Examining Emotional Support Animals and Role Conflicts in Professional Psychology

Abstract

This article examines the role conflicts that psychologists may face in their practices related to the evaluation and certification of emotional support animals (ESAs). It reviews the legal differences between ESAs and service animals (SAs), outlines ethical guidelines and legal policies/regulations regarding the use of ESAs, and examines the potential role conflicts that exist when a treating psychologist is certifying the need for an ESA. Finally, it makes recommendations to assist psychologists in staying within the standards of practice in order to avoid the ethical and legal risks associated with certifying an ESA.

Psychologists need to be clear about the activities/roles they perform in their practice settings. If they are not, their practice may be fraught with risky ethical dilemmas. In that spirit, psychologists are frequently called upon to perform services that expand the parameters of conventional treatment, that is, psychotherapy services. These activities or roles are often administrative in nature and usually, though not always, are designed to assist patients with something in some way. However, even though requests for these administrative services may only be indirectly related to treatment, they should be addressed carefully. For instance, psychologists may be called upon to provide disability statements to insurers to help those unable to work to obtain compensation. Another example includes providing evaluative or other information to others regarding the ability of their patients to safely perform their job or related functions and providing evaluative information about their patients to outside administrative and judicial entities like insurance companies, employers, and courtrooms regarding patients’ functional status. Most recently, many psychologists are being asked by their patients to certify their need to have a pet present in settings where the presence of the animal had previously been prohibited. This type of conduct is not without risk and can complicate psychotherapy if not properly handled. This complication includes the dangerous development of role conflicts and related conflicts of interest that can place the psychologist’s role as a treating professional in conflict with their role as an evaluator providing information to others, information that usually has impact on their patient’s life outside of the treatment setting (Greenberg & Shuman, 1997).

Conflict Between Therapeutic and Forensic Roles

Greenberg and Shuman (1997), in their landmark article on the role conflicts and related problems that can develop when treating therapists provide forensic services to their patients, attempted to draw a bright line between forensic/administrative services and clinical services. They outlined an extensive list of problems that can occur when treating therapists mix these roles (e.g., reliance on historical vs. narrative truth) and pointed out how this can impact the value and accuracy of the information that is provided to third parties. They also argue that mixing these roles might interfere with or damage the therapeutic relationship, which has a goal that is often quite different from the forensic goal (Greenberg & Shuman, 1997).

Greenberg and Shuman’s (1997) position regarding role conflicts and the objectivity problems that exist when therapists function forensically eventually found its way into the Specialty Guidelines for Forensic Psychology (APA, 2013). These guidelines state:

When offering expert opinion to be relied upon by a decision maker, providing forensic therapeutic services, or teaching or conducting research, forensic practitioners strive for accuracy, impartiality, fairness, and independence (EPPCC, Standard 2.01) … When conducting forensic examinations, forensic practitioners strive to be unbiased and impartial, and avoid partisan presentation of unrepresentative, incomplete, or inaccurate evidence that might mislead finders of fact. (APA, 2013, 1.02)

Conflicts of Interest

Regarding conflicts of interest, the guidelines also state:

Forensic practitioners refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to impair their impartiality, competence, or effectiveness, or expose others with whom a professional relationship exists to harm … (APA, 2010, 1.03)

Therapeutic–Forensic Role Conflicts

Finally, in a warning about dual roles, the guidelines state: “Providing forensic and therapeutic psychological services to the same individual or closely related individuals involves multiple relationships that may impair objectivity and/or cause exploitation or other harm …” (APA, 2013, 4.02.01).

Extratherapeutic Activities as Forensic Practices

All of this leads to the following questions: “Do the common extratherapeutic activities/roles of psychologists fall under the Specialty Guidelines for Forensic Psychologists definition of forensic practice? Are they arguably forensic practices? The answer to these two questions is easily found in the introduction to the forensic guidelines, which states:

For the purposes of these Guidelines, forensic psychology refers to professional practice by any psychologist working within any subdiscipline of psychology (e.g., clinical, developmental, social, cognitive) when applying the scientific, technical, or specialized knowledge of psychology to the law to assist in addressing legal, contractual, and administrative matters. Application of the Guidelines does not depend on the practitioner’s typical areas of practice or expertise, but rather on the service provided in the case at hand. These Guidelines apply in all matters in which psychologists provide expertise to judicial, administrative, and educational systems including, but not limited to, examining or treating persons in anticipation of or subsequent to legal, contractual, administrative, proceedings (emphasis added) … (APA, 2013, Introduction)

Clearly, the authors of these guidelines consider extratherapeutic activities/roles to be forensic-like activities because therapists are providing administrative information to third parties in order to address a patient’s psychological condition for a nonclinical purpose.

Emotional Support Animals and the Law

Service Animals Versus Emotional Support Animals

As noted above, one problem area related to extratherapeutic activities/roles for therapists that has recently developed deals with patients requesting a letter of support from their therapist that would allow them to take their pet—a dog or other animal—into restricted or no-pet areas. Such a letter would claim that because a patient is psychologically disabled, and cannot be without the stability that comes from the presence of the animal, he or she should be allowed to take their pets into otherwise restricted areas. Under the law, these animals are called Emotional Support Animals (ESA). It is important to note that ESA’s are not, however, the same as service animals (SA).

Implementing regulations issued by the Department of Justice (DOJ) under the Americans with Disabilities Act (ADA) defines a SA as a dog that is “individually trained” to “do work or perform tasks for the benefit of an individual with a disability.” The tasks a dog has been trained to provide must relate directly to the person’s disability (United States Department of Justice, 2011). Under the ADA, the animal is not a SA without individual training. The ADA also limits this definition to dogs only. While other animals cannot qualify as a SA, the DOJ requires “reasonable modifications in policies, practices, or procedures” for individually trained miniature horses (United States Department of Justice, 2011).

A psychiatric service animal (PSA) is a special type of SA that has been trained to perform tasks that assist individuals with disabilities to detect the onset of psychiatric episodes and lessen their effects. Tasks performed by these types of SAs may include: reminding the companion to take medications, providing safety checks or room searches, turning on lights for persons with anxiety or disorders, interrupting self-mutilation behaviors, anticipating epileptic seizures, and preventing impaired individuals from endangering themselves (Duffly, 2015).

As can be seen from above, ESAs are not the same as SAs; they do not require the training that is necessary to certify an animal as an ADA-compliant SA. Therefore, ESAs are not directly covered by Title II (Nondiscrimination on the basis of disability in state and local government services; 42 U.S.C.) or Title III (Nondiscrimination on the basis of disability by public accommodations and in public commercial facilities; 42 U.S.C.) of the ADA. Additionally, unlike SAs, ESAs can be pets. Interestingly, however, they are not considered pets under the law and special accommodations must be afforded to individuals who need ESAs to assist them psychologically. For example, housing that prohibits pets must allow ESAs, resulting in the waiving of a no-pet rule and any related damage deposit. Under the Fair Housing Act (FHA, 1968), an ESA is viewed as a “reasonable accommodation” in a housing unit that has a “no pets rule” and the imposition of a fee or deposit is considered contrary to the purpose of the law (Wisch, 2015).

Turning from housing to flying, the Air Carrier Access Act (ACAA, 2003) requires airlines to allow SAs and ESAs to accompany their handlers in the main cabin of an aircraft. Additionally, air carriers “shall not impose charges for providing facilities, equipment, or services that are required by this part [of the Act] to be provided to qualified individuals with a disability” (Federal Register, 2003). According to the Department of Transportation (DOT), passengers with a mental health disability can travel with their animal in the main cabin of an airplane if that animal is an “emotional support animal (ESA)”. ESAs do not have to have the individual training to qualify them for this but are believed to assist the passenger in being able to travel more comfortably due to their presence. Passengers who have such a disability may have to provide the airline with current documentation on the letterhead of a licensed mental health professional stating: (a) that the passenger has a mental health-related disability listed in the DSM–IV; (b) that having the animal accompany the passenger is necessary to the passenger’s mental health or treatment or to assist the passenger; (c) that the individual providing the assessment of the passenger is a licensed mental health professional and the passenger is under her/his professional care; and (d) the date and type of the professional’s license and the state or jurisdiction in which it was issued (Federal Register, 2003). Again, psychologists are often being called upon to write letters in support of a client’s need for an ESA. This is also where the conflict between forensic and therapeutic roles in providing letters of support for ESAs becomes clear.

The Legal Definition of Disability and Reasonable Accommodation

Tran-Lein reviewed the topic of ESAs from a legal and regulatory perspective. She concluded that federal laws recognize ESAs as reasonable accommodations for people with disabilities for purposes of housing and travel. She noted that, under the law, the presence of the animal is required because it impacts the symptoms of the disability (Tran-Lien, 2013). According to Tran-Lien, ESAs “perform many disability-related functions, including, but not limited to, providing emotional support to persons with disabilities who have a disability-related need for such support … but they must provide a disability-related benefit to such individuals” (p. 2). The key here is the definition of disability since the person being allowed this exception must, by law, be disabled by their psychological condition.

Legally, disability refers to a physical or mental impairment that substantially limits one or more major life activities (HUD, 2004). Another definition, taken from California law by Tran-Lien (2013), defines disability as “any mental or psychological disorder or condition … that limits a major life activity.” “Major life activities” is to be broadly construed, and includes “physical, mental, and social activities and working” (Tran-Lien, 2013, p. 2). Consequently, for the psychologist working with a patient, disability is not just a matter of discomfort, but a psychological disorder or problem that interferes with the patient’s ability to perform major life activities. Note the word substantially in the definition. This obviously does not mean discomfort, attachment to, or just wanting to be with the animal. It means that the patient needs the presence of the animal to remain psychologically stable, ergo the term disabled. Additionally, the term disability-related benefit in Tran-Lien’s (2013) quote about the functions ESAs must serve, is not clearly defined.

Emotional Service Animals, Media Publicity, and a Growing Industry

The topic of housing and airline accommodations being made for ESAs has attracted a significant amount of media publicity. For example, in a New Yorker article, “Pets allowed: Why are so many animals now in places where they shouldn’t be?” Patricia Marks reported that the National Service Animal Registry, a private commercial enterprise that sells certificates, vests, and badges for helper animals, signed up 11,000 animals online in 2013, even though the animals may not have merited certification (Marx, 2014). Similarly, in a USA Today (2015) article, the editorial staff took the position that while SAs were acceptable, ESAs infringed on other’s rights and reflected an exploitation of law and regulation by animal lovers. The article was critical of how some online commercial entities provide ESA certification, rendering a letter in support of needing an ESA without a licensed mental health professional seeing or evaluating an individual or their pet in person. These are but a few examples illustrating a larger problem. Correspondingly, the certification of ESAs appears to have become a growing industry. Even the most cursory search of the Internet produces a number of online commercial entities that specialize in providing SA or ESA certification for dogs and other animals without ever having seen or evaluated a person or their animal. For instance, the United States Dog Registry provides three levels of certification: SA dogs, ESA dogs and therapy dogs. In their advertising, the U.S. Dog Registry states that “Emotional support dogs help individuals with emotional problems by providing comfort and support …” and that the disabilities covered include “Anxiety, depression, bipolar/mood disorders, panic attacks, and other emotional/psychological conditions” (U.S. Dog Registry, 2015, Para 1). Their advertising also states that certification will allow the animal to fly in a commercial airplane for free and will allow the dog in all housing regardless of an existing pet policy.

The National Service Animal Registry (2015) “specializes” in registering dogs, cats, and other animals as ESAs. If an individual who is interested in registering their animal as an ESA has no therapist, or if their therapist is unwilling to write a disability letter, the National Service Animal Registry recommends using Chilhowee Psychological Services (https://www.cptas.com/), a licensed mental health services agency that specializes in online/telephone disability assessments and offers letters of prescription to clients who qualify. Similarly, the DOGtor (http://thedogtor.net/?gclid_CNn_5oSwwcwCFRFZhgodfPgORQ) provides an online mental health evaluation that consists of a brief examination that is later reviewed by one of the company’s licensed professionals who then writes a letter in support of an ESA. While a professional may later speak with a dog owner, the website states this is “rare.”

All of these are examples of how an industry has developed around the certification of ESAs, allowing pet owners to have their pets with them in housing that does not allow pets and to travel on commercial aircraft at no cost. Arguably, these commercial evaluative services are questionable from a professional standards perspective and inconsistent with psychological ethics and forensic standards (APA, 2010, 2013) and the law. Altogether, this media publicity and industry has implications for psychologists as they might be pressured by patient requests for a letter of evaluation in support of their need for an ESA or certification of their pet.

Therapeutic Benefit of Emotional Support Animals

Psychologists may consider the presence and use of animals during psychotherapy sessions when it is clinically appropriate. Indeed, there is a growing literature points to the therapeutic benefits of the use of animals in the therapy room or as an adjunct intervention (e.g., Boisvert & Harrell, 2014, 2015; Fine, 2015; Owen, Finton, Gibbons, & DeLeon, 2016), though most of these animals are trained SAs, not ESAs. However, this article is not about the therapeutic impact that the presence of animals has on others or the specific applications of animal-assisted therapy (AAT). Instead, it is about an underlying assumption made by many—professionals and patients alike—that being in the presence of animals has a therapeutic effect upon people, making them feel better, an assumption that does not appear to have substantial foundation in science. Indeed, Herzog (2011) has argued that a strong positive media bias incorrectly leads many to believe that ESAs are effective for mitigating mental health problems. Herzog (2011) notes that studies on pet ownership that have found no impact or even negative impacts on human physical/mental health rarely make headlines.

While some believe a companion animal may produce more positive outcomes (e.g., Le Roux & Kemp, 2009), little empirical data exists to support the conclusion that ESAs are effective in mitigating psychological disorders and related problems, and empirical research that does exist is inconsistent, sparse and emerging (Ensminger & Thomas, 2013). For instance, Gilbey and Tani (2015), in a systematic review of companion animals and human loneliness found only 21 relevant studies, some of which included AATs, and of that only three were randomized controlled studies. They concluded that none of the studies provided convincing evidence that companion animals alleviate loneliness. They also concluded that the data on AATs was promising, speculating that the positive results might have been due to aspects of the psychotherapy rather than the presence and use of the animal in the treatment setting.

Clearly, this is an area in need of rigorous, empirical research. Given the paucity of evidence regarding the efficacy of ESAs in augmenting human physical/mental health, it is problematic that psychologists are writing letters of support for their patient’s need for an ESA.

The Role of Treating Psychologists and the Emotional Support Animal

The thesis of this paper is focused on the question, “Just what is the appropriate role of a treating psychologist when dealing with a request by a patient for an ESA?” As highlighted earlier, treating therapists have a variety of valuable extratherapeutic activities/roles they play in the treatment dyad. These include initial certification for disability, verification of therapy to other entities, coordination of care with other health care providers, provision of health care information to insurance carriers, and so forth They also make many recommendations for therapy-related activities for their patients such as recommendations for treatment-relevant readings, referral to other professionals for services, referral to support groups, and so forth. That said, treating therapists must remember that they are advocates for their patients and thus, may not be able to be wholly neutral and objective in their recommendations, activities and roles. Consequently, they must take great care to avoid allowing that advocacy to impact their objectivity as much as possible. When treating psychologists find themselves unable to be neutral or objective, such as might be the case when a patient requests a letter of evaluation and certification of their animal as an ESA, they should refer their patient to a third party who can possess these qualities, that is, a forensic psychologist.

Treating therapists may have a role in recommending that their patients have an ESA if that recommendation was part of a treatment plan for that patient. That is, if the presence of the ESA assisted that patient in making progress with an identified psychological problem (i.e., is part of the treatment plan), then such a recommendation would be clinically appropriate. However, if the recommendation for the ESA could result in a permanent state of affairs and the presence of the animal is more palliative in nature, then it is best that recommendation come from an outside professional. The reasons for this are wrapped around the very same problems that occur with disability certifications by treating therapists. If the disability is transitory and time is needed for treatment that restores the patient’s functionality, that certification is appropriate. However, if the disability is permanent and not directly related to treatment, then the issue is more administrative in nature and those determinations should be referred out to avoid the risk that they might create problems with treatment (APA, 2013; Greenberg & Shuman, 1997).

It should be pointed out again that in some states it is actually a crime to certify fraudulently an animal as a SA or an ESA (Act Relating to Service Animals, 2015), and such conduct could be the source of disciplinary action by the state’s board of psychology, putting the treating psychologist who does so at risk. Further, should any special accommodations recommended in a letter of support for an SA or ESA that is written by the treating psychologist become a matter of legal dispute, she/he may be called upon to justify her/his statements in a deposition or in open court. It is important to remember that the evaluation and certification for a SA or ESA can result in legal action if the agency impacted by that request disputes the recommendations. Consequently, treating psychologists who provide such evaluation or certification have to ask themselves, “Can I defend my determination that the patient is disabled by a DSM disorder and that this disability requires the presence of an animal in exception to existing policy?” While writing a letter for a patient who reports that their pet alleviates emotional or distress or psychological symptoms might seem harmless at the outset, it might have serious ramifications for the treating psychologist later on. That is, the treating psychologist who performs this extratherapeutic activity/role must be prepared to prove in a legal proceeding that the presence of the animal was necessary. Frankly, if the treating psychologist is unwilling to risk the exposure to a legal action, then s/he is advised to refrain from such letter writing.

Consistent with Greenberg and Shuman (1997), problems can arise when the patient wants something that the treating psychologist cannot or will not provide, due to reasons such as professional competence or scope and standards of practice. If the treating psychologist does not believe that the patient suffers from a disability that necessitates the presence of the animal in previously restricted areas, or if the psychologist believes the patient no long needs the presence of the animal and the patient disagrees, how is this resolved? While the patient might be wrong in their assessment that they need the presence of the animal to feel or function better, the fact that the psychologist disagrees with this conclusion and will not evaluate or certify the animal as an ESA creates a classic conflict of interest that can risk damaging the therapeutic alliance.

Recommendations

The easiest way to avoid this type of ethical dilemma is to outline the services provided by the treating psychologist as part of the informed consent that occurs at the start of psychotherapy. The following statement would go a long way in preventing treating psychologists from finding themselves in a conflict that creates a conflict between their clinical roles and their administrative (extratherapeutic) roles:

Dr. X limits the services provided to you to those that are clinical in nature. Any requests for additional administrative services like disability certification and special accommodations related to a psychological condition will have to be provided by another psychologist. Short-term disability certification by Dr. X will be limited to a period of time not to exceed 4 weeks, at which time those determinations will also have to be made by another psychologist. The reason for this policy is to avoid having the performance of administrative functions interfere with your therapy.

Forensic Psychologists and Emotional Support Animals

Given that special accommodation recommendations for animals, particularly dogs, are largely administrative in nature, it is best that they are performed by a neutral third party who is not involved in the patient’s treatment. Whether one agrees or disagrees with the conclusion that these types of evaluations are forensic, they will likely find it hard to disagree with the conclusion that separating the treatment issues from those that are administrative in nature avoids any potential role conflict and is in the best interests of the therapy and the patient. That said, there are a number of things to be considered by any psychologist who chooses to perform these types of evaluations.

Like all forensic functions, a disability determination that would justify special accommodations for an ESA is almost always a complex professional activity that requires records review, consultation with treating professionals, interviews, and possibly psychological testing. Unlike the services offered by those who provide questionable, online assessments, determinations of psychological disability are not easy and are time consuming. Simply put, they should be performed with all of the care and caution of any forensic assessment. What is clear from the literature regarding the use of ESAs is that the person that qualifies for an ESA not only has to present with a DSM diagnosis, but they have to be significantly impaired by that psychological disorder or problem. Finally, the presence of the ESA has to have a significant impact on their psychological disorder or problem such that without its presence, the individual cannot adequately function. In essence, this type of determination is a complex process.

Psychologists who perform these assessments also need to be aware of how little scientific literature exists that supports the assumption that the presence of an animal has any palliative impact on a patient. The dearth of research evidence showing that the presence of the animal is necessary only makes the determination and subsequent recommendation more complex. Remember, those who provide these types of recommendations could find themselves defending them before an administrative/judicial entity where they might be called upon to answer the question of what empirical research exists to support a recommendation for an ESA.

Finally, psychologists who choose to perform these types of evaluations should perform them in a very thorough and careful fashion in order to avoid the risk of overstatement and misrepresentation. According to the APA Ethics Code (APA, 2010), psychologists are required to use assessments that are “appropriate in light of the research” (9.02a) and valid and reliable for the population tested (9.02b). In cases where validity or reliability has not been established, such as in the case of ESA assessments, psychologists must describe the strengths and limitations of test results and interpretations (9.02b). Remember, this is a disability determination not an assessment of a patient’s wants or preferences regarding their animal nor is it a process that is simply designed to make that patient happy or satisfied with one’s professional services.

Conclusions

Psychologists confronted by patient requests for the evaluation and certification of an animal for any extratherapeutic purpose need to understand that this is not a simple task nor is it without risk. Given the complexity of this area of regulation, this type of service and any recommendations stemming from it should be made by competent third-party evaluators who can objectively view the issue and whose recommendations and conclusions have limited impact on the therapeutic alliance.

Biographies

Jeffrey N. Younggren received his MA and PhD in clinical psychology from the University of Arizona. He is a forensic psychologist whose office is located in Rolling Hills Estates, CA. He resides in Columbia Missouri and is a Clinical Professor at the University of Missouri. He is a past chair and member of the Ethics Committee of the APA and the Ethics Committee of the California Psychological Association. He currently serves as a member of the Council of Representative of APA.

Jennifer A. Boisvert received her MA and PhD in clinical psychology from the University of Regina. She is currently in independent practice in Beverly Hills and Long Beach, California and also maintains an active research program. Her areas of professional interest include: body image, eating and weight disorders in women and men; gender and sex differences/roles; individual differences in hopefulness; diversity issues of race, ethnicity, culture, immigration, acculturation, spirituality, religiosity, sexual orientation, and age; feminism and masculinism; ethics; and cognitive-behavioral, hope-focused and animal-assisted therapies.

Cassandra L. Boness received her MA in clinical psychology from the University of Missouri where she is currently a PhD candidate. Her areas of professional interest include issues related to the diagnosis of alcohol use disorder; psychotherapy with deaf clients; dialectical behavior therapy; and ethics.