Monday, August 13, 2018

Write your patient a note for an emotional-support peacock?

Have you been asked to write a note for a patient for an emotional-support peacock, or perhaps an emotional-support snake? Or, more commonly, a dog or a cat that your patient says provides relief from stress and anxiety?

The desire for people's pets to travel with them has been mushrooming lately. While most emotional-support animals (ESAs) are dogs, or cats, in 2014, a woman tried to take her pot-bellied pig aboard a US Airways flight. (The pig was asked to deplane after becoming unruly and defecating in the aisle.) In 2016, a passenger took an emotional-support turkey on a Delta flight from Newark to Boston. And in early 2018, United Airlines refused to let a peacock fly on a plane from Newark…

Varied as those animals may be, they have something in common with thousands of other furry and feathered travelers: a note from a mental health provider or possibly a physician stipulating that they are therapeutically necessary for the emotional well-being of their owner.

While a lot of those notes are penned—for a fee—by online concerns, a growing number of physicians and mental health providers are fielding patients' requests for letters attesting to their need for an ESA. In fact, Delta Airlines is now requiring a signed document from a physician or a licensed mental health professional.

"This has now metastasized into the world of the family physician and the treating psychologist," says Jeffrey Younggren, PhD, a professor in the department of psychiatry and behavioral sciences at the University of New Mexico, who has published two papers on the topic. "They've opened Pandora's box."…

But it's not just scofflaws and ill-mannered pets that are to blame. Rampant confusion over the ESA designation is intensifying the problem. Many owners are under the misguided notion that their ESAs are "service" or "therapy" animals.

They're not.

Service animals, which are recognized under the Americans with Disabilities Act (ADA), are individually trained dogs (and rarely miniature horses) that perform specific tasks to assist individuals with disabilities. Therapy dogs are also highly trained and used to provide therapeutic benefits in hospitals, nursing homes, schools, and other settings. In contrast, ESAs are simply pets whose owners rely on them for emotional or psychiatric support. Legally, ESAs are covered only under the ACAA and the Fair Housing Act, which means that restaurants, businesses, and other public places are not required to accommodate them…

That confusion can be particularly acute for clinicians when patients ask them to write letters designating their pets as ESAs.

Chloe House, PhD, a psychologist in State College, Pennsylvania, has fielded several such requests. In one case, an undergraduate wanted to take his sister's dog into his pet-free apartment because his sister was moving abroad. He thought it would help his depression and anxiety. A second client wanted to move into a pet-free building with her Pit Bull.

In both cases, House declined to write the note. She'd never seen her clients with the respective animals and had no idea whether or not they provided any therapeutic benefit to them. What's more, she felt the requests represented a conflict for her in her role as a treating psychologist. The undergraduate, who ultimately obtained a letter from a provider in his home town, later found that caring for the dog exacerbated his anxiety. The woman with the Pit Bull got a letter from an online source…

"Does an animal ameliorate an individual's condition enough for me to write a letter for them? What about the people with allergies or the landlords thinking about the condition of their properties or the safety of any children that might be living in the building?" House asks. "Of course we all want our clients to feel better and animals may be a great way to do that, but the guidelines are very fuzzy."

Therapists aren't the only ones fielding letter requests, Barker says. Increasingly, primary care physicians are asking for guidance.

"I find it difficult when I am asked to write the letter for a patient to have a comfort animal mostly because they want to bring the dog they already have to a new apartment that doesn't allow dogs," writes one family practice physician. "They say they need it for their stress. I don't usually do this unless they can demonstrate this stress is an actual medical problem that requires treatment such as being on psychiatric meds or seeing a therapist on a regular basis, and I require they enroll the animal in a training program, and I need to see the graduation certificate. This was after a 'comfort' dog attacked one of our medical assistants when she was taking the patient's vitals."

The problem, says Younggren, is that the legislation effectively asks healthcare providers to certify something they are ill-equipped to evaluate. There aren't standards they can use to assess the animals and their impact on the owners' mental health, and even if there were standards, such assessments should fall to forensic psychologists, as they serve an administrative rather than therapeutic function, he says.

"The devil's in the details," Younggren says. "If you read the Air Carrier Access Act, it says you're certifying that the patient has a formal psychological disability and that that disability is ameliorated by the presence of the animal. But most of the time the people writing these letters have never seen the individual in the presence of the animal."

Barker routinely turns down requests for ESA letters.

"I tell them I am not comfortable writing a letter not knowing their animal or its temperament and that there are evidence-based treatments for conditions such as anxiety that they may be trying to address. We know EMDR (eye movement desensitization and reprocessing) works. We know CBT (cognitive behavioral therapy) works. We don't know about emotional support animals."…

And those objections don't even touch on risk, liability, and public health concerns. What if an ESA bites someone? (The Delta passenger bitten by the ESA dog required 28 stitches in the face.) What if an emotional support cat triggers a fellow passenger's allergy attack at 30,000 feet? What if it attacks a service dog thus endangering its owner?...

Then there's the issue of credibility. McNary describes the case of a well-meaning psychiatrist who signed off on a patient's need for an ESA even though she didn't consider the animal a therapeutic necessity. When the patient was later embroiled in a legal dispute with her condo board over her barking dog, the psychiatrist was subpoenaed. 

"The doctor hadn't documented anything. She had to take time away from her practice to testify and was embarrassed on the stand," McNary says.

But airplanes aren't the only place where dogs and other critters are becoming more common.

That's because many businesses, including medical practices, don't realize they're not required to accommodate ESAs, want to avoid causing a scene with an indignant owner, or are worried they might illegally discriminate against an ADA-protected service dog by mistake. After all, service dogs come in all breeds and sizes and many are trained to assist with conditions such as diabetes, seizure disorder, and post-traumatic stress disorder. A recent study by the University of California, Davis, concluded that psychiatric use is now the fourth most common use of service dogs in North America.

As a result, many businesses err on the side of caution and simply accommodate the animals.

"I had a dog jumping all over me while I tried to examine the patient," writes one family practice physician. A nurse writes about a man who brought his dog into the room while his wife was in labor and became upset when hospital staff wouldn't allow the dog into the operating room when the woman required an emergency C-section. House says she's seen an emotional support cat in her waiting area.

That said, there are limits. Barker notes that a man once came to the hospital with a python draped around his neck. Although he had a note from a nurse designating the animal as an ESA, "security escorted him out," she says.

Shelly Reese. Write Your Patient a Note for an Emotional-Support Peacock? - Medscape - Aug 07, 2018.

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