All right, well, why don't we go ahead and get started. We are so impressed that all of you have shown up. Thank you so much for hanging in until the very, very bitter end with us. My name is Ariana Nesbitt, and I am going to be presenting today with Dr. Mara Menon and Dr. Charles Dike. Our fourth presenter, Dr. Catherine Rideout, unfortunately is unable to be here, so Dr. Dike has graciously agreed to present on her slides. So this presentation is based on an APA resource document that we, along with many of our colleagues, and we were just saying, I'm not sure if we've got any of them in the audience. I don't think so. Please raise your hand if I'm missing anyone. We're all a little blurry-eyed at this point. So we published this along with many of our colleagues, and I want to especially mention our two primary authors who were Drs. Rene Binder and Dr. Tanuja Gandhi, and we did this publication last year on emotional support animals. The creation of this resource document was led by the Council on Psychiatry and the Law, but the Council on Quality Care, Council on Children, Adolescents, and Their Families, and the Ethics Committee also contributed. So the objectives for our talk this afternoon are to first describe relevant federal and state laws. Dr. Menon will take care of that. Dr. Dike will then cover Dr. Rideout's slides on the evidence base for the use of ESAs. I'm then going to talk about the process for conducting an ESA evaluation and cover the pertinent ethical considerations, and then Dr. Dike will cover the section that he was prepared to talk about, which is to talk about liability concerns and strategies to reduce liability. And without further ado, I will turn it over to my colleague. Great. Thank you so much. Thank you for the introduction. So my name is Mira Menon. I'm a psychiatrist at The Ohio State University. I specialize in college mental health and young adult mental health, and I always like to make a plug for the College Mental Health Caucus. If that's something that's of interest to you and you're interested in, you know, getting involved in our program or any of our listservs, just catch me after this and I can tell you how to do that. But I'm, you know, working in this setting. I've obviously, you know, had several, like a lot of people in this room, I'm sure, had a lot of patients ask me about emotional support animals, and so that's kind of what got me interested. I don't have any disclosures, and I do always also like to say if I express an opinion, it represents my own mind and not Ohio State University's. So let's get into it. So this first section, I'm going to be talking a lot about definitions and terminology. And in doing that, I think it is helpful to compare emotional support animals to other types of assistance animals, but primarily I'm kind of starting here. So an emotional support animal can be of any species, and they must alleviate the symptoms of a psychiatric disability through the animal's companionship or presence. So we'll kind of compare this on the next slide, but I think kind of the key elements of this sentence that distinguish the emotional support animal from other types of assistance animals or animals in general, the any species part, it has to alleviate a psychiatric disability, and then this piece about companionship. All right, so I love a good table. So here's a table if you want to take a picture of that. So this is comparing emotional support animals that you can kind of see here in the center role with other types of assistance animals. So let's kind of go through some of these to talk about some details. So I have service animal and psychiatric service animal distinguished on different lines here. A psychiatric service animal is a service animal. I think I have them on separate lines just to kind of highlight more so how it's the same as a service animal and make sure that it doesn't get confused when we're thinking about emotional support animals. So both service animals and psychiatric service animals, the species must be a dog. In some instances, like for example allergies, it can be a miniature horse who is serving as the service animal. The person who is helped by this is the specific individual owner of that who has a disability. And there is training that is required in order to complete, in order to train that animal to complete a specific task. In the service animal, it can be trained by the owner with the disability themselves. But it's trained to perform a specific task. So that is in contrast to the emotional support animal which can be of any species, doesn't necessarily have to be a dog or a mini horse. But one thing that it does have in common with the service animal is that it is also for someone with a disability. So it also is for someone with a psychiatric disability. It does not require any specific types of training because it's not performing a task. So this is in contrast also to a therapy animal which also goes into that assistance animal category. This is something I work with a lot in the college mental health setting especially and I think I guess a lot of other individuals probably do as well. But therapy animals are typically divided into two categories. So there is animal assisted therapy and then there is animal assisted activities. So animal assisted activities, that's kind of what I think of as like it's final exam week. The student affairs office is planning some specific programming and they have a bunch of therapy dogs in the student union that students can stop by and snuggle with for comfort and stress relief. Same thing goes for a hospital setting. So if you work in a hospital setting or another larger medical setting where they have therapy animals coming through and walking through waiting rooms or going into patient's rooms that kind of goes under the animal assisted activities where it's kind of like a presence and getting some sort of comfort. So animal assisted therapy is when it's kind of more when the individual clinician uses the specific animal in the therapeutic setting in order to do interventions. So we did a talk on this just earlier today and some of the examples we're using is you have your therapy animal in the room with you as the clinician and you're using the animal in session to help a patient with assertiveness for example by kind of talking through with the patient like how do you assertively call for this animal. Other ideas I've had about that are also what does this animal represent to you and kind of like thinking about what kind of internalized objects do these animals represent. So using just like you might with any other type of therapy tool using the animal in that way. So that's kind of what a therapy animal is. And then we have pets. So pets I think are what a lot of us are the most familiar with with a high percentage of our population having pets. So these are domesticated animals. They technically can be really from a whole wide variety of species. And the individual who's helped technically the owner I think really most of us would say that having a pet can be a really huge comfort. That's why we have them. And there's no laws that are mandating training or rules that are really mandating training. There might be laws in your area that have requirements for vaccination and microchipping, things along those lines. But the training requirement is less. So kind of going down the list I guess that kind of differentiates the species who's helped by this and then the training required. One thing I did forget to mention with therapy animals there is specific training required that is really kind of for the therapy animal and the owner in tandem because they work together as a group. And these are put on by various organizations that kind of monitor the training. Alright so let's compare the functions. So like I said I really love a good table so here's another table for you. I hope you love them as much as I do. So service animals and psychiatric service animals. So these are like I said before let's consider these to be the same things even though I have them listed separately. So service animals, what differentiates them from an emotional support animal is that the service animal is specifically trained to perform a task for someone with a disability. Whereas the emotional support animal they're going to help through just comfort which is very good and helpful but it's not performing a specific task. So a task for example could be I think probably one of the most common ones we think of for a service animal is a guide dog for example. So helping guide someone who's visually impaired through the world. So this is also one thing that's in common with the service animal psychiatric service animal and emotional support animal is this last column. So all of these are mitigated disability. I'll talk about this in a little bit. Service animals are protected by the Americans with Disabilities Act whereas emotional support animals they're not. So this is in contrast so let's compare these to therapy animals and pets. So therapy animals they do not perform a specific task or intervention but they are there for emotional support, comfort, companionship and they're not specifically being used to mitigate an illness or a disability. And pets also provide comfort and are not necessarily tasked with mitigating a disability or disorder. Alrighty. Okay. So here's some little quizzes. So we have a quiz. Emotional support animals versus psychiatric service animals. So I'm going to read these out individually and I'm hoping like maybe people can call out from the audience like what do you think you know which one do you think each of these are. So number one so top left an individual with depression feels comforted by their rat and is able to get out of bed due to needing to care for that rat. Well it's based on a real life experience of a patient of mine. So who I didn't write their ESA letter. I'll just say that. But yeah what do you think. Oh sorry I gave it away. It's an ESA. So and just to kind of be specific with it. So it's a rat. It's not a dog or a mini horse. So that would be kind of one way you can distinguish a service animal from an emotional support animal. And then it's kind of providing comfort and not a direct task for the individual. All right so let's try upper right and I'll try not to give away the answer for this one. An individual with a non-epileptic seizure disorder has a dog that detects warning signs and alerts them prior to the onset of an episode. What do you think this is? Is this an ESA or a psychiatric service animal? I think I hear people saying like psychiatric service animal. Yeah that's correct. So the hints here to make us think that it's a dog. The person also has a disability and then they're detecting warning signs and kind of signaling them. So it's a specific task and intervention. So here is the last one. So an individual with schizophrenia has a mini horse that is trained to bring the pill bottle to them, thereby improving medication adherence. What do we think this is? ESA or PSA? Psychiatric service animal? Yeah. So again we got our mini horse. The mini horse is performing a very specific task for the individual with a disability. But how does the horse affect the person? How does the horse affect the person with schizophrenia? Now I was just going to say that since we would like you to ask questions on the microphone or you just repeat the question. So either way might be fine. They're recording the volume, the audio. Yeah I think we forgot to say up front this is being recorded for the on-demand. So preferably questions into the mic, but I'll, if you can't make it, we'll repeat it for you. So how is the mini horse helping? So really, whoever has approved this has determined the schizophrenia to rise to the level of the disability. So it's impairing to major life functions, and this individual has difficulty with medication adherence. So the horse is kind of reminding the patient to, literally bringing the medication to them so that they can make sure that they take it. I think other examples I've seen of this are the service animal, the psychiatric service animal, will see their owner having a panic attack and will literally bring them the anxiolytic medication to help in the moment as well. So it's another example specific to psychiatric service animals. I've worked with one patient when I was working with the Department of Defense, who had PTSD and non-epileptic seizures. And so that individual, I guess I used that as an example before, so that psychiatric service animal helped with detecting when the seizure was going to happen, and also even kind of protected them in the moment, and was trained to kind of, like if he had fallen with a seizure, was trained to kind of hop on him to make sure that people didn't try to move him while he was in the middle of a seizure as well. All right, so let's talk about some of these federal, state, and local laws. So this is another chart. I think one thing, I'm going to say this now, and I'm probably going to repeat it again, because it's really important. So it's really important to stay, especially if you're considering writing these letters. Honestly, even if you're not, I think it's really important to stay up to date about what the federal, state, and local laws are in this area. I think especially the state and local laws, we do not necessarily see those getting advertised as widely as some of those federal laws as those get changed. And those can really influence the way in which we do these evaluations, and what the different rules are surrounding emotional support animals, and writing these letters of support. So when we think about different laws, one of the areas that we think of is, does the law grant this animal permission to be in certain spaces? So service animals are permitted to be in any public establishment. So if you see a restaurant or other area where they have a sign on the front that says, no animals allowed, being a service animal permits you to get past some of those things and be able to use that. I think of it almost like really many other assistance devices, you wouldn't tell someone who used a wheelchair or used a cane that they can't use it in certain spaces. They have to use it all the time. So you can kind of think of that service animal as that assistance device. Do they have the right to enter medical settings? So yes, but potentially with restriction. So some places will have kind of specific rules and laws about, like for example, a dog being in an operating room. One example that we were talking about yesterday in another talk was a veterinary medicine student who had a service animal for PTSD. And there can certainly be some issues if you're bringing your service animal in to a space where there's other animals where they can potentially be exposed to different diseases, thereby putting the service animal themselves at risk. And so the school had worked with the student to kind of come up with a plan about how to make sure that service dog stayed safe. And so in this specific instance, the service animal didn't necessarily follow that vet med student into each individual patient room. They kind of stayed in a nearby area where they could potentially be called on if needed. Other things, so therapy animals, and I'm just gonna kind of go through the first two columns first, so therapy animals do not have any legal rights to enter public establishments, but they might have some rights to enter legal establishments if they're being used for this type of work. If you do have a therapy animal, just you can't just bring them into places, like especially medical establishments. You need to check with the facility and really go through the process of having the approval to have them make sure that they're in that specific space. Like I said, I'm really familiar with the college setting. And so one other thing is different buildings in an institution might have different rules about therapy animals. And so if you're granted access to say the public health building, you may not necessarily be granted access to the chemistry building. So even that might vary. And pets do not have legal rights to enter really any settings. And how are these things regulated? And I'll talk about each of these different things specifically. Service animals are protected by the Americans with Disability Act. Emotional support animals, some of the relevant laws include the Federal Housing Act, the ACAA or the Air Carrier Access Act, IDEA and state and local laws. Therapy animals do have some state and local laws regulating them. And there are not really any specific state and local laws for pets other than the ones that are potentially related to vaccination requirements and things like that. Okay, so let's talk about the Americans with Disabilities Act. So as we all know, the ADA came out and it's there to protect individuals with disabilities and prevent discrimination on the basis of disability. It does specifically state, so dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA. That is specifically what the service animal section of the ADA talks about. It also defines dogs and miniature horses as the species that can be permissible to be service animals. I think one thing that we all struggle with, at least I did before I knew more about this, is if the service animal is not behaving in certain ways in concession, do we have any sort of rights? So we need to think of it as the service animal as an extension of the owner with the disability. So if they're not housebroken, if they're biting staff, or I had one colleague who got her sweater torn by a service animal, they can be asked to leave the premises because they're not acting as an extension of the owner. And this is kind of a tough question because in our settings, we're naturally inquisitive people and this can be a struggle in some of the settings, but according to the ADA, there's really only two questions you can ask someone with a service animal, and they're written right here. So one, is this dog or mini horse a service animal that is required for a disability? So that's a yes or no question. And then the second one is, what work or task is it trained to perform? So you can't, especially, and I'm mostly talking about front desk staff, or again, in my setting, if it's someone who's your RA or hall director, the questions that they're permitted to ask, one-on-one in my clinical setting, we obviously have more rights to ask questions of our patients and kind of learn more about them. But when it comes to service animals, if you happen to be running the front desk that day, I suppose you can't ask them for, can you have your animal demonstrate the task for me? Can you really explain in a lot of detail what your disability is? How did it come to happen? This, that, and the other. So this is really important, I think, to pass along with our staff, because I think, especially, if someone has a cute animal come in, you're naturally inclined to wanna ask a lot of follow-up questions, but you really can't. So the Fair Housing Act. So this one, I think, really talks, and I was talking to someone else before this presentation, it kind of opened the door, I think, to emotional support animals, I think. So it also prohibits discrimination in house, or it prohibits discrimination, but in the housing setting. But unlike the ADA, the definition of assistance animal is more expansive when it comes to the Fair Housing Act. So it includes service animals and emotional support animals as assistance animals. And also, what it says is that landlords must permit reasonable accommodations for emotional support animals. So when I think of this, I'm thinking of, like if, like when I drive through downtown Columbus, like where a lot of the students live, and I see no pets, I usually think to myself, like, oh, I wonder if I'll have a patient asking for me to write a letter because they wanna live in that space. Or if an apartment complex has a pets fee, that is waived if someone has an ESA letter. One thing, you know, the last two lines are also important. Landlords can request documentation, but they can't, they aren't entitled to medical records. So a brief, succinct letter is really all they can be asking for. All right, so the Air Carrier Access Act. So this is, well, I suppose 2021 was already two years ago, but I think of this as being kind of a newer change. So the Air Carrier Access Act, that came out January 2021. And really what it says is, so one, airlines cannot discriminate against individuals on the basis of their disability. It highlighted that. But it also gave, so it protected service animals, but it basically gave the airline the discretion to decide whether or not they would permit emotional support animals. And what happened in February 2021 and March 2021 is basically all, like, when I look up all the, you know, the most common airlines in the US, they all produced a policy after that saying that they wouldn't permit emotional support animals. So I think leading up to this was when we saw on the news, like a lot about the emotional support peacock and the emotional support pig. And we're not really seeing a lot of that since then. You are allowed to be on a plane with a psychiatric service animal, however, or a service animal in general. Like I said, those two, we kind of think of them as being the same thing. So the Individuals with Disability Education Act, this, you know, so individuals with disabilities are entitled to free and appropriate public education, so it protects the use of a service animal. And then I definitely, we don't have time for me to go through all of the state and local laws, so I will not do that. But, you know, again, I'll highlight, it's really important to be aware of what the state and local laws are in your area because all of our areas are different. So for example, in California, the clinician must be licensed in California and have an established relationship with the client for at least 30 days prior to providing the letter. Michigan has a similar law where, I think it's 180 days of like established client, like patient-doctor, patient-clinician relationship in order to write a letter. Florida says a clinician must have at least one in-person appointment prior to writing the letter. So we could probably assume that they came up with this to minimize the use of like kind of like online ESA mill like letter writing companies. And so New York City, so certain non-domesticated animals are prohibited by public health code and can be excluded as ESA. So you can't have an emotional support raccoon in New York City, perhaps in another town, but not New York City, so but check the local laws. And there are, I believe there's around 33 states in the United States at this point who have laws prohibiting ESA letter fraud. So that's something that's really important to be aware of. I suppose I'm kind of skipping ahead and this is something my colleagues are gonna talk about, but I think especially because these laws are different state to state, I would think twice about and probably not write a letter for a person who's gonna be out of state. This is something I run into a lot working with college students who are constantly going home for breaks or moving or going to their internships. So if one were to ask me to write, one who is qualified to, or if a patient that I had, I felt met criteria for an emotional support animal was going to be looking for an apartment in another state, I would probably work on referring them to someone in that state and not writing that letter myself. So that's my section and here are my references that are really tiny and I'm sure easy to read, but we'll take more questions at the end. And I think we have our slides also uploaded to the APA app as well, so if you happen to miss something, we definitely would encourage you to look up the resource document as well, because that's really thorough. There we go. Good afternoon, everyone. I want to assure you all that that's not my name. But Catherine, unfortunately, could not make it here today, so I am presenting her slides. And the presentation really is on the evidence. What is the research evidence for the use of emotional support animals? There's not much has been written about this in the research. There's actually been only one real study, but you'll find out how real that study was in a minute. This is a pre- and post-study that looked at 11 subjects with serious mental disorders. And this study actually showed significant reduction in loneliness, depression, and anxiety symptoms 12 months after living with an emotional support animal. However, this study did not control for psychiatric treatments during this time period. So it's really hard to talk about what was working, whether it was the psychiatric medications or the emotional support animals. There's one other study that's currently going on with veterans regarding PTSD. And so with such limited data regarding emotional support animals, perhaps we can draw some inference from other types of animals that have had more studies. For example, therapy and service animals have had a lot more studies in PTSD, anxiety disorders, dementia, autism spectrum disorders, and schizophrenia. Quite a few studies have been done in this area. Unfortunately, again, the results are mixed, and they are also dogged by the difficulty of small numbers, underpowered research, and lack of randomization or randomized control. So again, it's very hard to draw a lot of inference in this area of work. So then you think, well, if we can't draw enough inference from therapy and service animals, perhaps we can draw some inference from pets. We've had pets for a long time, and lots of studies have been done regarding pets. And everyone knows that pet ownership is associated with reduced cardiovascular disorder risk, improved physical and psychological well-being. However, when you now look deeper into it, the actual benefit was because of social support and social interactions that happen when you have your pet, as opposed to really the direct effect of the pets on your mental status. They also found that a lot of the positive findings or negative findings, for that matter, might be related to other factors, such as personality traits, age, economic status, and health status of the individual. Now the other things that happen with pets is that even if there are comments and findings of significant benefits to mental health or physical health for individuals who have pets, you have to balance that with the burden of having a pet. If you have significant psychiatric difficulties, that can be quite burdensome. Or if you now lose your pet, in addition to your significant psychiatric impairment, you have to deal with having lost a pet. And those two things can be quite difficult. So in summary, really, this is a very short presentation about the clinical evidence. As you can see, it's very short because there's no evidence of anything that is significant. Thank you very much. All right. Thank you, Dr. Dike. So again, my name's Ariana Nesbitt. I'm the Deputy Chief Medical Officer at Central Regional Hospital, which is a state forensic hospital in North Carolina, the central region of North Carolina, to be specific, if you couldn't guess that. And I'm also on faculty at Duke and UNC Chapel Hill. With regards to disclosures, I have no financial disclosures, and my opinions are my own and not those of my employers or of any of the associations I'm affiliated with. So the objectives for this section are, first, to review the two components of an ESA evaluation. Second, to help you all make sure you understand that ESA evaluations are essentially disability evaluations. And finally, to recognize the importance of consulting state laws prior to writing an ESA letter in case Dr. Menon did not drive that point home well enough. That is a big key take-home. So if you are in practice and you're getting numerous requests for ESA evaluations, one of the first questions that you might ask yourself is, should I get formal training in this area? Well, unfortunately, even if this would be beneficial, there are few formal training opportunities for ESA certification. And most of those that are available are produced either by animal enthusiasts or the organizations that they associate with. So they might be biased. Which leads me to think that I probably should have mentioned one other disclosure, which is that I myself am an animal enthusiast, and yes, these are my two dogs. This is Bubba and Bonnie getting ready for their daily walk. And no, as one of my friends asked, there's nothing wrong with their legs. They just tire easily. So here I am. Here is my disclosure. But I am a forensic psychiatrist, and like any good forensic psychiatrist, I am going to strive for objectivity during this presentation. So knowing that we don't have many training programs and that those that are available may be biased, is this okay? Well, maybe not, because in one recent study, 36% of mental health professionals felt unqualified to make an ESA determination. Luckily, some practice guidelines have been proposed, and we're going to review some of those recommendations, which again have been summarized in our resource document today. So there are two basic components of doing an ESA evaluation. The first is, does the patient have a chronic mental impairment due to a psychiatric condition as defined by the DSM-5 that is substantially limiting their functioning? In other words, does the patient have a psychiatric disability? And the second component of the evaluation is to determine whether the ESA will alleviate those impairments. So what you can take away from this first point is that essentially, ESA evaluations are disability evaluations. So what is a disability evaluation? Well, it is one of the most common psychiatric evaluations requested for non-therapeutic reasons. And this isn't surprising, because neuropsychiatric disorders are the leading cause of disability in the United States. So when doing a disability evaluation, the evaluator is usually required to answer some very specific questions using some very specific language and definitions. So for example, there might be very specific definitions for terms such as disability, or impairment, or what qualifies or is defined as a mental health condition. So again, these definitions are really important. The overall purpose of a disability evaluation is to gather information so that an organization or a system can translate it into a specific course of action, such as providing workplace accommodations, authorizing healthcare benefits, arranging for medical care, making changes in employment status, awarding damages or disability benefits, or for our sake here today, certifying an emotional support animal. And given that there are such a wide range of purposes for disability evaluations, it's probably not surprising to see that many things fall under this umbrella. So for example, social security disability insurance evaluations determine whether someone meets criteria for a disability under this definition and is therefore eligible to receive financial assistance. Worker's compensation evaluations for occupationally acquired injuries or disorders. Private disability insurance claims. So many of us probably have private disability insurance to provide additional compensation beyond what might be provided in the case of a worker's compensation claim or meeting criteria for SSDI. And all private disability insurance companies have their own specific definitions as well. VA benefits. Disability evaluations related to litigation. So a plaintiff might be seeking compensation for damages due to injury. The Americans with Disabilities Act is also a different type of disability evaluation where you're not looking to seek compensation, but rather you're looking at what might be a reasonable accommodation for someone if they have a disability according to the definitions of the ADA. There are also fitness for duty evaluations to see whether someone is experiencing a temporary or chronic disabling condition that prevents them from being able to do their job. Return to work evaluations, which are almost like mini fitness for duty evaluations. And finally, ESA evaluations. So all this is to say that this is a huge topic, this area of disability evaluations. But this kind of puts it in context of kind of what we're doing here. This is just one type of disability evaluation. Now we still haven't defined what a disability is. So again, this is mostly because definitions vary. So you have to be aware of the definition that is being used by the agency for which you're doing the evaluation, as well as for emotional support animals, the local laws. Generally speaking, though, the definitions have something to do with this. So a mental or physical condition that substantially impairs a person's functioning. For example, their ability to work or to engage in social activities. So note here that this functioning piece is very important, and that a diagnosis alone is not sufficient. So of course, a thorough review of all things disability evaluations is way beyond the scope of this presentation. But if you would like more information on this subject, I suggest looking at this excellent practice resource from Apple on the forensic evaluation of psychiatric disability. Some key points to take home from this resource document are as follows. So when you are doing a disability evaluation, you need to link the chronic mental impairments to the mental disorder. Someone could be impaired or appear to be impaired for all sorts of different reasons. But in order for it to be a disability, generally speaking, it needs to be due to a DSM-5 diagnosed mental disorder. Similarly, always consider explanations for the reported disability other than a mental disorder. This is really important because some authors have noted that probable malingering is there in up to 30% of cases of individuals undergoing disability or workers' compensation evaluations. So we have to be skeptical when we are doing these evaluations, and always consider a potential secondary gain or other explanations. And to this point, because these are objective forensic evaluations, the evaluation should include not just a psychiatric interview, but also a review of their records, as well as other collateral information to corroborate or maybe dispute what the patient is reporting. We can't take the patient's report at face value. So turning back to the two components of an ESA evaluation, we have covered point one and determined that this is an essentially a disability evaluation. But how about number two? Will the ESA alleviate those impairments? So how do we answer this question? Well, it's a really hard question to answer, because as Dr. Dike showed, there's not a lot of evidence on this. So we have to recognize that because the evidence is limited, it's probably going to be hard to say with a whole lot of certainty that an ESA is definitely going to alleviate someone's impairments. That being said, we are not unfamiliar with practicing and prescribing things or employing treatments that might not have a robust evidence base in psychiatry. But just keeping this in mind when you are deciding whether or not to write an ESA letter for a patient. So one practice guideline by Younggren and colleagues that does a good job of summarizing what it means and what a psychiatrist should be thinking about when conducting an ESA evaluation says this. So what he says is, disability does not mean that the individual has an attachment to the ESA, feels happier in proximity to the ESA, or just wants to accompany the animal, which is usually their pet. It means that the person requires a presence of the animal to function or remain psychologically stable. So when in doubt, keep this in mind and recognize that it is a relatively high standard. So we've now covered the two essential components of conducting an ESA evaluation, but there are several other considerations worth pointing out. So first of all, as my colleagues have talked about already, consider the patient's ability to care for an animal. This animal is not going to enter the patient's life in a laboratory setting, so pet ownership can be expensive, time-consuming, labor-intensive. As an owner of two bulldogs, I can certainly contest to this, oh my goodness. And always, always, always consider whether the risk for that specific patient are going to outweigh the potential benefits, which again, there's not a lot of evidence for. Also, be aware of state-to-state variability in the definitions. So as Dr. Menon pointed out, there are wide differences in what different states require with regards to doing these ESA certifications. Their definitions vary and their requirements for things such as, is a clinician-patient relationship required? If so, what does that need to look like? Does there need to be an in-person evaluation? Does it have to have existed for a certain amount of time? All this is really crucial to make sure that you are acting within the law. Similarly, when writing an ESA letter, there might be jurisdictional requirements regarding what to actually consider in this letter. You want to provide minimally necessary clinical information to protect confidentiality. So you do not want to be writing in these letters that are going to go to third parties, long narratives about the patient's suffering over the years and all their symptoms and diagnoses. That being said, some states do require specific things such as specific symptoms, specific diagnoses. So consult them, provide just the minimal clinically necessary information and try to keep it at that to protect them. And finally, some guidelines recommend reviewing the effect that an ESA is having on a patient about every six months with the argument being that this is kind of a treatment just like any other kind of a treatment and you want to be assessing its efficacy, the risk, benefits and alternatives on an ongoing basis. So ideally, you're not just going to write the letter and forget about it. Now, of course, there are going to be some complications if you suddenly withdraw the letter and the patient's moved into an apartment only because you've written the letter and the pet's allowed there. So again, these are complicated, complicated evaluations and just really think about the implications before you embark on doing one of these evaluations. So one question that is debated in the literature is should the psychiatrist evaluate the pet itself? So on one hand, Younggren and colleagues assert that the clinician should consider the animal's temperament, disposition and their training, even going so far as to obtain collateral information from a certification program, animal behaviorist or veterinarian. One example of a certification program is this good canine good citizen program. Just as a reminder, ESAs do not need to be trained, but some might undergo the certification. So I don't want to confuse that point, but these authors say that we need to be a little bit more stringent about it and we want this information. And the authors also suggest that the psychiatrist actually watch the patient and the pet interact. So they say, bring the pet into the office and let me see if it is doing what you say it does. You say this pet reduces your anxiety, well, let me see it. So that is one view. On the other hand, others like Hoy-Gerlach state that the clinician does not need to meet the animal, but instead can rely on a patient's self-report. And she equates this to evaluating many other more standard clinical interventions. So for example, she says that psychiatrists may suggest that a patient go home and practice mindfulness techniques or other coping strategies. And although sometimes we ask them to do this in our offices, we don't require it necessarily. We will just ask them at the next appointment, you know, how did that meditation go that was going to help you fall asleep or whatnot? So she says, you know, this isn't necessarily what we always do. It's okay to rely on their self-report. So where did we come down in our resource document? We had an interesting discussion about this. But where we came down is that at the end of the day, we are psychiatrists. We are not trained to assess an animal's temperament and evaluating animal suitability as an ESA is just outside of our area of expertise. So for those of you who are hoping to come to the APA next year and see something like this where we have a workshop on the assessment of animal temperament, I am so sorry. You are out of luck. Maybe in the future we will change. But for now, we are saying that this is outside of our scope. That being said, common sense, let it prevail. So if you have a patient who comes in who wants to get their dog that you know bites people and urinates in public and tears apart apartment certified as an ESA and is causing them all sorts of stress, do think twice. Or if they want their boa constrictor certified, use common sense and ask questions. We don't have to be, you know, enough said. So shifting gears now to some ethical considerations. So the objectives for this section are first to look at the legal and ethical implications of misusing ESA certifications as legal loopholes, recognizing that it is ethically permissible to decline to write ESA letters for patients with genuine disabilities, and we'll discuss that. And finally to consider potential ethical concerns regarding role conflict. So before we delve into some of the more controversial and complicated ethical issues, I first want to point out some clear ethical pitfalls. First, it is unethical and illegal to engage in disability fraud by writing ESA letters simply to allow patients to bring pets to non-pet friendly venues, override pet restrictions, et cetera. So people, myself included, are crazy about their pets and will go to any length to keep them close. So some of you may have seen pictures that came out of New York when the New York subway system passed a new law that said that only dogs who can fit inside of a bag can be permitted onto the subway. So I have no professional opinion about what these pet owners are doing. However, we do not want to use our professional licenses to help our patients discard the law. And the only consequence to doing so, that is disability fraud. And in addition to being held liable for disability fraud, there are other consequences of misusing ESA certifications. So misusing these certifications negatively impacts the public's perception of the disabled and it undermines justice for patients who genuinely require an ESA. And due to the misuse of ESAs, complaints regarding ESA accommodations really did spike, as Dr. Menon mentioned a couple years ago, with the popular media perception of ESAs being predominantly negative, primarily because there was problematic animal behavior on airplanes, very strange atypical species being brought onto these planes or into houses, and clearly pets that were being claimed to be ESAs in order to avoid paying for pet travel or housing. So some of you probably have seen pictures like this, but as Dr. Menon mentioned, my flight here did not look anything like this, luckily, but this is still in people's minds. And here's another example of a headline, so emotional support animals is helping explain how America is losing its mind. Last week, United Airlines denied a woman's attempt to bring a peacock on a flight as an emotional support animal. And this is a problem, right, because a negative press of inappropriate ESAs results in negative impacts for all working animals. This jeopardizes the ability of those who truly need an ESA or a service animal to be able to do so safely and without judgment. So we need to be thoughtful when we do so. So at this point in the presentation, some of you might be asking yourselves, well, gee, should I ever write an ESA letter? And I think that's a fair question. And what we said in our resource document is that it is perfectly ethically permissible to decline to write letters, even for patients with genuine disabilities, given the limited evidence supporting their use. And really, all of us should be thinking about ESAs as an unconventional and unproven treatment. And like any unconventional treatments, a psychiatrist should carefully weigh the risks and benefits, including the paucity of evidence supporting their use. However, there is something different about ESAs compared to the typical types of unconventional and unproven treatments that we might prescribe for our patients. And this is that ESAs directly impact not only the patient themselves, but also those around the patient. Think potential bites, tearing up apartments, which could be the landlord's only primary source of income, allergies. There are lots of potential direct impacts that are hard for the psychiatrist sometimes to foresee when they write these letters. And of course, as treating psychiatrists, our primary obligation is to the patient. However, we do, as physicians, always have secondary obligations to public health. And we need to keep this in mind when we are weighing the risks and benefits of an animal. Another major ethical conundrum is the role conflict that occurs when a treating psychiatrist tries to switch hats and act as an evaluator. So, Dr. Menden, you're not the only person who likes tables. Here we go with a table here. So this is a table showing some of the differences between being a treating psychiatrist and an evaluating, or what you can think of as a forensic psychiatrist, although I use that term loosely. You don't have to be trained in forensic psychiatry necessarily to do what I would consider a forensic evaluation, so an objective evaluation for a third party for some legal reason. So, the driving ethical principles for treating psychiatrists are beneficence and non-maleficence, I think most of us are familiar with that, and although evaluators should still be respectful of the person they are evaluating, they recognize that their evaluations might not always help the person, so their primary ethical obligation is to truth-telling, recognizing that sometimes their evaluations in search of the truth might actually hurt the person that they are evaluating, so this is a major conflict. With regards to confidentiality, this is expected to occur within a treating relationship, but in an evaluating relationship, confidentiality is going to be limited, and therefore the limits to this confidentiality are usually presented up front when you're evaluating someone, because of course the whole purpose of the evaluation is to let some third party know what is going on with the person's mental health condition, and how that interacts with the law that is being considered. When approaching the relationship and the orientation to the patient and the approach to the evaluation, so when you're a treating psychiatrist, you generally are a patient advocate, and you are heavily reliant on the patient's self-report. This doesn't mean to say that we never get collateral records, but generally, when you think about an ongoing relationship with a person, you're gonna see them visit to visit, mostly taking their self-report at face value when making ongoing treatment decisions. In contrast, when you are an evaluating or forensic psychiatrist, your orientation to the person you're evaluating should be respectful, but skeptical at all times, because what your goal is is to strive for objectivity, and therefore you are heavily reliant on collateral, always wanting to check what the patient or the evaluee is saying to make sure that there is corroborating evidence, or if there are some kinds of discrepancies, trying to figure out what to make of it. So you can see here, these are two very different orientations, approaches, two different types of guiding ethical principles. And a seminal article that has explored the concept of role conflict was published in 1999. This is the famous On Wearing Two Hats paper, and what the authors of this paper said is that attempting to treat and evaluate the same person typically creates an irreconcilable role conflict. Although circumstances sometimes compel practitioners to assume the dual role of treater and evaluator, the problems that surround this practice argue for its avoidance whenever possible. So what do we do about role conflict in ESA certifications, where usually it is the treating psychiatrist who is being approached by their patient to write an ESA letter? Well, excuse me, first things first, you have to assess your own biases and recognize that in this circumstance, if you're gonna undertake this task, it's your obligation to strive for objectivity, and recognize that ESA evaluations need to be conducted with the same rigor afforded other disability evaluations. And this includes an assessment of malingering. Now, if you've been trained in structured malingering assessment instruments, fantastic. If not, that's probably okay, but this needs to be something that you are thinking about. And finally, being aware of the internal pressure from allegiance to the patient to write a letter that is going to make them happy. So some things to consider before agreeing to evaluate the patient for an ESA are the potential effects that the assessment that does not support the patient's wishes may have on a therapeutic relationship. Consider how hard of a conversation this is gonna be if you're gonna undertake this evaluation and find that you cannot support the patient's wishes. On the other hand, do not forget the potential harms associated with writing a letter that you yourself do not support. And recognize that if the patient knows that the psychiatrist does not believe what they're writing, their credibility is gonna be undermined and trust may be lost. So these are serious, serious considerations. All of this may lead you to wonder, should ESA evaluations only be done by forensic psychiatrists? Well, this may be ideal and there are some papers that actually suggest that this is the ideal circumstance. This eliminates concern about role conflict and this is our stuff. We get formal training in legal concepts, disability assessments, psychological assessment instruments, how to minimize bias. This would eliminate a whole lot of problems. However, unfortunately, a lot of states require evaluators to have a prior treatment relationship and forensic resources are limited. And not only are they limited, but they're expensive and this is certainly not something that insurance companies are gonna provide. And we recognize that although role conflict is real and although this is problematic, this happens. And we just have to be aware of what we're doing and going in it with as clear of a head as possible. And with that, here are my references and I will turn it back over to Dr. Dekay. Thank you. Everyone, I am Charles Dike. Can you get in trouble when you write ESA letters? That's my task is to try and see if we can answer that question. But in terms of disclosures, I work for state government, I work for federal government sometimes, but everything I say here is mine and mine alone, not any of these entities. And we're gonna just explore whether there's any liability risk for psychiatrists approving this type of letters, even for patients who have gotten these letters at their liability for them versus service animals, and then what the requirements are for a valid ESA letter. So we've already talked about some of them here today. I'll just start with a few examples of people who've gotten in trouble, and then we can talk later about other issues related to them. So this is Carla Jean Black. She's a licensed marriage and family therapist in California, and she was held liable by the California Board of Behavioral Sciences, the Department of Consumer Affairs. Why? Her license was revoked for practicing out of state without a license to do so, and for not doing a proper assessment before writing the ESAs. Now, what are the findings that the board found or listed? There was a statement on her website that she specialized in ESA letters. She's a specialist in ESAs, and we just talked about training and all kinds of things related to that, but this is what she had on her website. And then she was providing telehealth evals, which lasted 10 minutes sometimes, to an hour to individuals far away from California that were desiring ESAs across the country in areas where she had absolutely no license to practice. By the way, which is really important sometimes because of the easy access of telehealth, and especially in COVID era, sometimes people forget that you actually need license to practice in other areas you're doing telehealth. As soon as these emergency orders are coming to an end, we have to pay more attention to those things, but she was doing that even way before COVID, and so the board revoked her license to practice because of these findings, but she wasn't alone. There are other individuals who also had the same trouble. This is another individual, a limited licensed professional counselor, is how they refer to her. So she diagnosed this patient, I don't know if this was her patient or not, with a differential illness under the DSM. See, and this differential illness substantially limited one or more of the major life activities. However, Ann Vernett did not state what the differential illness was, or what type of limited life activity was impaired by this illness. But this actually became a real problem because it went to court. At a district court hearing, Vernett testified in support of her letters, explaining that she determined the need for an ESA after only a brief phone call. That's another assessment, right? Phone call for like two seconds, then you're writing the letter. The district court, despite that, the district court ruled in her favor, and that ruling was affirmed by the circuit court. You have to understand, there was this move at this time of ESAs. This was when it seemed like everyone was having an ESA done, and there was a need to be sensitive to people's needs, but the courts also were caught in this idea of the need for it. However, when it got to the Court of Appeals, they vacated the ruling, and accused the district court and the circuit court of avoiding their gatekeeper role by not actually allowing a deeper exploration of these letters and how the individual concluded that these individuals, their patients needed ESA. So they got in trouble. What I found interesting in looking at this is that even the letterhead that they used to write it had a canine bust, which essentially is showing I'm an expert in this area, and look at my, even my letterhead supports that. And in this other one, the letter was written by Monique Snelson, also a licensed marriage and family therapy associate, and the landlord in this case requested a whole lot of material to support the letter that the landlord had received from Monique Snelson, and this is it. Even more, like the nature of the mental or physical impairment, I'm gonna read that into this document so that people who are not here can also have access to it. So they requested the nature of the mental or physical impairment that is disabling, including a reference to the DSM-5 description of the condition and a statement of what major life activity this disability interfered with. They also asked the question, was a physical examination conducted on your patient? Did you interview the patient in person? How many sessions did you have with the patient? And approximately how long was each session? They wanted a statement from the LMFTA indicating that she conducted an examination of the patient appropriately for the diagnosis of mental impairment in question under the professional guidelines applicable to licensed clinical social workers and as described in the DSM, and they also wanted the individual to provide a copy of their license. This was a landlord that you would say was quite upset after having received the letter and was trying to make sure that they got everything right. So the trial court said that the landlord's questions exceeded the reasonable inquiry to which it was entitled. So in court, the first trial court actually was not happy with the landlord. But the appeals court also came back here and said that yes, even if the questions asked were excessive and exhaustive, they really needed to answer the question of whether there was a link between the disability and the need for an ESA, that that question was crucial. All the other questions might be too much, but you needed to have that link. You just can't remember when Dr. Arianna was talking about the definitions of what was needed. You have to identify the disability and then the link between them. What was it doing to help solve your problem? This is the one that has a psychiatrist patient. This was an Air Force veteran who was diagnosed with PTSD by his psychiatrist. And the psychiatrist wrote an ESA letter for accommodation, but the landlord refused or rejected the letter, despite three different supportive letters, in fact, that the psychiatrist wrote over several months. And the psychiatrist in this case was very clear in documenting the therapeutic relationship between the patient's pet and his dog, and that the patient's condition, which was PTSD, limited his ability to work directly with other people such that without the emotional support of his dog, his social interactions would become overwhelming. So this psychiatrist really put together exactly what you would like to see in a letter of this nature. But despite that, the landlord did not agree. So the patient filed suit claiming that the association, the condominium association's denial of his request for a reasonable accommodation violated federal and Florida's fair housing laws. And the Court of Appeal found that the psychiatrist's letters which were provided contained all the information that was needed, that it contained all the information that was needed to make a determination. And therefore, the refusal of this condominium association was wrong, essentially. All right, so that's all about the... There's been a few more people who've gotten into trouble for writing ESAs. Many of them are other specialties, licensed clinical, as you've said, in what I have written so far. But we have not been able to find any psychiatrist yet that has gotten in trouble for writing the ESAs. But you see the connections. All right, let's talk a little bit about other special circumstances. Dog bites. You know, if there's a dog bite, then the owner of the dog is liable for any injury that the dog causes, of course, especially in public or in other public areas that are not supposed to be, unless there was provocation by the victim. You know, if you provoke the dog and you're provoking everyone and you get bitten by the dog, that might be a problem, or you were trespassing. That could also be a problem for you. And that is the same with ESAs, exactly the same. There's no special dispensation for emotional support animals. Unlike a service animal, we've got all the definitions, most service animals wear a vest that warns bystanders not to bother the animal. If an injury occurs because the victim bothered the service animal, despite the warning, the owner can argue in court that they are not at fault for the victim's injury. However, the animal must also be in control because if the animal is out of control, then you might lose your argument in such situations. So the recommendations are that, first of all, you practice with a valid license. You also practice only in the states that you're licensed to practice. And I just mentioned the alertness around telehealth because you can get lured into it and make a mistake. It's required that you have a physician-patient relationship before an ESA is written, as you've seen from some of the laws that I have presented here already, that you have to state the clinical justification and the recommendations for, the clinical justification for the recommendation for the use of ESAs must be stated in your letter. And you state the major life activity that is impaired by the patient's psychiatric disability for which the ESA would help. And as you're offering a professional opinion at the end of the day, that the ESA would help alleviate some of the impairment. Now you also have to warn the patient, of course, even if you have written the ESA letter and it's been approved, you have to warn the patient that that does not remove them from liability if their pet was to bite somebody or injure some other individual in the public. They have to be very careful that that does not give them any special privileges. Now, in reviewing thousands and thousands of documents before we wrote the resource document, we found that ESA letters have been written by a whole lot of other people, or even physicians, primary care physicians, pediatric neurologists, psychiatrists, and so on. A lot of people have written those letters. But they've all been written appropriately when it comes to the physicians, at least, in the context of a patient-physician relationship. And they have identified exactly what they needed to identify as a disability for which they were recommending an ESA because it was affecting an identified major life activity as well. So, to date, we haven't seen any evidence that a psychiatrist has been implicated in the laws involving ESAs. But we need to understand that this is really an evolving area of practice and of the law. And the more people write these things, the more, of course, the risk of getting in trouble with the law would occur. But at this point, given where we are, there hasn't been any difficulty so far. So we need to remain alert to the potential of being sued if we deviate from any of those clearly laid-out ideas of how to practice. Thank you very much. I have a couple of questions. So one is, you indicated that only some people with service animals may wear the vest. So if a patient of someone comes in, a patient or somebody accompanying a patient and has the dog, and let's say it's a patient that has a dog, but they don't have a vest, you can ask the two questions you mentioned. How do you know they're not lying? Can you ask for some sort of a verification? And do you want me to answer all three questions or one at a time? One at a time. Okay. I mean, I don't know if the others have, you know, opinions on this, but you may not know that they're lying. And that being said, so I guess I nodded my head to one of the questions, yes, you can ask those two questions, but you may not know that they're lying because you don't have a legal right to ask for the proof of documentation. And then that being said, if they are still supposed, the service animal is still supposed to act like an extension of the individual with the service animal that you have not been able to prove. And so if that service animal is not housebroken, is not behaving, you do have the right to ask them to leave. Okay. So the question is, oh, yeah, okay. Sorry. So is the question that in order to write a letter? No, no, because I'm actually talking about examples that we've experienced in clinics before. Okay. Patient comes in and says that. Yeah. Okay. Thanks. So the question is, a patient brings in a service animal, but the dog, however, makes the people in the waiting area quite uncomfortable. What about the rights of those people in the waiting area, in a psychiatric waiting area versus the rights of the individual with the disability? I can talk about this a little bit. So at Ohio State University, we, and I am aware of this based off of news articles that I read, not out of my involvement. So we had a situation where an individual had an emotional support animal in a sorority house, and then it triggered the allergy, it triggered, so there's another individual in the sorority house who had allergies to dogs that triggered her irritable bowel disease. And initially the university found in favor of, the way the university used to handle kind of housing disputes was who signed their housing contract first. And in this case, it was the individual who had the allergies, the irritable bowel disease, and not the person who had the emotional support animal. So a lawsuit came up and it was found in favor of the individual with the emotional support animal because they had a disability. And so that's kind of what comes to mind when we're talking about this scenario. So the person with the service animal might make other people uncomfortable, but the person with the service animal has the documented disability, and so the priority is to make sure you're not discriminating against the person with the service animal. That being said, I know we don't all have huge waiting rooms, but one consideration might be, if you have a large enough waiting room, having areas that are designated where people can wait versus where the service animal, so there's space for people to spread out. And I would just add, I mean, just adding on to what you had said in answer to the first question, again, if the animal's making people nervous because the animal's misbehaving and acting inappropriately, then that's reasonable to ask them to leave because they're not acting housebroken, they're not acting as an extension of the patient themselves. That being said, if there's just a phobia to dogs, I mean, that's one of those things you have to keep in mind when you're writing ESA letters because people do have phobias of dogs and we can't ask everyone to bend their knees to accommodate phobias. You know, you could have a wheelchair phobia and we are not gonna ask people to not go around with wheelchairs, but just keep it in mind because that's not an uncommon thing. So, halving away that risk against the benefits that someone might have when having an ESA. Last question I have is related to the landlord. So, if there is, and maybe it was answered in there, but it wasn't quite clear to me. So, if there's an individual landlord and they basically, as part of the requirements for their unit or their, whatever, their rental, says no pets allowed, they would still have, and then, this is upfront, they said that, but the person still wants to rent the unit and says, I've got a disability, then you have to accommodate that. Yeah, the landlord has the right to request documentation, but not all the amount of detail that was in some of the liability. So, they can get documentation that the individual has a disability that is being treated by the emotional support animal, and that is something to have, and it's considered a reasonable accommodation according to the Fair Housing Act. That being said, again, the animals are extensions of the humans, and so, there is still recourse if the person is not keeping the space sanitary or if there's animal neglect. Thank you. Great, thanks. I'm really glad I didn't catch the earlier flight because this was terrific. My question is, it seems like we're focusing the whole time on emotional support animals, and that's probably the answer to my question, but I want to verify it. I wonder if we're asked to write a letter for a service animal, and I tried to say, I'm not a dog trainer, I can't even evaluate their warm, fuzzy appeal, like you said, to alleviate psychiatric diagnosis, but to fulfill a deficit? I mean, is that just way out in left field? I mean, is that something where we could say, I'm not a dog trainer, there's no good studies, I can't write you a letter for a service animal, right? It's actually Joyce's question, because it's her patient. So, do you do that? Do you write letters for service animals as opposed to a dog? So, I'm not sure if the others have. I have not been asked to write a letter for a psychiatric service animal, but I think the distinction is the task that the animal is performing, so in order to alleviate the disability. So, I honestly think if I were to be asked for the psychiatric service animal, I almost, when I get asked to have ESA letters written, it's usually a college student saying, not Dr. Menden, they'll say, Mira, I'll save $40 if you give me this letter. That's a different distinction from the person who has PTSD or the panic attacks that are impacting their major life activities and the animals performing a specific task. I personally would probably also kind of, I live in a big city, so I could probably find someone else in town to educate me on this, but it is a tough thing, but I think there also are a lot of ways in which someone is eligible for a psychiatric service animal. Would any of you, oh, great, you're reaching for the mic. Would you say that you would write for a service animal? Can you speak into the mic? Knowledge is about two years old, but thank you so much for the presentation. So, in service, two years ago, at least, I do work with a lot of veterans, service animals did not need letters. They don't need to be trained by an institution. That was in, the service animal just needs to be, the person has to have a disability, and the dog needs to be able to perform a task to alleviate the disability. A letter is not needed to fulfill those requirements. So, two years ago, that's where it was, and so doctors really didn't get in the fold of having to write the letters for the psychiatric service animals. So, that's what it was two years ago. It may have changed. I do want to say. I think the only exception to that now is with the Air Carrier Access Act kind of changing the realm of, you know, limiting emotional support animals, but psychiatric service animals are allowed. The airlines, the ones I read, they require a new letter about every year if you're to be, within a year, signed by a clinician asserting the psychiatric service animal. Thanks for hopping up here, because that was when we read the laws of Washington State closely. That's what they said. And I said, you don't need a letter. And they said, well, we do need a letter. I'll just say one last thing. So, I just, two years ago, everything was different. The Air Carrier Act hadn't been released. These lawsuits weren't up here. I learned, I'm kind of embarrassed how much I don't know. So, thank you, and I plug for them to come to these things regularly to get made aware of the new laws. We love the group discussion. Yeah, and ditto. We were just saying, great, because we've never been asked to write service animal letters. It's, yeah, rare. So, thrilled you were able to speak up. I hope you also saw that the evidence for the service animal is mixed. It's really very difficult to say that these things work. On the other hand, they might work in certain ways for certain people, but in order to be able to actually write these letters properly, professionally, you need to have more collateral. It's all about what the patient tells you, right? They tell you, and you're writing a quasi-forensic report based on only what the patient tells you, and no collateral information that tells you that, in fact, these animals can help them in certain ways. So, to relieve my anxiety. How do you know that this animal will relieve the anxiety? How do you know it helps their trauma? How do you know it helps their PTSD? Is it just what they tell you, or do you have actual evidence from so many other sources? So, it's not a casual, just write this letter for me, because you really need to be able to convince yourself that this is gonna work for this individual before you write the letter. Yeah, I think my question was along those lines. So, it seems like most pets provide emotional support for people, and you made the distinction about disability, and I already see a lot of abuse along those lines. I wanna get my pet fee waived. I know in the airlines, people were doing that so they didn't have to pay. It seems like it's a ripe area for people to try to save money, and I personally know people that have done that. So, I'm wondering if you can present a few cases that were difficult to ascertain, and how you made those distinctions between an emotional support pet and an emotional support animal, if that makes sense. And all the secondary gain that people get from calling it an emotional support animal. Yeah, it's so hard to determine, and I think your questions are spot on, and it's gotta be individualized, because again, this is an intervention that there is little to no evidence to support it. I mean, so we have to be really, really, really careful. Examples I can think of anecdotally, someone with an autism spectrum disorder who is so paralyzed by social interactions that they have trouble going about their daily activities, and with a pet by their side, suddenly they feel more confident. The pet provides a calming influence. It helps them feel more confident, initiate social interactions, initiate conversations, and can sometimes even lean against them, not necessarily in a trained way, but apply that proprioception kind of like a weighted blanket You could say, especially if you get some collateral information that indicates that, oh boy, yeah, the patient's attendance at work has really improved, because they're no longer paralyzed to go into the office place, because they feel like they can actually speak up and they've got this animal by their side. You could imagine a case where that might be legitimate, but I agree, it's so tricky, and it has such a bad reputation now, because I agree, the vast majority of cases I've seen have been what you're saying, is people are looking for their fees to be waived. Gosh, I've had friends call me up and say, hey, can you just write one of these? I hear everybody's doing it, which is, you know, it's such a problem, and that's so dangerous for us as psychiatrists, for our professional standing, our credibility, so we have to be really careful, and say the vast majority of times this probably is inappropriate, but again, case by case, it's kind of an experimental treatment, almost. Right, and thank you, and along those lines, it seems really unfair to landlords that if I'm a landlord and I don't want pets in there, for whatever reason, it's my place, right? Why does that person have to choose my place to live, right? I'm just looking at it, it's not the actual situation, but I'm just saying, like, it seems really unfair, and if it's not grounded in research, I don't know how these laws have gotten passed. I mean, it is tricky, right, when it's not grounded in research. I mean, I think we just have to think of it as the way the laws are written, it's like they're seeing it as a reasonable accommodation for the disability, so you might have people in the workplace who suddenly come in and want the job there, but boy, they can't type, so you have to get their dictation service set up, and you think, could they have chosen a job where there's a dictation service already set up, or you know what, or whatever, or that's kind of what we do, though, for individuals who, again, have disabilities, so this really is supposed to be for people who are chronically disabled by their mental health conditions, so this should not be rampant, but I 100% understand what you're saying, which is why there's some outcry about the decisions. I'm an animal lover, by the way. Absolutely, absolutely. Thanks for a great presentation. I've had several requests, but I've only written a letter once, and I find usually that a good education about what it means to have a psychiatric illness, what it means to have active symptomology with impairment, and what it means to have a disability usually ends it right there, because the vast majority of my patients don't see themselves as disabled, and they're not. The one time I wrote a letter was actually my idea to write the letter, and I had a patient who, my office is not in a medical building, so she would bring her dog with her to the visits, and then I got a call from her nephrologist that she was classically skipping out of dialysis early, and she said it was because of anxiety, so I said, perhaps if you were bringing the dog to your dialysis, you could stay for the whole session, and she said, well, they don't allow it in the building, and I said, well, if I write a letter, and we have a good reason to, they would, and they did, and it worked out perfectly, so I'm just curious, has anyone here ever recommended writing a letter without the patient actually requesting one? And isn't that kind of strange, because shouldn't we usually be thinking of what will help our patients with their illnesses and disabilities rather than the patient, because it's the only time where that's always 100% the reverse, and that kind of sets up a red flag that something's different there. Kind of like medical marijuana, but. Exactly. Sorry, not over. You're spot on. Thanks. I saw a hand up, I'm curious, was that someone in the audience who has, I'm curious, I haven't. Yeah, I can comment on that. There was one time that thought about it for a patient with severe OCD, and for example, they had a lot of obsessive thoughts, extreme obsessive thoughts. One was feeling like they were, every time they drove, that they had run over somebody and hadn't realized it, and so part of the exposure was to encourage them to drive more, but other thoughts they had were they were reluctant to get pregnant, because another worry is that they harmed children, and that they were worried if they had a kid, they would harm the child, and they needed assurance from family members to tell them constantly that they hadn't harmed a child, but they also had that same obsession with animals, so we had to thought through whether would it be helpful for them to actually have a dog next to them and realize that it was still there and that they hadn't harmed them. Ultimately, they didn't end up getting a dog for that purpose, but we had thought about it clinically. So many of the patients we treat have a disability. They're already being deemed as having a disability, right? If you have an SMI, or any of the kids you see, severe anxiety, so then if they have a pet, does that become an emotional support animal, right? Because you know that they have a disability. So then are you really kind of stating, because what I have done in my letters is so-and-so has severe depression or severe anxiety and has a dog that gives him emotional support. I mean, you're not certifying the pet. You don't know the pet. You just are stating, like you said, and that's what I do. I'm not just saying they reported having significant decrease in anxiety with their pet. So you're really kind of stating what they're telling you. And then, you know, whoever wants to do whatever they want to do, they can do. Yeah, I think the nuanced part is the features of the disability are alleviated by the comfort that the pet slash ESA provides. So that ends up being the nuanced piece of it. And yeah, and just to emphasize, it's that their functioning actually improves, that the disability itself, not just their anxiety, but the disability, their functional impairments related to the anxiety improves. And I agree, it sounds like that would be really hard to be trying to determine retrospectively because you don't necessarily have evidence of how the patient was functioning before they had an animal. But I think that is the important distinction is it doesn't just make them feel better. It's actually they're more functional or that they're unable to function without the animal. Thank you very much. So the function is what major life activity is being impaired by the disability. And it has to be something that you can say to state that, you know, you can state what the major life activity is. And therefore, once they have the PSA or the pet, that activity is improved. And so you can do that retrospectively to see that the major life activity has now been improved. It's not just a disorder. What you're doing, what you're asking me to do is if it's a service animal, we have to go through whatever process to certify that it's a service animal. But what we are being asked. Yeah, you do the microphone, yeah. So generally what practitioners are being asked is, you know, I'm going on a trip or I'm gonna move into a new apartment, they don't allow pets. And you know, my child needs his dog. So can you write a letter? I mean, this is what day-to-day practice, that's what you encounter. So do you say no? Or do you say, okay, I'm gonna write a letter and the letter is that, you know, you're validating their symptoms, they're in treatment. And that, I mean, we all get reduction of anxiety, so I believe it. So I'm gonna just write a letter instead of going into, you know. You don't understand the distinction though, right? This is not about they get better. There's a serious distinction here. But that's up to the landlord to decide. No, no, no, that's up to you, the writer. So you are the one make, your letter is certifying that as a result of this animal, their function as a result of it is improved. You have to do that. But how do you determine that? That's why you can't write it. You see, you can't write it if you can't determine it. That's the point. But I'm not writing it. But I'm just saying. I'm writing something that could be of use or could be of help. All right. I think also it's the letters that, I think, so I actually had run into this. I do evaluations for individuals seeking trans-affirming surgical treatment. And so one thing that I've learned also is I only write a letter if they're eligible. I wouldn't write one that was kind of wavering in between because I think there's a lot of misinterpretation that can happen from that too. You tell them. Yeah. They get very upset. Yeah, I tell them. And I think you talked, I think I would think about the ESA letters who is this is a prescription. I am prescribing you to have this animal to alleviate the consequences of this disability and your ability to perform major life activities. I was gonna make a couple comments. Actually, our colleague Mark Riggins is giving a college mental health talk. We stopped in and he said he has switched over to community street medicine. And he mentioned that he actually does write ESA letters because his population is homeless and trying to get them into housing. Many of them have dogs. So he has recently been writing a bunch of them. I can also give, I don't know if this is helpful at all, but I do have a friend who really wanted an ESA letter. And so they asked their therapist. The therapist said, no, but I bet that if this is what you really want, you will find a way to get it. And sure enough, if you Google ESA letters, I mean, there's just, I mean, they will give it to you today if you want it. So there might be the question of whether or not we really need to be the ones writing ESA letters. It's not like it's not accessible. It might cost a little bit, but. And I think that's such a good point. And not that that's okay, but I think at the end of the day, we just have to remember that when we're asking to do it, if we're assigning our name to it, it is our license. It is our credibility. It's our name. And we have to take that really seriously, because if we're fudging things, I mean, what's to say? I mean, it's our name. It's our license. It's our career. I think others can do what they want to do, but I think we need to take that really seriously. Yeah. We have time for one more? Yes. First of all, thank you. This has been an amazing session. So my question is perhaps a little more shrinky, as we sort of know shrinky. I'm from New York and I follow the rules. And right now I'm working for a quickly growing telepsychiatry program practice where I'm in a leadership role, but I also see patients. So I'm all for this. I have a college student whom I've been caring for who had profound anxiety. She had a little cat in her dorm, upstate New York, and then they were moving. They had to move, and the new on-campus housing wouldn't allow it. She asked me for a letter. Thrilled to write it, wrote it that day, and it's been enormously helpful for her. As in ESA. I have a young woman patient who, her diagnosis would be ADHD, in her 20s. Somewhat entitled, who asked me, and I saw her on the screen, you know, with a little coy smile. Oh, Dr. P., I'm moving to a new building. They don't allow pets. Could you please write a letter for me? I said, well, no, I can't. Oh, please? No, that's my license. That's not what we use it for. This, of course, was the same young woman who lived in New York, but became medically ill with staying with family in New Jersey, where, without torturing you all with the laws in New York and New Jersey, the controlled substance laws have changed as far as who can prescribe with telepsychiatry. I could very easily until last July, and so I told her so. Well, you know, can't you just make an exception? I said, if I make an exception for you, I can lose my license, so that's not going to happen. So the shrinky part of the question is, I have, and I've been doing this a long time, I have profound countertransference about these, the attitude, like, what is Woolworth's? You know, you go in and you write a letter, or what the medical license means. So I'm wondering if any of you have encountered that, and how one deals with that without going into analysis. Just saying. Yeah, I definitely struggle with the countertransference, too, because I think it's a similar age group that I work with, where I think they also, developmentally, well, and maybe this is also what kind of keeps me grounded, too. I remind myself that developmentally, they may not be aware of my, even if I've told them, they might not have an understanding of my training and the impact of losing one's license, and kind of the different ways that one can go about doing that, but I'm here with you, because I've definitely, the same person who calls me by my first name and says I can save them 40 bucks if they do this, when I say, when we have a nice discussion about it, and I ultimately say no, they say, oh, don't worry about it, I'll ask my doctor to do it. So, and so, all right. I think we are at time, but if you wanna approach and kind of talk one-on-one, that would be fine. Thank you, everyone. Thank you.

emotional support animals

ESA evaluations

psychiatric disabilities

legal considerations

ethical dilemmas

disability fraud

jurisdictional requirements

writing ESA letters

legitimate cases

service animals

telepsychiatry settings

professional reputation

ethical boundaries