the state I live in is Michigan has put together bills that say to validate an emotional support animal, the healthcare provider would have to be practicing in Michigan for at least 180 days so that the person who writes the letter has to practice in the state they've written the letter for and have an office located in the state. They would also have to provide a notarized letter saying they've been treating the pet owner for at least six months and penalty for fraud is 90 days in jail or a $500 fine, so a pretty strict law. All right, so I want to pose this question to you. Who do you think should write ESA letters? Who's qualified? Who's qualified? Yeah, take a stab at it. I laugh when I say nobody's qualified. These are animals that are nice to have and we're not, I mean, in the law in Michigan makes no sense to me because you haven't evaluated the animal. It could be a very, you know, aggressive animal. People like having Rottweilers, they like having pit bulls, they've really helped them and so who are we as therapists to be qualified to certify an animal unless we're a vet and can really want to go on the line and say something about the animal. I really think that if animals are allowed in an area, absolutely people should have them and if they're not allowed, we put ourselves a huge liability. I don't see why we would, I've really changed and I can't do this. Yeah, and I think, I mean, the answer to this question is I suppose like it varies and it is kind of tough to say if we are qualified, especially since a lot of the formal training out there is kind of biased and maybe produced by kind of people who are more likely to be advocates for increasing animal, emotional support animals out there. Another thought too, well, I'm skipping ahead a little bit, but one resource, one article that's a really good resource in kind of weighing, like educating people about emotional support animals and kind of weighing all the considerations when it comes to writing these letters, that article does suggest that you as the clinician have kind of seen the animal interacting with your human patient and kind of make a comment on that, whereas the American Psychiatric Association recently, after the HEMA guide, they came out with a nice resource document on emotional support animals that I'd also encourage you all to take a look at. And one thing that they talk about is it's, I mean, are we, we're not qualified as psychiatrists to be able to assess the temperament of animals. I know I certainly am not. I really only follow animals on Instagram. I haven't really ever had a pet. So, you know, just kind of keeping in mind that you might not want to write down that fluffy specifically is essential for the emotional support of this specific individual due to their psychiatric disability. You might want to instead kind of talk more about the mental health side of it that you're familiar with. Yeah. Alyssa. Yeah. So I, I kind of, I'm echoing sentiments of some other people that some of us think, you know, pet rent, things like that are stupid. So some of us have been inclined to sign because of that. I usually try to put in a snippet of patient may benefit from support animal. And I usually try to put something provider does not accept liability. Does that help me at all? I don't know that it necessarily, it's, I think it's, I think it's fair to include. I don't know that it necessarily would protect you from liability. As far as I'm aware, some of the liability cases that have come up so far are when, when people have written ESA letters for individuals out of state. At the same time, you know, you can get sued for anything. And so it's still possible that it might get, you might, you might win it, but you might still get caught, brought up to court. As a college mental health psychiatrist, I think one issue we face in general is the increasing abundance of letters we're asked to write in general. And I think that's one reason our university says we can't write, mental health providers on campus can't write emotional support animal letters. But in terms of who's qualified, let's say there is a campus policy that someone can write the letters. In terms of our time, I think it's best if someone, maybe someone at a social work level can write it because we are facing too many letters right now. I had a student just doing a summer internship, and she had to fill out a health form, and I had to write a letter. It's safe for her to work in an agricultural setting. It was absurd. So I just, I think our time is being eroded, and we want to do our therapy and a medical, you know, psychiatric evaluations, medication, and we just can't keep up with the letters. So I don't think, I think MDs in general should be writing fewer letters. No, and the tough thing, too, is I think in Ohio, social workers, like their local board says you need to have X hours of specialized training in order to write letters of support. So that's like another example. I agree with you, and it's another example of just needing to be aware of all your local laws in regards to this, too, because there is enough variation state to state. I guess as we're talking about risk, I have another question regarding, like, as this is a transient population who's moving back and forth to other states, potentially, where you're not certified to write the letter, is that something you're going to discuss as well in this talk? So I think, I guess not. We don't have, we're not planning to discuss that, but I can kind of answer the question best I can. But I think if I were to be writing this letter, I think one part of the evaluation is what the environment is going to be. So, for example, one of the individuals in Columbus who has, I believe has more training to write these letters and is someone that a lot of people refer to to do the evaluation for emotional support animals, I noticed on her website she updated it to say, I'm no longer writing letters if you're living in a communal environment. So that might be a consideration, too, about the individual's ability to take care of an animal if it's a certain setting. And included in that discussion is where are you going to plan to live? So it's kind of similar to that practicing across state lines issue that a lot of us are dealing with now, like with telehealth. I think same goes for this. So if you're planning to take this ESA letter and go out of state, you're not aware of what those laws are in that other state, and so you might not be able to write that letter. So, you have a question? I was at first very reluctant to write these letters because I had no training in it. Just I saw it like prescribing certain medications. And then I realized how important it was to certain patients. And I realized that social workers are writing these letters. So, you know, why would I not? And I came to kind of emphasize the attachment of the patient to the animal and to write it on that basis and their history together. But I wasn't aware of liability issues. I'm sorry if I'm... I don't think there tactically have yet been... I'm doing another talk tomorrow in the afternoon that's about emotional support animals and this APA resource document. So, my colleague on that talk is kind of talking about the liability issues. So, I definitely would encourage you to look at the resource document that the APA has put out recently. And I don't believe that there have... we're not aware of court cases to date where the clinician writing the letter has been liable, held liable. That being said, I have a psychiatrist friend who wrote a letter for someone that landlord's lawyer called the friend up and said, would you be willing to testify in court about it? So there's no formal lawsuits, but there could be potential. We don't know. I had one patient who had a PTSD survivor who had an emotional support animal, and she was in college, and there was another student with an anxiety problem who could not be near that animal. So my patient and her animal were not permitted to go certain places because of that other student. Can you unpack that and what's going on? I think it is difficult because, you know, the individual with the emotional support animal has a psychiatric disability, and so I think it's nice that they were able to agree to not go into certain places. And technically, the ESA letter should be written, it's most likely to be written for housing specifically. So there are certain designated places where that individual with the service animal might be confined to or restricted to. So certain areas where the emotional support animal might be restricted to. But it's also tricky when it comes to having this conversation because you want to be aware of not discriminating against someone with a disability. And just to add to that, so when they think about that in dorms, when they're putting policies together, the place that the emotional support animal can be, one is in the student's room, right? Places they can't be might be the bathroom, the study lounge, the general lounge. They have to think about where does the animal toilet. And so you need to think about if it's a dog, of course, you know, are there outside places that you can take that dog? And of course, it's okay to, you know, take a dog wherever you might on a campus like that. But that ends up frequently a disciplinary issue, is that animal, you know, traveling through the dorm? Yeah. One of the questions that came in through the virtual program is, you know, what rights do, you know, individuals with ESAs have in the workplace? So our expertise is really more within the higher education setting. But to kind of, you know, take a stab at that question, the laws right now, the federal laws right now talk about ESAs in housing. It doesn't necessarily talk about in workplace. That being said, you need to be aware of the local and state laws to see what, you know, what kinds of permissions there are for that as well. Yeah, there's a lot of complex layers to this. And we've tried to sidestep liability in our clinic by having a letter request form that patients fill out. And they have to sign that. And what they're signing to is that we do not accept liability, that we have not evaluated the animal, and that they're the handler is responsible for any actions of the animal. I don't know if that holds legal weight. We didn't have a lawyer review it, but we're hoping that including that language and having a patient attest to it would help. With respect to disability, I think there's some important points to be made about whether the institution is made aware of a person's disabling condition. Because the ADA has provisions for things like equal access, including wheelchair ramps and stuff. But it does stop there when it comes to animals, because the ADA does not cover access for animals explicitly unless it's a therapy or rather a service animal. And students cannot expect accommodations for disabling conditions unless they've registered those with the institution. And that's why access centers exist in colleges, is because you have to document your disability with the school. Otherwise, the school, if it's not informed of your disability, doesn't have an obligation to fulfill some accommodation for your disability. Imagine a person with visual problems who needs an extra large monitor. They don't provide extra large monitors in every classroom. That's why you have to file your disability with the institution. And any mental health diagnosis has the potential to be considered a disabling condition. But if the school's not notified about that, then they're not in a position to have to make accommodations for that. And in that respect, I think you can't treat an emotional support animal like a wheelchair, because there isn't a blanket provision for that under ADA. Yeah, I think just to clarify, too, the question before was specifically with the service animal, not emotional support animal. And you also make a good point, too, is with service animals specifically, you can't require someone to register with disability services. That being said, that person may not be able to get the accommodations if no one knows that something needs to happen to accommodate that. And so, yeah. Let me kind of, we might need to go a little faster, which is totally fine. So basically what this map is, so kind of going back, reminder, we're talking about who should write ESA letters. And so several laws, there are 33 states out there who have laws against writing fraudulent letters. Lee's state does have such a law. My state of Ohio does not have such a law. But again, it's very useful to be aware of what the requirements are. And several states are coming, including Florida, have come out with laws that also have that, you know, some rule about needing to have established a doctor-patient relationship or a clinician-patient relationship, needing to have seen them on an ongoing basis before writing these letters. So now talking about the legal versus ethical consideration. So what is disability? So disability is based on federal laws. And so the disability is not just discomfort. It's something that's impairing the individual's ability to perform major life activities. So this is also unique for me, you know, having worked at Ohio State. I have, the university in general has a lower threshold to do academic accommodations for individuals with many mental health disabilities, many mental health diagnoses. However, it's a different standard, higher standard when it comes to emotional support animals. It's kind of more of that traditional sense of disability. And this is kind of talking about that as well. Like, you know, this is the specific terminology in case you want to read this in ADA later. But disability means with respect to an individual, physical or mental impairment that substantially limits one or more major life activities of such individual, record of such an impairment, and it's being regarded of having such an impairment. So this is that article that I had mentioned that is also a really good resource, the Young-Gruen article. And they talk a lot about, you know, different things to consider when writing emotional support animal letters. And this kind of is also a summary of things that we've already mentioned. But the thing that's kind of unique to, and APA does not have a specific policy. However, they have that resource document with suggestions, just like the ESA guide, the HEMA ES, or the Animals on Campus guide. So this, so that's in contrast to this article where it does suggest an evaluation of the animal's ability to perform the function consistent with animal's abilities and temperament. And then evaluation of the interaction of animal with owner to support the claim of amelioration. Right now, they're really, you know, use of emotional support animals is still an experimental treatment. There isn't a, you know, a significant amount of evidence out there right now. And so, you know, one other thing I've read about this too is this is a big topic of discussion among, like, veterinary physicians as well. Because they on the flip side will have, you know, their, you know, their clients, so the humans who come in with their, you know, with their animals request letters from the veterinarian. So the veterinarian is thoroughly trained to assess the animal itself. But what the different, like, veterinary medicine associations remind the vets is that you're not trained to evaluate the human with the dog too. So it's kind of, maybe one day there's going to be, like, a collaborative model where we're working with vets to try to figure out this issue. And we're both kind of assessing one side of, you know, we're each assessing different sides of the coin. So other things to talk about. So recommendations for ESA policy. So a comprehensive policy needs to clearly state which office is responsible for evaluating the ESA request. And the policy needs to be kind of clearly describing the process for requesting an ESA accommodation and defining the criteria for determining if the presence of the animal is unreasonable. And these are examples of different collaborative stakeholders that you could also. So we had edited these slides, but it didn't save them. So basically Student Affairs, General Counsel, Accessibility or Disability Services, Residence Life, if you have an equal opportunity, Equal Employment Opportunity Office, Counseling Center, Housing, Dean of Students. And so other recommendations include, you know, defining the process like we said. Clearly outlining that the appeals process is no different than any other accommodations and outline on a case-by-case basis. And then clearly articulate what are the situations in which the owner might be able to remove the ESA from housing. I think that a lot of these things are, yeah, are kind of reiterated. Yeah, so there's some really good guidelines and things there that you can go to and refer to. I think in the guide, if you happen to be on a committee or working with someone who's putting one of these policies together, and those are all really clearly spelled out there so you don't have to remember them from the slide. So one of the things we're going to do is we had some model policies to show you from a couple of different schools. And they just exited the computer, but there's one from, did you get it? So this is an example from UC Irvine. And I'd encourage you to kind of, if you're developing a policy, this is one example of something that you can look up. But just kind of to outline, it's very thorough when it talks about, you know, it makes sure it defines what are all of these different, you know, what is a direct threat, what counts as an example of disability, just so that it's incredibly clear. And this is something that they came up with in collaboration with multiple different offices on campus, including legal. That is a tough thing. A lot of the questions we've posed today are kind of like, what are the laws surrounding this? And I know we're not lawyers here, so that's why it's so important to collaborate with, you know, with the legal team that you have at your institution. So I'm going to scroll through this really fast, not slow enough for you to see it, but I think it's just impressive how long it is and how thorough it is. So it has a really nice, so it starts out with purpose and scope, has a really nice definition section, lots and lots of definitions, basically what the different policies are for, are different policies that are there, including like we see in this one, there's a specific section on how do you remove an emotional support animal and why. Responsibilities of every party are taken in there, including the university's responsibilities as well as the students' responsibilities for this to work. What are the procedures? How do you do this? Appeals, complaints, and notes. So that it's remarkable when you put a university policy together that is really thorough, how much it takes, how much time it takes to put it together, and I think the better constructed it is, the more it supports those people on the ground when they're dealing with difficult situations. We have a second link that we're not going to go to from Colorado State, but those are also, there's also links in the guide that you can get to from there if you were looking for model policies for universities. Okay, so we have about 15 minutes left. We've got a couple of cases. I think I'll run through the cases quickly and then if there are questions that people would like to bring up, we'll have a little bit of time. So the first case is Cassie. She lives on campus at State University with Clementine, her ESA cat, and Molly, her roommate. Cassie has severe anxiety and Clementine's presence brings her great comfort. Lately, Molly, the roommate, has noticed Clementine's litter box is full and she's begun making messes outside the box. The litter box smells have become overwhelming. Cassie has not attended class for weeks. Yesterday, Clementine scratched Cassie on the face when she tried to rouse her from bed to feed her. Molly is unsure whether Cassie is feeding Clementine and is becoming concerned for Clementine's welfare. Molly called the counseling center to express concern for Cassie and complained to the RA about the smell and Clementine's well-being. What issues do you see? Hygiene. Hygiene. Lack of compassion. Liability. Did you... Cat. Yeah, Cassie seems to be languishing in the best of cases, right? Is there neglect going on with the cat? You know, how is the roommate doing? Okay, and so the next question is, should Cassie be allowed to keep Clementine on campus with her? And maybe I think in the interest of time, if we had a little bit more time to break out and talk about this, I would, but I think the issues, the answer is we don't know yet because I think Cassie needs to be evaluated. We need to understand what's going on with the situation. We need to understand if there's neglect as well or any harm coming to the cat or the roommate. And another aspect is, does your response change if you were the person who wrote the ESA approval letter? I see a lot of people shaking their heads no. Does anybody want to support yes? I had initially said yes because my initial instinct is to, I'm worried that I approved this for this individual. What's my liability now? Because I, you know, I didn't predict that this person would not be able to take care of the animal. Although leaning into, leaning into making a mistake is not always the best thing to do in a liability situation, right? Yeah, and the situation has changed from the time that you wrote the letter, right? You wrote the letter understanding that Cassie was well enough to provide the care needed for the cat and the situation seems to have changed. Well, and hopefully when I did do the initial evaluation, you, me, me in quotes, but hopefully that was a consideration that I documented. Yeah. Yeah, that's lovely. I'm going to repeat what Diane just said for the home audience and the people who couldn't hear is that Clementine, the cat, is providing lovely clues to what's going on with Molly and Clementine may be that canary in the coal mine right now. Clementine and Molly, of course, the roommate. Yeah. Okay. This is our last case study. This is Peaches, and Peaches is a 12-week-old beagle puppy who was brought to the dining hall by their owner. Peaches was tied to a table while the owner went through the dining line. She slipped out of her collar and got into a low-lying bin of snacks. When asked by staff, the owner said the puppy was a service animal, which is not possible because it's a 12-week-old puppy not performing any tasks. The student then claimed that Peaches was a service animal in training. However, this does not remove the responsibility to keep the animal under the handler's control at all times. The issue was referred to student conduct. Discussing the requirements of a service dog in training and whether the state gives them the same rights as a service animal with a conduct officer, the student was reminded that even service animals in training must be well-behaved and under the control of the handler at all times. The student was fined the cost of the bin of snacks ruined by Peaches. The student subsequently registered Peaches as an ESA and never brought her to the dining hall again. Okay, so the first question is, how should student conduct office be informed of the incident to follow up? And this might be a better NASPA question when we've got all of the university administrators there. Does anybody have ideas of how this happens on a university? No? I would kind of assume it's perhaps the dining hall who would notify student conduct, and they don't have the same confidentiality requirements that we do in our clinical space, but I'd assume that they would be the ones reporting. Yeah. Yeah, so the owner broke their own kind of confidentiality in this dining hall space by expressing that it was a service animal in training. Yeah. So the other part that that underlines for me is just, again, when you put these policies together, having everybody at the university, the relevant offices involved, and so student conduct knows right away, you know, how do we get to the ESA policy, the service animal policy, and pieces like that. Do you all feel like the sanction was appropriate? Yeah. And what can be learned from this incident to inform policies and procedures for confronting students who fraudulently present a pet or an ESA as a service animal? Yeah. So I like that answer. So I think what you said was that the student would know from a form what their responsibilities were with the animal. So if they had attempted to register them as a service animal or a service animal in training or an emotional support animal, they should be aware of what their own responsibilities are, right? Yeah. Yeah. The other thing that maybe I would learn from this is, you know, we think about college as this place for transitional age adults and trying to figure out how to be firm and strict enough and have really good boundaries and at the same time not come down too hard the first time, right? That they were asked to pay for the snacks that were ruined and, you know, not kicked off campus or some big, big consequence with the first violation. And I also assume that that first violation involved them learning a lot about what responsibilities were and what was allowed and not allowed on campus. And if there was a second violation that there would have been greater consequences. Okay. So we have only five minutes left, but are there any thoughts or questions that people have? Oh, wait, wait. Before I do that, I'm also going to scroll to the QR code so that if you scan that, that will take you to the link where you can download the guide from the HEMA website. So I had a clinical situation recently where I had a homeless veteran who owned two Huskies that wanted a designation for his animals to support animals. And this is obviously a complicated situation because his housing is going to tantamount for this particular veteran. But the question I have in my mind is whether or not anybody here or in your experience that you could justify having two emotional support animals or what is the limit on that? Is that a consideration at all? It's, yeah, I'm not sure. I think it is really, it's difficult because I feel like I already hesitant to write a letter when someone's asking for one, but the extra one that would be kind of difficult. I did have a patient once in one of the group therapy groups that I facilitated who had two emotional support rats in the residence halls. And what she had said was she was able to, I don't know anything about rats, but I guess rats need to be with another rat. I probably not because they're always kind of running around the subways and stuff like that on their own. But somehow she was able to justify that. Whoever wrote the emotional support animal letter, you know, signed off on the two. I've heard of it being done at least once. But it is difficult to kind of prove that you need two animals. If they're raised together. They weren't raised together. They were just two huskies they got. And they were on the streets when they got them. And it was a, it's been a mess. Anyway. Yeah, I don't, I don't know the answer to this either. But I have this kind of vague recollection that there's some literature out there about it, because I remember reading about it a while ago, but I don't remember what the answer is. That I'll just piggyback on that, because I think that's a good example of how I've probably experienced most requests for ESA letters is that it's a pre-existing pet. And it happens to be somebody that I'm seeing for mental health and they want to waive their pet deposit. So can I make my pet of seven years my emotional support animal? And it does come up in our situation as well that someone may already have more than one pet. One thing that I wanted to try to open up for discussion is about the, whether we would have obligations to these animals, independent of whether someone's requesting an ESA letter from us, because if we're talking about the possibilities of a person not being able to take care of it, does it matter if they asked us for an ESA letter? Should we be reporting the risk to the animal, whether or not we've been looped in to write a letter? Because it sort of sounds like if we're being asked to write a letter, we're suddenly responsible for this animal in a way that we aren't if they don't ask us for a letter, but the behaviors are the same or the risks are the same. So that's one question I have is, are we shirking a responsibility if we're not asked for a letter? And then a more general question about these letter requests is, are we really being asked to certify this animal or are we being asked to certify that a patient would do well to have an emotional support animal for their mental health? And it's not really in our purview to say that it has to be this one or that one. I wasn't the recipient of this in our clinic, but someone came in and asked for an emotional support letter for a snake and one for a spider. So who am I to say what kind of animal provides somebody with emotional support or stability? I think some of the recommendations, especially with housing, like housing urban development is to specify the animal. However, I wouldn't do that. I would say, you know, they would benefit because of their psychiatric disability. They would benefit from an emotional support animal. I might go as so far to say a cat or a dog. I don't know enough about any other animal to be more specific than that, but I wouldn't, just because I don't know how to evaluate a spider other than running away from it. I wouldn't know. I wouldn't know what to write down. And the other, remind me of the other, the second question real quick. Oh, so what I've typically done when I don't think someone, when I don't think someone meets criteria for this letter, I'll document that. And then I've typically said, this person requested a second opinion and I provided them from the, with these other clinics. So I kind of, in my own documentation, I say, we discussed it. This is why I didn't think that they were eligible for this. However, this was the next step. So I do end up documenting it. Yeah. So to be mindful of time, it is 930 right now. So I'm going to officially end the session, but we can continue talking. Okay. So that if people want to leave for something, I wanted to add a comment is that you also have to pay attention to school specific policies. So I'm currently doing, working with a telehealth company where I work with multiple colleges and each of them have different policies around emotional support animals. And so one of them that I work with does need you to specify the animal. They have had to have a previous relationship with this animal and they have a certain amount of time, like for four months or something, or eight weeks. And, and they had good reasons for developing that policy and a thought process around it. But, so that's a case where you have to take the law into account, the best practices in the community into account, and then the very specific university policies into account. So at that school, one of my students who really wants to have an emotional support animal, when she goes home over the summer, she's acquiring a cat that she will keep at her mom's house over the summer and then can make the request in the fall to bring the animal back. She does have a disability that qualifies. They, they have to have known the animal for eight weeks. So they can't get a letter and then just go get an animal from the shelter in the middle of the school year. And they had specific problems that led them to kind of come to this iteration of it for university housing. There might be some renewability though. I know in my state, the expectation is that the letter is written annually. So it's a, it's a consideration. To address actually the last two questions for, I actually completely would disagree with that policy. I think it's great if you write a letter on behalf of the patient and put a disclaimer. I have not evaluated the animal. I cannot say anything about the appropriateness of the animal, but I think the patient might benefit from it. Rather than saying you have to know the animal, treat the patient for 48 weeks, put a disclaimer in. Completely, you really have no ability to evaluate an animal. As to the other one about two dogs, three dogs, the job of every kid is to test the boundaries. And this is just a great example. Where does it end? Two dogs, three dogs, two cats, one dog. That I think we have to have a policy and stop there. But we're always going to have people stretching the limits. And the last thing I wonder about, I think ESA is a great term. Is there any legal entity to it? Why are we even having these discussions with students and, and so on? Animals are great for support for people, but what is the legal entity of an ESA that we need to have all these policies and be, and get ourselves entrapped like this? You want to start with that, Mira? Yeah. I mean, I think, you know, the policies certainly don't proceed, you know, you know, I think we're kind of catching up with how do we meet these demands from students. So we're kind of forced to come up with these policies in order to navigate these requests that are going to be, that are going to be coming, coming out and are continuously coming out. And because it is for a psychiatric disability, I think it's, you know, it's reasonable to have policies in place so that you're not liable for discrimination. Right. It's a great sounding term, but is it an entity? And it is ethically permissible to not write these letters as well. So yeah. Thank you for the very interesting discussion. It's kind of like the talk of the day with all the ESA requests. So I have a patient who is graduating from high school and going to college with just a diagnosis of ADHD. There's no depression, anxiety, no other DSM diagnosis. She asked for the, she asked for a letter and I said, I don't think ADHD qualifies. So what do other people think? Just a general comment I wanted to make anyway, it's built into our DSM diagnoses that it has to have clinically significant It has to be clinically significant or impairing in Functioning in these different domains. That was the definition of disability in the Fair Housing Act It's built into our definitions. We have to give a mild moderate severe Specifier. No, we don't if we're issuing the diagnosis We're saying it rises to that level because that's built into the diagnostic criteria So I get the idea that anxiety can be mild for one person and more severe for another person But if it's that mild, why are you diagnosing it in the first place? I'm gonna say that it's for me. It's not even the severity of the diagnosis. The question is how would it help? How would it help I am just speaking as a mother of College students with ADHD. I would be afraid my kids would forget to Properly care for the animal because their head is all over the place So is I mean it and so my question to the students is how do you think the animal will help you? If it's if it's because they have separation anxiety Then it's not just the ADHD and that might be the case like they might need the comfort of the animal Because there's a continuation of the home environment But but I I always ask them and I know my first letter that I ever wrote ever was somebody with severe anxiety and complicated grief because he had just lost a parent and He did a lot of research. He adopted a dog and two months later He decided I cannot care for like I have to care for myself and he responsibly Rehomed the animal that whole experience because it was really genuine on his side and on my side It was not about policy. It was a clinical decision Really informed the conversation that I had with everybody. It's like, okay. I'm not opposed to you having an animal But like how do in your head? How do you see that that animal is gonna help? Explain it to me so I can explain on my letter and just Just full disclosure in my institution. We're not allowed to write letters. I'm a University of Florida. That's policy We do not write letter for students for ESA because if it's a service animal, it's all the documentation. They don't need a letter I Appreciate that question and I appreciate both of the answers that went there that it is embedded in DSM criteria right to make a diagnosis that it is clinically impairing and Lose point as well is what does the animal do, you know, does it? Ameliorate some of the symptoms of the illness in a meaningful way, right? What does it do and and to that end I think with ADHD it could go either way because the truth is Perhaps this person does better when they have the structure of taking care of this animal reminds them Oh, I have to brush my teeth. I have to take a shower. I have to do my own work Nice. Yeah And then the other half to that answer is if be aware of if the students moving out of state because If you're not aware of the local laws related to this You might not be able to write a letter and the one case we are aware of where a clinician was held liable was a Marriage family therapist was writing letters for people all out of state online And so that was an example of a university-specific policy, Lou? Something that the university specifically had put in place? A university-specific, yeah. We'll have you do our last question, but then if people want to gather and kind of chat we can do that So go ahead So I've read through the ethics Paper for the APA, but I haven't looked through your guidelines yet, but I am just curious Does it discuss including in your policy what happens like in that? Discussion with Cassie if she were actually to be hospitalized what happens with the animal Yeah, yeah, so the the guide does not address every situation And the hope with the guide is that a pre it gives a roadmap to universities To think about all of the things and I think that's one of the things that guide recommends is you know what happens? When the student is away, whether it's a way to a hospital they go away for the weekend Is someone else allowed to take care of that cat or does the cat need to go with them? And so policies can get very specific about what happens with ESA animals in Unexpected situations like that. Yeah, excellent question develop a partnership with the local shelter as well Yeah, all right, thank you all it's a tough issue

emotional support animals

service animals

college campuses

mental health professionals

therapy animals

legal rights

ethical dilemmas

student housing

animal welfare

campus policies

conflict resolution

Americans with Disabilities Act

ESA letters

higher education