Puppies, Kittens and Hamsters–Oh My! Important Tips for Therapists when writing Emotional Support Animal Letters (ESA)

Photo Credit Unsplash

Photo Credit Unsplash

You may have noticed a rise in requests from clients for Emotional Support Animal Letters, sometimes referred to as an “ESA or ESL” letter.  If you haven’t yet, it is likely that you will receive a request like this at some point in your clinical career.

Emotional Support Animal letters in the therapeutic world are most often requested from clients who have been diagnosed with anxiety, depression or other mental health issues.

As such, the client may request an ESA letter from their therapist so that the client can provide the letter to, for example, an airline in order to take their pet on a plane.

A client may also request that their therapist write an Emotional Support Animal letter for a client’s landlord who normally does not allow tenants to have a pet. Such a letter would verify that there is a mental health reason for the client to have a pet in the client’s rental home or apartment.  

Important Tips for ESA Letter Writing

We therapists want to help our clients live their best lives, and there are legitimate situations where an ESA letter from a therapist would support a client’s treatment plan and mental health.

However, there are also individuals and organizations who attempt to take advantage of therapists in order to obtain an ESA letter, even though there is not an existing mental health issue that supports an ethical reason for a therapist to write an ESA letter for a client.  

In these unfortunate cases, the therapist, out of compassion or concern for the client, may unwittingly put their license at risk with their state board by providing such a letter.

Before writing an ESL letter for a client, please be sure to consider the following:

1.     What state does the client live in?

Example: You are licensed in the state of California only and provided 3-therapy sessions to “Jane Jones” who was a resident in California during the time you provided the clinical support.  Jane sought therapy with you in order to heal from a breakup of a long-term boyfriend, and to reduce symptoms of grief and sadness.

After 3 therapy sessions, Jane then terminates therapy citing that she is moving to Oregon to be closer to her family and to start her life over again. You share with Jane that you are no longer able to continue therapy with her as you are not licensed in the state of Oregon. You provide Jane with 2-3 referrals to therapists in her area, and the therapy ends on good terms.

Three months later you receive a friendly email update and a request from your former client Jane asking that you please write an ESL letter so that she and her pet dog can obtain housing in a building that normally does not allow for animals.  Jane shares that she did not resume therapy in Oregon and you are her last therapist.

Additionally, she shares that only with an ESL letter will the landlord consider allowing Jane to lease in the building with her dog.  Jane goes on to share that her new dog has helped her heal from the break up, and she can’t bear to be separated from her beloved pet.

 Perhaps you tell yourself that this seems like a reasonable request. Jane was a lovely client to work with, she is doing better, and she has cited that her dog is an important emotional support for her.  You (like me) may be an animal lover, and personally understand the importance of pets in one’s life

Photo Credit Jonas Vincent

Photo Credit Jonas Vincent

You don’t see the harm in providing such a letter, so you have Jane sign a Release of Information, and then write a letter to Jane’s potential Oregonian landlord citing mental health challenges and the need for Jane to live with her dog. You send the letter to Jane, wish her well, make a copy for your files, and note the exchange in your former client’s file. And that’s that.

Or is it?

During a recent live video presentation in October 2018, CAMFT attorney Dave Jensen discussed two current legal cases pending against California therapists for writing ESL letters to clients over state lines.

In one case a California therapist’s client had moved to Pennsylvania and requested that their California therapist provide an ESL letter to their Pennsylvania landlord. The therapist complied with the client’s request.

When the Pennsylvania landlord reviewed the letter and noticed that the therapist was located in a different state than their potential renter, the landlord filed a complaint with the California Board of Behavioral Science who then took legal action against the therapist.

The second case that Dave Jensen cited had to do with an investigative reporter who was writing a story on how easy it was for people (in this case the undercover reporter) to obtain an ESL letter from a therapist. The reporter shared that they had booked one session, and by the end of the session with the therapist had the requested ESL letter - complete with a DSM V diagnosis.

Because of the reporter’s story, the therapist who provided the ESL letter to the undercover reporter is now dealing with legal concerns.

Another risk factor that therapists may not be aware are the existence of national companies who are now attempting to recruit therapists to write ESA letters for individuals with the promise of paying the therapist to do so.

Emotional Support Animal Letter Check List

Here is an important checklist to go over before writing an Emotional Support Animal letter for a current or former client. As always, do not simply take advise from a blog, a colleague, or the man or woman next door. When in doubt, always check with your state board or an attorney with your professional organization; better safe than sorry!

ESA Letter Check List:

1.     Where is the patient from? Remember, therapists may not provide therapy outside of their state of licensure. Even if this is a former client who has moved since working with you, providing clinical opinions or diagnostic information outside of your jurisdiction in writing an ESL letter could be construed as clinical care. Be careful and always check with your board or professional organization and attorney.

2.     If the client is within your state of licensure, you still must be careful to meet a standard of care with an ESL letter.  Standard of care should include:

a.     Best practice with a solid assessment

b.     Mental Status Exam

c.      Sufficient length of time with a therapist to give ample opportunity for the therapist to fully assess the client

 3.     Do not provide an ESL letter if you have only seen the client a handful of times and have not done a full evaluation with diagnosis. A key issue with many boards, including the Board of Behavioral Sciences in California, is that boards tend to frown upon therapists who provide an ESL letter after only a couple of sessions.

4.     Be prudent and thoughtful about how much information to disclose in the ESL letter if you choose to write a letter for a client. Confidentiality is still the cornerstone of every therapist/client relationship.

5.     Obtain a signed and dated Release of Information from the client and keep a copy on file if you plan on providing a ESL letter for the client

6. If you plan on charging the client for your time in preparing an ESL letter, be sure you have this clearly outlined in your clinical intake forms. To meet standard of care, and to hold solid ethical boundaries in your practice, a client must be informed in writing what your policies are regarding letter preparation at the start of the clinical relationship.

Additional Tip on the ESA Letter Assessment Process

Charlotte Hiler Easley LCSW is a respected and trusted therapist who provides equine assisted therapies, intensives, and workshops, as well as EMDR and Equine assisted EMDR for women in Lexington KY.  Working with animal assisted therapies, Charlotte offers this tip for assessment before writing an ESA letter:

“At my practice, part of the assessment process includes meeting with the client and their animal to assess whether the animal /client partnership is healthy so that the ESA is not further isolating or producing more anxiety for client because the animal is not socialized, housebroken, or has behaviors that are not appropriate, ( i.e. a dog that the client isn’t able to ask to sit/stay or one that growls if you come close to client).

Also, it is equally important to consider if the reasons the client is asking for the letter also supports a healthy environment for the Emotional Support animal.”

You can learn more about Charlotte’s work and women’s healing equine workshops at: www.charlotteeasley.com

The Law and ESL Letters

There is no current definitive law (as of this blog on 10-18-18) with respect to a therapist providing a client with an emotional support animal letter. However, it is in each clinician’s best interest to fall back on best practices when considering a client request for an ESL letter. 

To recap one more time: Best practices include a good assessment process, a mental status exam, sufficient length of time in working with the client, not providing an ESL letter to a client outside of one’s state of licensure, consider how much information to share in the letter, obtain a signed and dated ROI, add a note to the client file.

Ultimately, each clinician must decide where to draw the line on ESL letters. We work hard for our licenses, so it is important not to put your license at risk simply because a client wants to take their dog on a plane with them, or is applying for an apartment - especially if the client is not actually dealing with a mental health issue that would require such a letter.

In these particular situations, saying no to a client is not always easy. I am a big animal lover and want my clients to have the support and love of their precious pets. However, as mental health practitioners, we must follow and adhere to our licensing guidelines and legal and ethical requirements.

I hope this information has helped round out your thinking regarding ESA/ESL letters. Feel free to comment or introduce yourself in the section below.

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Kindly and in support,
Mari A. Lee, LMFT, CSAT-S