Emotional Support Animal Assessments: Toward a Standard and Comprehensive Model for Mental Health Professionals

Abstract

Growth in the presence of Emotional Support Animals (ESAs) in our society has recently garnered a substantial amount of attention, both in the popular media and the professional literature. Public media abounds with stories focusing on the increasing number of animals claimed as ESAs, the impact of this growth on society, the industry claiming to certify ESAs, and the various types of animals described as “certified.” The authors propose an assessment model for ESAs certification comprising a four-pronged approach for conducting these types of assessments: (1) understanding, recognizing, and applying the laws regulating ESAs, (2) a thorough valid assessment of the individual requesting an ESA certification, (3) an assessment of the animal in question to ensure it actually performs the valid functions of an ESA, and (4) an assessment of the interaction between the animal and the individual to determine whether the animal’s presence has a demonstrably beneficial effect on that individual. This model aligns with professional ethics, standards of professional practice, and the law and seeks to provide clear guidelines for mental health professionals conducting ESA evaluations.

Full text

Running head: ESA ASSESSMENTS: TOWARD A STANDARD FOR PROFESSIONALS 1
Emotional Support Animal Assessments:
Toward a Standard and Comprehensive Model for Mental Health Professionals
Jeffrey N. Younggren
University of New Mexico
Cassandra L. Boness
University of Missouri
Leisl M. Bryant
Private Practice
Gerald P. Koocher
Quincy College
Accepted Version* (6/23/2019)
*May differ from printed version
Professional Psychology: Research and Practice
Author Notes
Jeffrey N. Younggren received his M.A. and Ph.D. in clinical psychology from the University of
Arizona. He is a forensic psychologist who resides in Albuquerque, New Mexico. He is a
Clinical Professsor in the Department of Psychiatry and Behavioral Sciences at the University of
New Mexico. He is a past chair and member of the Ethics Committee of the APA and the Ethics

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 2
Committee of the California Psychological Association. He currently serves as a member of the
Council of Representative of APA and is a Risk Management Consultant for The Trust.
Cassandra L. Boness received her M.A. in clinical psychology from the University of Missouri
where she is currently a Ph.D. candidate. Her areas of professional interest include issues related
to the diagnosis and treatment of alcohol use disorder; statistics and psychometrics;
psychotherapy with Deaf and Hard-of-Hearing clients; and professional ethics.
Leisl M. Bryant received her Ph.D. in clinical psychology from Duquesne University and her
diplomate in forensic psychology from the American Board of Professional Psychology. She
served for over a decade on the New Hampshire Psychological Association Ethics Committee,
currently runs a private practice, and is a Risk Management Consultant for The Trust.
Gerald P. Koocher earned his PhD in clinical psychology at the University of Missouri. He is
currently Provost and Senior Vice President for Academic Affairs at Quincy College. He served
as APA President in 2006, and former Chair of The Trust. His special interests include pediatric
and forensic practice, professional and scientific ethics, and psittacine aviculture.
Correspondence concerning this article should be addressed to Jeffrey N. Younggren,
Department of Psychiatry and Behavioral Sciences, University of New Mexico. Contact:
JYounggren@salud.unm.edu

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 3
Abstract
Growth in the presence of Emotional Support Animals (ESAs) in our society has recently
garnered a substantial amount of attention, both in the popular media and the professional
literature. Public media abounds with stories focusing on the increasing number of animals
claimed as ESAs, the impact of this growth on society, the industry claiming to certify ESAs,
and the various types of animals described as “certified.” The authors propose an assessment
model for ESAs certification comprising a four-pronged approach for conducting these types of
assessments: (1) understanding, recognizing, and applying the laws regulating ESAs, (2) a
thorough valid assessment of the individual requesting an ESA certification, (3) an assessment of
the animal in question to ensure it actually performs the valid functions of an ESA, and (4) an
assessment of the interaction between the animal and the individual to determine whether the
animal’s presence has a demonstrably beneficial effect on that individual. This model aligns with
professional ethics, standards of professional practice, and the law and seeks to provide clear
guidelines for mental health professionals conducting ESA evaluations.
Key Words: ethics, emotional support animal, ESA, disability, assessment

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 4
Emotional Support Animal Assessments:
Toward a Standard and Comprehensive Model for Mental Health Professionals
The pervasive presence of Emotional Support Animals (ESAs) in our society has recently
garnered a substantial amount of attention both in the popular media and the professional
literature (e.g., Boness, Younggren, & Frumkin, 2017; Younggren, Boness, & Boisvert, 2016).
Public media abounds with articles that focus on the increasing number of animals certified as
ESAs, the impact of this growth on society, the ESA certification industry, and the various types
of animals described as “certified” (Herzog, 2016) - a list that includes squirrels, peacocks, pigs,
ducks, monkeys, hamsters, turtles, and even snakes. The novelty evident in such a list requires no
explanation and the basis on which some of these animals acquired certification remains a
mystery. Taking matters to the extreme, an airline recently fielded a request to allow an ESA to
travel with another animal as its own ESA (Matyszczyk, 2018).
Professional publications have detailed concerns about the certification of ESAs,
including ethical concerns about whether treating mental health professionalsshould even offer
such certifications, particularly given such work constitutes boundary crossings and has little to
do with therapy (Younggren, Boness, & Boisvert, 2016). In addition, the issue of whether any
scientific basis exists to support the notion that ESAs have a measurable impact on the
psychological condition of the person alleging a need “…is inconsistent, sparse and emerging”
(Younggren et. al, 2016, p. 4). Existing reports of benefits likely suffer from bias and
correlational artifacts (Crossman, 2017; Le Roux & Kemp, 2009). Further, a recent survey study
of practicing forensic and clinical mental health practitioners failed to reveal any consensual
model for how to evaluate individuals reporting need for an ESA, such as which assessment
instruments should be used when conducting such an evaluation (Boness, Younggren, &

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 5
Frumkin, 2017). As such, this has resulted in a murky state of affairs related to ESAs and ESA
evaluations/certifications.
Such certifications have allowed most ESAs to travel with their owners on airlines free of
charge and to reside in housing otherwise prohibiting pets without the requirement of a pet
deposit or fee. Demands for ESA accommodations have created a burden for airlines, who have
tried to cope by adjusting their policies in an attempt to reasonably control the growth of these
travel companions on flights (Gilbertson, 2018). In addition, landlords have also begun to tighten
up the way they deal with the impact of the growth in ESA certifications by insisting that the
presence of any animal conforms to law, meaning that ESAs cannot wander around a building’s
common areas and must stay in their owner’s apartment (Disability Rights California, 2014).
Clearly, emotional support animal certifications, whether legitimate or not, have significantly
affected several sectors of society including travel, public accommodations and housing.
In order to obtain access rights for an ESA, per the Air Carrier Access Act (ACAA,
2003), a letter from a treating mental health professional is required. A major difficulty with
most ESA certifications involves a general lack of awareness regarding ESA laws on the part of
many mental health professionals writing certification letters, as well as a lack of consistent
standards for performing appropriate assessments (Boness, Younggren & Frumkin, 2016). Some
professionals providing putative assessments and offering certifications online have suffered
disciplinary actions by their licensing boards (e.g., State Board of Licensed Professional
Counselor Examiners v. Stanford Sutherland, 2016), suggesting a recognition of malfeasance in
the practitioner community and need for clearer assessment guidelines within the field of
professional psychology.
The Ethical Challenge

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 6
In spite of the fact that the professional literature cautions mental health professionals
about providing certification letters for their own clients (e.g., Younggren et al., 2016), many
psychotherapists and health care professionals continue to perform this service. In addition, the
popular media is replete with evidence that the number of people asserting needs for ESAs is
striking and continuing to increase, placing a burden on those charged with accommodating such
requests. The ethical issues inherent in this discussion fall into three primary categories:
competence, assessment practices, and boundary problems. Understanding the laws and policies
that regulate ESAs (described in more detail below) comprises part of the competence problem,
and is well described elsewhere (e.g., Younggren, Boness, & Boisvert, 2016). Additionally,
mental health professionals who lack full awareness of the law will likely fail to recognize that
writing such letters constitutes a disability determination that becomes a part of the individual’s
clinical records. Such mental health professionals may also fail to fully grasp the elements of an
assessment necessary to confirm ESA eligibility or may lack the skills needed to perform a
formal and comprehensive disability assessment. While these issues are important, they have
been elaborated on previously (see Boness et al., 2017 and Younggren et al., 2016). Therefore,
the remainder of the manuscript focuses on the ethical concerns related to boundary issues.
The boundary issue arises when a mental health professional agrees to evaluate a
psychotherapy client for some purpose not directly related to the treatment, in this case, for a
psychological disability. In making such a request, the individual may expect that the mental
health professional who has shown them support and positive regard, will comply in advocating
for them by drafting the letter. In many cases, providing a documentation letter requested by a
given individual may pose no ethical problem for a treating mental health professional. For
example, letters confirming the fact that an individual has regularly attended therapy sessions,

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 7
documenting a diagnosis as a focus of treatment, or providing proof of payment for services for
valid medical expense purposes provide instances in which providing a simple letter in response
to an individual’s request poses no boundary problem. Documenting the disability necessary to
support a lawful need for an ESA, however, rises to another level of assessment.
The psychotherapist, who must focus on maintaining a therapeutic alliance, will become
compromised when attempting to avoid bias in conducting an objective evaluation (Greenberg &
Shuman, 1997). Will the psychotherapist simply determine ad hoc that the individual warrants
such a letter based on their work together, without an additional focused assessment? Will the
psychotherapist recognize their own potential biases that might preclude an objective
assessment? What will happen to the therapeutic relationship if the psychotherapist’s assessment
does not support the individual’s wishes? These are all questions that demand thorough
consideration before assuming the role of assessor in this context.
In the pages that follow we will document the key components necessary to establish the
need for an ESA, consistent with professional standards of assessment and integrity. While some
contend that ESA assessments can be conducted by treating therapists, consistent with the
wording of the law, we hold that conducting this type of an assessment creates a risky role
conflict for treating psychotherapists and has very little to do with psychotherapy (Younggren,
Boness, & Boisvert, 2016). Consequently, such evaluations, which are clearly forensic in nature
(see Younggren, et. al.), should be conducted by individuals having no other relationship with
the person seeking to qualify for ESA accommodations. However, as with any evaluation
intended to answer a legal question, the mental health professional must own the responsibility to
assess their personal competence, biases, integrity, and potential consequences to the therapeutic
relationship in agreeing to consider preparing documentation to support the need for an ESA.

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 8
The Emotional Support Animal Evaluation Model
Despite the rapid increase in ESA requests and certifications, there remain no extant
guidelines for conducting such assessments. The lack of clear guidelines has resulted in a highly
ambiguous state of affairs whereby current ESA certifications have no standards against which
they can be compared and judged as valid or not. Given the need for standard guidelines, we
propose the following model for mental health professionals who agree to conduct ESA
evaluations. This model is comprehensive, arguably consistent with the existing standards of
practice for psychological assessments (e.g., Standards for Educational and Psychological
Testing, American Psychological Association Specialty Guidelines for Forensic Psychology,
American Academy of Psychiatry and Law [AAPL] Practice Guidelines for the Forensic
Evaluation of Psychiatric Disability) and comports with the requirements of law. We believe that
appropriate certification must include four related components: (1) understanding, recognition,
and application of the laws that regulate ESAs, (2) a thorough assessment of the individual
requesting an ESA certification, (3) an assessment of the animal in question to ensure it is
capable of performing the valid functions of an ESA, and (4) an assessment of the interaction
between the animal and the owner to determine whether the animal’s presence has a
demonstrably beneficial effect on the owner. This model is depicted in Figure 1 which represents
the four components as cyclical in nature rather than in a step-by-step process. The cyclical
nature of the process aligns with our belief that each component of the model should inform the
others, rather than occurring in a step-by-step fashion. Below we elaborate on the relevant
components of our ESA assessment model. For each component, we articulate relevant
guidelines. These guidelines are summarized in Table 1.
The Law

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 9
Guideline 1: The mental health professional must be able to understand, recognize,
and apply the laws that regulate Emotional Support Animals. We contend a mental health
professional intending to engage in the certification of an ESA for a given individual must have
solid familiarity with relevant law. Younggren, Boness, and Boisvert (2016) discussed, in detail,
the confusion that often arises with dealing with ESAs and how the use of these animals is, or is
not, authorized by law. First, there is no legal clarity regarding which types of animals are
covered under the Americans with Disabilities Act (ADA). As a civil rights law prohibiting
discrimination against individuals with disabilities, the ADA aims to ensure equal opportunities
in access to public accommodations, employment, and transportation (ADA, 2018). The ADA
covers Service Animals (SAs) and Psychiatric Service Animals (PSAs) but not does not cover
ESAs. Therefore, the ADA does not directly apply to or entitle the use of an ESA. (For a
thorough discussion of the different types of service animals see Younggren et al., 2016.)
In the spirit of clarifying any confusion, readers should note that only two laws directly
apply to the use of ESAs in public accommodations: the Air Carrier Access Act (ACAA, 2003)
and the Fair Housing Act (FHA, 1968). Under the ACAA, the ESA must be allowed to
accompany their handler in the main cabin of an aircraft at no charge. As applied to the FHA, the
ESA can stay with its owner in a housing unit that otherwise prohibits pets and the landlord must
not impose a fee of any sort related to this special accommodation (Wisch, 2015). The ACAA
and FHA describe specific requirements that must be met before an ESA is granted these
protections (see Younggren, Boness, & Boisvert, 2016). First, the individual must have a
psychiatric diagnosis consistent with the DSM-5 and assigned by a licensed mental health
professional. Second, the person must qualify as disabled based on the psychological condition
and the presence of the animal must ameliorate some of the symptoms of that disability. They

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 10
key criterion in the second requirement is the word “disabled.” Tran-Lein (2013), an attorney,
emphasized that the ESAs must “…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 (emphasis added) provide a disability-related benefit to
such individuals” (p. 2). The definition of disability becomes critical because the person allowed
this exception must, by law, qualify as mentally or emotionally disabled by their psychological
condition.
Disability, broadly defined, refers to a physical or mental impairment that substantially
limits one or more major life activities (24 CFR 8.3). For the psychologist working with an
individual, disability as it applies to ESA certifications is not simply a matter of discomfort
experienced by the individual. Disability, in this case, describes a psychological condition that
substantially interferes with the individual’s ability to perform major life activities. Disability
does not mean 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 the presence of the animal to function or remain psychologically stable. Arguably, then,
the individual who receives an ESA certification for a psychological disability must undergo a
comprehensive assessment which, as a result, allows the qualified assessor to describe the exact
nature of the disability and how the presence of the animal impacts that disability.
Assessment of Client
Guideline 2: The mental health professional should conduct a thorough assessment of
the individual requesting an Emotional Support Animal certification in order to establish a
disability and disability-related need. Remain mindful that ESA certifications include a
disability determination (Younggren et al., 2016). Those undertaking such an evaluation must,

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 11
therefore, understand the definition of a disability, how to assess the condition, and how to
determine the manner in which the ESA measurably assists the disabled person. This can pose
confusion because the term “disability” has more than one legal definition. That said, one of the
most commonly used definitions of disability is that found in the Social Security Act (SSA)
which defines a disability as “the inability to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment(s) which can be expected to result
in death or which has lasted or can be expected to last for a continuous period of not less than 12
months” (SSA, 2012). The critical point to glean from this definition is that a disability
determination is not a casual opinion about a person’s psychological condition, but rather a
formal determination of “mental impairment” that relates to a “significant deviation, loss or loss
of use of any body structure or body function in an individual with a health condition or a
disease” (Anderson & Cocchiarella, 2008, p. 5). Examples of specific criteria for mental
disabilities may be found on the Social Security web site (for adults see:
www.ssa.gov/disability/professionals/bluebook/12.00-MentalDisorders-Adult.htm; for children
see: www.ssa.gov/disability/professionals/bluebook/112.00-MentalDisorders-Childhood.htm).
The next question of ethical importance involves how one conducts a competent
disability evaluation. The American Academy of Psychiatry and the Law (Anafang, Gold &
Meyer, 2018) has taken the position that the purpose of a disability evaluation involves tying the
impairments to a mental health condition. In so doing, the Academy contends that an appropriate
evaluation includes a review of records and collateral information, a standard examination of the
subject of the evaluation, an examination of the relationship of the impairment to the “mental
disorder,” a review of alternate explanations for the alleged disability, and a formulation of
opinions (Anfang, Gold & Meyer, 2018). The American Psychological Association has not

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 12
produced a similar document on conducting disability evaluations, however, we can turn to the
Specialty Guidelines for Forensic Psychology for guidance (APA, 2011). According to the
SGFP, when a psychologist conducts a forensic assessment of a person, they use multiple
sources of information (SGFP 9.02), strive to utilize appropriate methods and procedures in their
work, and seek information that will differentially test plausible rival hypotheses (SGFP, 9.01).
Some of the questions that should be answered before the certification of a disability lend
themselves to evaluation with psychological test data, while behavioral assessment may prove
useful in evaluating others. For example, does the presence of the ESA allow the individual to
more effectively perform activities of daily living (ADLs) commonly done by others, reduce
anxiety sufficiently to yield measurable improvements in concentration, or facilitate improved
social interactions with other people?
Guideline 2a: A necessary component of the comprehensive disability assessment
includes an evaluation of malingering. An additional component of this examination, per AAPL
guidelines for Forensic Evaluation and Psychiatric Disability (Gold et al., 2008), includes
assessing for malingering or “faking bad.” This becomes particularly necessary if the claim is
based primarily on self-report, given that malingering commonly occurs in disability
determinations (e.g., some authors have noted evidence for probable malingering in over 30% of
disability or worker’s compensation cases [Mittenberg et al., 2002]). Given disability evaluations
involve complex, multifactorial assessments of an individual’s psychological condition, they
should typically include some assessment of malingering.
In any case, the mental health professional will need to document three phenomena to
comport with this guideline: the presence of a mental disorder, the disabling nature of the
symptoms, and the amelioration of some symptoms or level of the disability’s severity by the

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 13
presence of or interaction with an ESA. These phenomena cannot be adequately described
without also assessing the client’s interaction with the animal intended to be an ESA.
Assessment of the Animal
Guideline 3: The mental health professional should consider if the animal in question
is capable of performing the functions of an Emotional Support Animal. Another necessary
aspect of an ESA evaluation involves assessing the temperament of the animal that meets the
individual’s need for emotional support. Though mental health professionals are more than likely
not trained or competent to directly assess animal temperaments, consideration of this factor via
collateral information is nonetheless critical to ESA certification. This is particularly warranted
because some animals simply do not match the purported role of an ESA well. With recent
evidence of companion animal attacks on other airline passengers (e.g., Hefferman, 2018) and
some animals’ inability to cope with the stresses of exposure to the public and alien
environments (e.g., air travel, shopping areas, or other highly stimulating environments that
include encounters with unknown people), the reality is that not all animals can reasonably serve
as an ESA (Mashable, 2019).
Recall that in order to meet criteria for certification, the presence of the animal must
ameliorate some symptom(s) of the disability or provide a disability-related benefit to the
individual. Some animals simply cannot do this, and some may be able to do so in certain
contexts or environments but not in others. Take, for example, the situation of a dog who
purportedly reduces the anxiety of its owner. Perhaps the dog achieves this effect via its calm,
steady presence; or by leaning steadily into his/her owner when the individual starts to panic and
allowing the owner to pet him/her; or by being playful and silly and distracting the owner from
his/her own anxiety. But when brought into a foreign environment that is scary or overwhelming

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 14
(such as a busy airport), that same dog might no longer be able to provide the steady presence
that was so calming to the individual at home.
In fact, the media is replete with examples of dogs becoming so scared they defecate,
vomit, or aggress toward others (Hefferman, 2018). If the animal itself is so overwhelmed,
scared, or aggressive that it’s behaving in a distressed, uncharacteristic, possibly attacking
manner, it is highly unlikely that the animal has the ability (in that state) to provide a grounded
steady presence for the individual. To the contrary, the animal’s presence may actually serve to
increase the individual’s distress as the disabled person witnesses their beloved animal suffer
and/or attack others or as the person must attempt to manage the potential angry responses by
other humans distressed or harmed by the animal’s inappropriate behavior. Repeated instances
of such behavior, while obviously not helpful to the animal, may also be damaging for the
animal-human relationship (Patronek et al., 1996, Kwan and Bain, 2013). From this perspective,
consideration of the animal’s temperament should also be context dependent; that is, taking into
consideration the environment in which the animal is supposed to serve as an ESA. Living in a
quiet, fairly predictable home environment is far less stressful and more readily managed by
most animals, than going into public, sometimes chaotic, environments with lots of strangers and
unpredictability (e.g., airports, flying on an airplane). An animal may be able to serve the role of
ESA in the former environment, but not in the latter.
Guideline 3a: When necessary, the mental health professional should seek collateral
information regarding the capability of the animal in question to serve as an Emotional
Support Animal. It is incumbent on the mental health professional to consider the temperament
of the animal and obtain reliable collateral information to support a conclusion that the animal is
able to serve the ESA function in the environment in which it will be placed. Such collateral

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 15
information could come from a variety of sources. For example, with dogs, one option is to
obtain documentation that the dog has passed the Canine Good Citizen (CGC) Test
(https://www.akc.org/products-services/training-programs/canine-good-citizen/), which tests for
a fairly basic standard of temperament and decorum in public environments. The CGC is a
prerequisite for many therapy dog groups, is encouraged by homeowner’s insurance companies,
and is sometimes required by landlords. Alternatively, information could be obtained from an
animal trainer, animal behaviorist, or veterinarian who has assessed the animal and can speak to
the animal’s temperament and likely behavior in novel, potentially stressful environments. The
mental health clinician can then use such information when considering whether the animal is
able to fulfill the role of an ESA in specific contexts, in much the same manner that forensic
clinicians rely on collateral sources in a multitude of forensic or administrative evaluations. What
is key here is to respect the reality that the assessment of the animal is beyond the skill set of
most mental health professionals and that this information usually needs to be gleaned from other
sources unless the professional has demonstrated competence in these types of assessments. In
cases where the Emotional Support Animal has not been evaluated and collateral information is
not available, the mental health professional must consider how this severely limits the
comprehensiveness of the ESA evaluation and any resulting certification.
Assessment of Client-Animal Interaction
Guideline 4: The mental health professional should assess the interaction of the client
with the animal to determine whether the animal’s presence has a demonstrably beneficial
effect on the patient. It is important for the ESA evaluation to include an assessment of the
client-animal interaction in order to determine whether there is indeed beneficial impact of the
animal’s presence on the individual. This “beneficial impact” should be directly relevant to the

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 16
individual’s disability and disability-related impairment. This step is consistent with the forensic
or quasi-forensic nature of the assessment and with general standards and ethics for conducting
such evaluations (e.g., Greenburg and Shuman, 1997; Specialty Guidelines for Forensic
Psychologists, 2012). It is not sufficient to simply take the client’s word that the animal helps or
to simply assume it is so because the individual loves their pet. Part of the necessary distinction
requires differentiation between someone who is emotionally attached to and enjoys the
company of their pet (which could include most pet owners) versus individuals who must rely on
the animal for reduction or alleviation of disability related symptoms. In order to do this, it is
important to first assess whether there is a bona fide disability, and if so, to identify what the
disability is and in what specific way the animal is thought to have an impact on that disability.
Then, we contend, an observation of the individual and animal together is essential for
ascertaining whether a disability-related amelioration of symptoms occurs. There must be
opportunities for the mental health professional to see the individual both with and without the
animal present so as to compare the individual’s mental status and comportment in both contexts.
Some things to consider during the observation of the individual and animal together include:
Does the individual interact with the animal in some specific way and, if so, what is the effect on
the individual? Is there any change in the individual when the animal is present versus when it is
not? What evidence can the mental health professional identify and describe to support the
conclusion that the animal is providing a disability-related benefit? What disability-related
symptoms are being impacted by the animal and in what way? Are the disability-related
symptoms decreased or mitigated in some way when the animal is present? Given the answers to
these questions do rely on clinical judgment, the mental health professional could also include
formal assessment instruments that measure the reduction of the disability-related symptoms. For

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 17
example, the mental health professional may use a standardized, objective measure of
symptomology directly relevant to the disability (e.g., the GAD-7 for anxiety symptoms) in a
pre-post fashion. That is, the individual’s anxiety symptoms are assessed without the animal and
again in the presence of the animal to determine if there is any amelioration of symptoms and
related impairment. The ability to answer such questions is necessary for completing a
comprehensive ESA evaluation.
Unintended Consequences to Consider
When a mental health professional conducts a formal disability assessment, that report
and associated data become a part of the individual’s medical records. A finding of mental
disability can lead to subsequent adverse consequences for the individual. Questions about
mental disability can legitimately be asked as qualifications in certain employment
circumstances (e.g., child care, teaching, or public safety job screening) or licenses (e.g., school
bus driver or firearms license). In some states a, psychologist may have a reporting obligation to
certain state agencies upon finding an individual mentally disabled. For example, Illinois
licensed psychologists may have a mandatory obligation to notify the Illinois Department of
Human Services Firearm Owners Identification (FOID) Mental Health Reporting System (430
ILCS 65), upon finding some individuals mentally disabled. The question of mental disability
will come up if the individual seeks government security clearance, and in some cases life or
disability insurance. Obtaining a disability finding and subsequently failing to report it on certain
applications (e.g., for employment, insurance, or security clearance) may have serious
consequences for the individual. Documentation of mental disability may also become a factor in
subsequent child custody disputes. As part of the informed consent process, therefore, the mental
health professional has an ethical obligation to alert the individual to the potential adverse

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 18
consequences of carrying a mental disability finding in their health care records and take care to
ensure the individual understands the long-term risks that go with receiving a psychiatric
disability.
Discussion
The purpose of the current paper was to delineate a seminal model for conducting
comprehensive ESA evaluations. Our model, intended for use by mental health professionals,
argues that ESA evaluations must include four related components: (1) recognition and
application of laws that regulate ESAs, (2) a thorough disability assessment of the person
requesting the ESA certification, (3) an assessment of the animal, and (4) an assessment of the
client-animal interaction and the specific disability-related function the animal serves. This
model is consistent with standards of psychological assessment and requirements of the law and,
therefore, the absence of any of these four components results in an ESA certification that is
incomplete.
The ESA assessment model offered here serves as an important risk-management
strategy. Previous work has demonstrated the potential ethical and legal issues relevant to mental
health providers writing ESA evaluation letters (Younggren et al., 2016) and a general lack of
awareness of these issues among professionals (Boness et al., 2017). This model, therefore, aids
mental health professionals in ensuring they are upholding the ethical and legal standards of the
profession when deciding whether or not to engage in such an evaluation, and, when applicable,
conducting such evaluations. It is our belief that the use of this model will also aid in reducing
the negative impact illegitimate ESA requests have on society, particularly in the cases of air
travel and housing, while also encouraging the upmost professional standards are maintained.

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 19
As with most models, this should be used as a guiding framework, making necessary
adjustments and decisions where needed. While we have intended to be broad in describing the
requirements of a comprehensive ESA evaluation, the way in which this information is acquired,
measured, and assessed may vary based on each case. For example, while we have argued the
importance of assessing for malingering, we intentionally do not offer suggestions regarding
specific assessment instruments. This omission is intentional given that such a decision should be
specific to the referral question and case at hand. Similarly, assessment of the animal’s
temperament may vary based on the type of animal in question, the resources available in one’s
area, and the disability-related benefit they are claiming to provide. Consider this model dynamic
in nature and intended to serve as a starting place for identifying the core components of a
thorough ESA evaluation, rather than offering guidance on the specific tools and techniques
necessary for a comprehensive evaluation. This is why it is particularly important to ensure that
mental health professionals have, or take the necessary steps to acquire (e.g., through training,
consultation, or similar activities), competence related to the components outlined by the model
(e.g., the law, disability assessment).
Given the complexity of conducting comprehensive ESA evaluations, it is our hope that
this model will provide mental health professionals with a clear starting place while also
safeguarding them against potential ethical or legal pitfalls. As more research on ESAs continue
to emerge and the role of the mental health professional becomes clearer, particularly as
elucidated by the law, it is possible that new considerations will need to be incorporated into the
current model. In the meantime, the current model is intended to serve as the first set of
guidelines for conducting comprehensive ESA assessments.

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 20
References
Americans with Disabilities (ADA) Act National Network. (2018). What is the Americans with
Disabilities Act (ADA)? Retrieved from https://adata.org/learn-about-ada
Andersson, G. B. J. & Cocchiarella, L. (2008). American Medical Association: Guides to the
evaluation of permanent impairment (Ed 6), Chicago IL: AMA
Anfang, S. A., Gold, L. H., and Meyer, D. (2018). AAPL practice resource for the Forensic
evaluation of psychiatric disability. Journal of the American Academy of Psychiatry and
the Law, Online March 2018, 46 (1 Supplement), S2-S47.
Boness, C. L., Younggren, J. N., & Frumkin, I. B. (2017). The certification of emotional support
animals: Differences between clinical and forensic mental health practitioners.
Professional Psychology: Research and Practice, 48(3), 216–223.
Crossman, M. K. (2017, Effects of interactions with animals on human psychological distress,
Journal of Clinical Psychology, 73(7), 761-784
Disability Rights California. (2014). Psychiatric service and emotional support animals.
Retrieved from http://www.disabilityrightsca.org/pubs/548301.pdf
Ensminger, J. J., & Thomas, J. L. (2013). Writing letter to help patients with service and support
animals. Journal of Forensic Psychology Practice, 13, 92-115.
Gilbertson, D. (2018), Spirit Airlines tightens rules on emotional support animals. USA Today
Oct 14, 2018, (I know this is not right)
htps://www.usatoday.com/story/travel/flights/2018/10/03/sprit-airlines
Gold, L. H., Anfang, S. A., Drukteinis, A. M., Metzner, J. L., Price, M., Wall, B. W.& Zonana,
H. V. (2008). AAPL Practice Guideline for the Forensic Evaluation of Psychiatric

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 21
Disability. The Journal of the American Academy of Psychiatry and the Law, 36(4), S3–
S50.
Greenberg, S. A., & Shuman, D. W. (1997). Irreconcilable conflict between therapeutic and
forensic roles. Professional Psychology, Research and Practice, 28, 50–57.
Heffernan, D. (2018, November, 13), Comfort Animals' Do Not Belong In An Aircraft Cabin;
Regulators May Act Soon To Address The Problem, Retrieved from
https://www.forbes.com/sites/davidheffernan1/2018/11/13/comfort-animals-do-not-
belong-in-an-aircraft-cabin-regulators-may-act-soon-to-address-the-
problem/#513121fb4aba
Herzog, H. (2016) Emotional Support Animals: The therapist's dilemma, retrieved from
https://www.psychologytoday.com/us/blog/animals-and-us/201607/emotional-support-
animals-the-therapists-dilemma, Psychology Today, July 2016.
Housing and Urban Development 24 CFR 8.3 Subtitle A (4-1-04 Version).
Mashable (2019). A complete guide to airline policy on emotional support animals. Retrieved
from https://mashable.com/2018/02/27/emotional-support-animal-traveling-airplane-
policy/#M_oDujiXR5qsbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
Matyszczyk, C. (2018). On this United Airline’s flight, an emotional support animal had its own
emotional support animal. Retrieved from https://www.inc.com/chris-matyszczyk/on-a-
united-airlines-flight-an-emotional-support-animal-had-its-own-emotional-support-
animal.html
Miller, Z (2018). 10 dog breeds that may make great emotional support animals, Insider, Nov.
15, 2018. Retrieved from https://www.thisisinsider.com/best-dog-breeds-emotional-

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 22
support-animals-2018-
10?utm_source=email&utm_medium=referral&utm_content=topbar&utm_term=desktop.
Mittenberg, W., Patton, C., Canyock, E. M., & Condit, D. C. (2002). Base rates of malingering
and symptom exaggeration. Journal of Clinical and Experimental Neuropsychology, 24,
1094–1102.
State Board of Licensed Professional Counselor Examiners v. Stanford Sutherland (2016)
Retrieved from
https://www.dora.state.co.us/pls/real/ddms_public.display_document?p_section=DPO&p
_source=ELIC_PUBLIC&p_doc_id=473699&p_doc_key=C9581B58DF08B56A95AF0
3C3B36FB50C
Tran-Lien, A. (2013). Reasonable accommodations and emotional support animals, The
Therapist, January/February, 2013. Retrieved from
https://www.camft.org/COS/Resources/Attorney_Articles/Ann/Reasonable_Accommodat
ions_and_Emotional_Support_Animals.aspx.
United States Social Security Administration Office of Disability Programs: Disability
Evaluation Under Social Security. Retrieved from
https://www.ssa.gov/disability/professionals/bluebook/general-info.htm on October 25,
2018.
Wisch, R. (2015). FAQ’s on emotional support animals. Retrieved from
https://www.animallaw.info/article/faqs-emotional-support-animals
Younggren, J. N., Boisvert, J. and Boness, C. (2016). Examining emotional support animals and
role conflicts in professional psychology. Professional Psychology Research and
Practice, 47(4), 255-260.

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 23
Table 1
Summary of Guidelines for Mental Health Professionals Conducting Emotional Support Animal
Evaluations
Guideline
Description
Guideline 1
The mental health professional must be able to understand, recognize, and
apply the laws that regulate Emotional Support Animals.
Guideline 2
The mental health professional should conduct a thorough assessment of
the individual requesting an Emotional Support Animal certification in
order to establish a disability and disability-related need.
Guideline 2a
A necessary component of the comprehensive disability assessment
includes an evaluation of malingering.
Guideline 3
The mental health professional should consider if the animal in question is
capable of performing the functions of an Emotional Support Animal
Guideline 3a
When necessary, the mental health professional should seek collateral
information regarding the capability of the animal in question to serve as
an Emotional Support Animal.
Guideline 4
The mental health professional should assess the interaction of the client
with the animal to determine whether the animal’s presence has a
demonstrably beneficial effect on the patient
Note. This table of guidelines is intended to serve as a quick-reference and should be
accompanied by the full descriptions provided in the main of the manuscript.

ESA ASSESSMENTS: TOWARD A MODEL FOR PROFESSIONALS 24
Figure 1. Standard Model for Mental Health Professionals Conducting Emotional Support
Animal Evaluations. This figure summarizes the main components of Emotional Support Animal
evaluations. The cyclical nature of the figure is consistent with our belief that each component of
the model should inform the others, rather than occurring in a step-by-step fashion.
•Thorough assessment
of the individual
requesting an ESA
certification to
establish a disability.
•Assessment of the
animal in question to
ensure it is capable of
performing the
functions of an ESA.
•Understanding,
recognition, and
application of the laws
that regulate ESAs.
•Assessment of the
interaction of the animal
with the individual to
determine whether the
animal’s presence has a
demonstrably beneficial
effect on the patient.
Interaction Law
ClientAnimal