Abstract

While anecdotal accounts describe mental health recovery-related benefits of having Emotional Support Animals (ESAs), to date there have been no studies on such within peer-reviewed journals. This pilot study yields data on how ESAs may facilitate mental health recovery and related benefits for persons with Serious Mental Illness (SMI).Through an ESA placement program, the Hope and Recovery Pet program (HARP), shelter dogs and cats were placed as ESAs with adults (N=11) with SMI. A longitudinal mixed method research design was utilized to explore potential ESA impact. Pre- and post-placement data from participants was collected on depression, anxiety, and loneliness. Biomarker data (saliva analytes assessing oxytocin, cortisol, alpha amylase) were collected before and after ten-minute interactions with ESAs at 1, 3, 6, 9, and 12 months. Qualitative data was collected twelve months post-placement. Significant reductions in anxiety, depression, and loneliness scale scores via the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and UCLA Loneliness Scale (UCLA), respectively, were found. While not significant, there was a pattern of oxytocin increase and cortisol decrease after ten minutes of ESA interaction. Qualitative data indicated participants attributed their improvements in mental health and well-being to their respective ESAs. Findings underscore the need for continued research on ESA companionship as a mental health recovery support.

Animal companionship is associated with a range of physical, psychological, and social benefits for humans (Wells, 2019). Based on the potential of a serious mental illness to impact physical, psychological, and social domains of human functioning, individuals with serious mental illnesses (SMI) may find such benefits of animal companionship to be particularly helpful. SMI is defined by the National Institute of Mental Health (2019) as: “… a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities” (no page number). Despite ongoing or intermittent symptoms, people with SMI can experience substantial improvements in well-being, quality of life, and other important aspects of life. The framework of mental health recovery encompasses such improvements, going beyond traditional mental health outcomes such as symptom frequency and hospitalization to include individualized experiences of hope, active growth, safety, symptom management, social support, and wellness (Lusczakoski et al, 2014). Although companion animals have been identified by individuals with SMI as important supports and facilitators of mental health recovery-related outcomes (Brooks et al, 2016, 2018; Wisdom et al., 2009; Zimolag & Krupa, 2009), there is currently no peer-reviewed published research on the impact of companionship of animals specifically identified as Emotional Support Animals (ESAs). The overarching aim of this article is to take a first step toward addressing this gap, through reporting findings of a longitudinal mixed-method study on the perceived impact of ESAs among a sample of adults with SMI.

Understanding the Role of ESAs

The term “Emotional Support Animals” emerged in the United States through several federal discrimination-related disability legislative acts. An ESA can be defined as a companion animal (pet) who helps to reduce disability-related impairment for a particular person through the animal’s presence and everyday interactions. The animal needs no special training or certification to be an ESA. Verification of a person’s disability-related need for an ESA by the person’s treating clinician or healthcare professional via a simple written statement, commonly referred to in practice as an ESA letter, conveys federally recognized legal ESA status for the animal serving as such (U.S. Department of Housing and Urban Development (HUD), 2020). With regards to such provision of verification, HUD (2020) clearly states that clinician knowledge gleaned through routine clinical practice is an adequate and appropriate information source: “when providing this information, health care professionals should use personal knowledge of their patient/client – i.e., the knowledge used to diagnose, advise, counsel, treat, or provide health care or other disability-related services to their patient/client” (p.16). Claims that an expert disability evaluation from a forensic specialist clinician – one who is not providing ongoing treatment or healthcare services to the person being evaluated – is necessary to verify disability criteria for ESA eligibility (Younggren et al, 2019) are thus unsubstantiated and inaccurate.

Currently, federal recognition of ESAs occurs within the Fair Housing Act (FHA), where it is stated that emotional support from a companion animal can be disability-ameliorating and thus needed and protected as a disability accommodation within housing (HUD, 2020). It is important to note that different disability-related policies utilize different definitions of disability. Disability entitlement-related policies utilize far more stringent definitions than disability anti-discrimination policies such as the FHA. For instance, people who would not meet the disability eligibility criteria for financial supports provided through the Social Security Act and state level workers compensation laws can quality as having a disability under the FHA, and are thus eligible for FHA-protected accommodations such as ESAs (HUD, 2020).

Within the FHA, disability is simply and straightforwardly defined as “a physical or mental impairment that substantially limits one or more major life activities” (HUD, 2020, p. 9). HUD recently issued guidance that individuals who meet the diagnostic criteria for certain disorders – such as Major Depressive Disorder, Bipolar Disorder, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, and Schizophrenia – automatically meet the FHA definition of disability (U.S. Department of Housing and Urban Development (HUD), 2020). Readers are referred to Hoy-Gerlach, Vincent and Hector (2019) and the HUD (2020) notice Assessing a person’s request to have an animal as a reasonable accommodation under the Fair Housing Act for a thorough explication of whether and how to verify ESA need for FHA accommodation.

Until January 2021, ESAs were also recognized as an accommodation within the Air Carrier Access Act (ACAA). The U.S. Department of Transportation implemented amendments eliminating ESAs as air travel accommodations which will go into effect in 2021 (U. S. Department of Transportation, 2020). Of importance, ESAs have never been recognized by the Americans with Disability Act (ADA) as an accommodation within public spaces prohibited to pets; unlike individuals with service animals who are taught to perform specific tasks to alleviate disability, individuals with ESAs do not have public access rights to bring their ESAs into public spaces (American Veterinary Medical Association (AVMA), 2017).

Empirically-supported benefits of human-animal interaction (HAI) – spanning the physical, psychological, social, and emotional dimensions of human functioning – help to illuminate how animal companionship may function as a disability accommodation. Cross-walking these HAI benefits to symptoms and impairment from a given person’s mental or physical health condition can provide the “nexus” between that person’s condition and a disability-related need for the animal (Hoy-Gerlach et al, 2019). As summarized by Hoy-Gerlach et al (2019):

The clinical rationale for an ESA is essentially a delineation of how the biopsychosocial aspects of a person’s functioning that are adversely impacted by a chronic mental illness may be ameliorated by the biopsychosocial benefits of [human-animal bond] HAB. For example, a person living with debilitating depression may experience challenges with motivation (impairment in psychological functioning) and isolation (impairment in social functioning). Behavioral activation of ESA care and socialization are HAB benefits which directly impact isolation and motivation. Thus, this person may experience symptom amelioration through ESA companionship. (p. 205-206)

Knowledge of how HAI benefits may help ameliorate symptoms and related distress and impairment can be acquired by clinicians through the range of mechanisms used for knowledge dissemination in mental health practice, such as: continuing education; consultation; courses; and supervision.

Clinicians in various health and mental health professions are approached by clients with requests for ESA verification letters, and the value of and need for ESAs has been recognized and codified in U.S. federal law, however, there is currently no peer-reviewed published research that focuses explicitly on the impact of ESAs. Such research could inform understandings of the mechanisms through which people living with chronic health conditions such as SMI may benefit from ESAs, as well as how to better leverage such benefits for human well-being. Understandings of how ESAs may help ameliorate disability-related impairment are currently extrapolated from existing peer-reviewed literature on human biopsychosocial benefits associated with living with companion animals. The overarching aim of this research article is to begin to address this gap in research literature on ESAs through providing a pilot exploration of how ESAs may benefit adults with SMI.

The Biopsychosocial Benefits of Human-Animal Interaction (HAI)

While there is not yet a body of empirical literature on ESA benefits, the related empirical literature evidencing companion-animal related HAI benefits (henceforth referred to as HAI benefits) for people can be situated and understood within recognized dimensions of human-functioning: physical, emotional, social, and psychological (Hoy-Gerlach & Wehman, 2017). Recent reviews have highlighted reductions in depression and anxiety associated with animal companionship. In a review on HAI and older adults, both animal-assisted therapy and companionship via living with animals were associated with decreased depression and loneliness, improved cardiovascular health, and increased physical activity (Krause-Parello et al, 2019). Gee and Mueller (2019) similarly found in a systematic review that having a pet was associated with decreases in loneliness and depression and improved cardiovascular health in older adults, while cautioning causality assumptions about such. Hughes et al (2020) likewise found in a systematic review of 70 articles that companion animals – whether as pets or through interventions – were associated with reduced symptoms of depression and anxiety, and improvements in blood pressure and heart rate variability in older adults. The evidence of cardiovascular benefits associated with having a dog is robust enough that the American Heart Association put out a scientific statement stating that having pet, particularly a dog, is likely associated with decreased cardiovascular risk and may have some causal role in such (Levine et al, 2013).

HAI benefits do not occur isolated from each other, but rather, often augment each other. Beetz and colleagues (2012), in a review of 69 empirical studies, stated:

… well-documented effects of HAI in humans of different ages, with and without special medical, or mental health conditions are benefits for [emphasis added]: social attention, social behavior, interpersonal interactions, and mood [emphasis added]; stress-related parameters such as cortisol, heart rate, and blood pressure; self-reported fear and anxiety [emphasis added]; and mental and physical health, especially cardiovascular diseases” (p.1).

Beetz and colleagues (2012) further proposed, based on their review of empirical research on HAI benefits, that “… the activation of the oxytocin system plays a key role in the majority of these reported psychological and psychophysiological effects of HAI” (p.1), referring to such as a stress-mediation response.

Oxytocin and Human-Animal Interaction

Oxytocin is a hormone associated with affiliative bonding in addition to being released during interactions with people that one is attached to, it can also be triggered through stroking, holding, or even gazing (Nagasawa et al, 2015) at one’s companion animal. Oxytocin has been measured during the formation of affiliative bonds (Beetz et al., 2015); affiliative bonds are present in social bonding, sexual activity, maternal bonding (i.e. lactation), cooperation, forgiveness, and empathy (Cassidy & Shriver, 2002). The release of oxytocin associated with affiliative bonds can help offset physiological reactions associated with human stress responses; for instance, oxytocin is associated with reduced heart rate, respiration rate, and blood pressure (Beetz et al, 2012).

Numerous studies have explored physiological affiliation behaviors between humans and dogs using the bonding biomarker oxytocin and stress biomarkers cortisol and alpha amylase. Odendaal (2000) designed a study with humans (n=18) and dogs (n=18) using such parameters to identify positive interaction; this research found a significant increase in oxytocin as well as a decrease (although not significant) in cortisol. Nagasawa et al. (2009, 2015) researched and demonstrated mutual effect of both dogs and their owners on the peripheral oxytocin levels of both when gazing and physical contact between them occurred. MacLean et al. (2018) furthered this line of inquiry by measuring affiliative bonding within HAI by comparing salivary and blood plasma oxytocin samples; evidence from this research suggested that salivary oxytocin – a less invasive measure – could be collected and reliably measured in HAI research.

Levels of oxytocin were found to peak between one and five minutes after the introduction of a stimulus (e.g. a dog) in participants’ blood (Handlin et al., 2011). Petting a dog for as little as 2 minutes or sharing eye contact for as little as 15 seconds can begin to induce a positive biological response in both human and dog in bonded pairs (Nagasawaet al., 2009). Thus, the initial release of oxytocin may be relatively quick and may last in the body-system for a prolonged time. Current research has typically measured oxytocin in 5 or 10-minutes intervals (MacLean, 2017; Vincent et al., 2020).

Animal Companionship and Mental Health Recovery

The benefits of bonds between people with SMI and their companion animals (not identified as ESAs) is the focus of an emerging body of peer-reviewed literature (Brooks et al 2016; Brooks et al 2018; Brooks et al, 2019; Wisdom et al, 2009; Zimalog & Krupa, 2009; Zimalog & Krupa, 2010). While none of these studies addressed ESAs specifically, participants expressed a range of ways their respective companion animals mitigated aspects of impairment related to living with a SMI. Examples of such, congruent with a mental health recovery lens, include: social support (Brooks et al 2016; Brooks et al, 2019); higher levels of community integration (Zimalog & Krupa, 2010); increased feelings of self-efficacy and empowerment (Wisdom et al, 2009); and having a source of “consistency, unconditional support, and acceptance” that helped to mitigate stigma experiences related to mental illness (Brooks et al, 2019, p.329). In a study of self-care strategies identified by individuals with bipolar disorder, “spending time with your pet or other animals” was ranked as one of the top self-care strategies, and reported to be perceived as “very helpful” (Wynter & Perich, 2019, p. 138).

Peer-Reviewed Studies of ESAs

Authors of this article did an extensive literature search on ESA studies; 576 peer-reviewed journal databases were searched through EBSCOhost Research Platform using the term “emotional support animal*”, most recently in May 2020. Inclusion criteria included: primary empirical research study that addressed ESAs; English language; and published in peer-reviewed journal. Three articles were located that met this inclusion criteria.

Each of these three articles reported on descriptive studies of understandings of ESAs within particular sub-populations (other than individuals living with ESAs): the general public (Schoenfeld-Tacher et al, 2017); professional veterinary programs (Schoenfeld-Tacher & Kogan, 2017); and university counseling centers (Kogan et al, 2016). Findings indicated while members of the public had concerns about the ESA access on airplanes, the majority perceived ESAs as a legitimate role and felt there was a low amount of ESA misrepresentation (Schoenfeld-Tacher et al, 2017). Kogan and colleagues (2016) found that in a sample of university counseling centers (N=248), the majority of centers were not being asked often to write ESA verification letters; comments on the survey indicated that many counseling staff members felt uncertain about how to respond to ESA verification letter requests, and a need for ESA-related campus policy development was identified. In a survey of 28 professional veterinary medicine programs, Schoenfeld-Tacher and colleagues (2017) found that only a third of veterinary programs had received a student request to have an ESA on campus in the past two years, and a need for ESA-related campus policy development was again identified.

Methods

The Hope and Recovery Pet Program

To help leverage human-animal interaction (HAI) benefits for individuals with SMI, a pilot program known as the Hope and Recovery Pet (HARP) was developed to place shelter animals as ESAs for adults with SMI. HARP operates through a collaboration between the Toledo Humane Society (THS), a large regional non-profit healthcare system known as ProMedica, and the University of Toledo. HARP clients are individuals with SMI who are on a fixed income and may not otherwise be able to afford an ESA; food, supplies and veterinary care for ESAs are provided through HARP for the duration of an ESA placement.

To help ensure the welfare of both the humans and animals involved, inter-professional collaboration between human and animal service providers is an integral component of HARP. Ongoing monitoring and support of the ESA placement is provided by a HARP intern and other designated staff, including humane society staff. A community advisory committee for HARP is comprised of various stakeholders, including veterinary and humane society staff, who provide ongoing input on HARP operations. If a HARP client needs hospitalization or is otherwise temporarily unable to care for the ESA, foster care for the ESA is provided through THS at no cost to the HARP client. If for any reason the HARP client is permanently unable to care for the ESA, THS will take the ESA back and re-home the animal. A locally owned veterinary practice that focuses on veterinary service accessibility, the Community Pet Care Clinic, provides veterinary services to all HARP ESAs, as well as ongoing input to HARP through the advisory committee. Supporting the ongoing well-being of both human clients and the animals serving as ESAs are of paramount importance within the HARP model.

HARP goals are consistent with the One Health framework; One Health has been embraced by the World Health Organization, and can be briefly explicated as an approach that explicitly acknowledges and strives to leverage connections between human health, animal health, and environmental health to gain added value/benefit within and across these areas (Hediger et al, 2019). The goals of HARP are two-fold: 1) to improve health and wellness for individuals living with mental illness; and 2) to increase placement opportunities for homeless shelter animals through developing a program model that could be replicated through partnerships between other healthcare systems and humane societies.

Participants

Through convenience sampling, all study participants were recruited from the HARP Program. Study eligibility criteria was generally consistent with HARP program eligibility and as follows: SMI with prominent depression and/or anxiety symptoms; psychiatrically stable as per referring provider; stable housing; living alone and at risk of social isolation (as per referring provider); no current pet; low income via Medicaid eligibility; sober at least one year if diagnosed with substance use disorder; and no history of violence toward animals or people. The initial sample consisted of twelve HARP participants. The average participant age was 53.67 years; four identified as African American (33%), six as Caucasian (50%) and two as multi-racial (17%). Primary diagnoses for participants were Major Depressive Disorder (MDD) (63%), Bipolar Disorder (18%), and Schizoaffective Disorder (18%). Demographic variables were included in analyses to contribute toward a foundation for additional research on factors relevant to ESAs.

At the time of enrollment in the study, participants had not yet obtained their ESAs. All participants adopted shelter animals as ESAs from the Toledo Humane Society, through the HARP program. As per HARP program criteria, each participant was offered the option of adopting a dog (one year of age or old) or a cat or kitten. Each participant selected their respective ESA, in consultation with humane society staff who helped guide them to candidates based on their expressed preferences. Animal care needs, size, temperament, and energy level are all considerations discussed pre-adoption with humane society staff. Seven participants adopted a cat or kitten (58%) and five adopted a dog (42%). One participant withdrew from the study, resulting in a final sample size of 11 participants. From the time of ESA adoption to the completion of this study, each participant resided with their respective ESA about 12 months. See Table 1.

Table 1. Description of sample

	N	%
Gender
Male	2	22
Female	9	78
Ethnicity African American	3	27
Multi-Racial	2	18
Caucasian	6	55
Diagnosis
Major Depressive Disorder	5	45
MDD + PTSD	1	9
MDD + GAD	1	9
Bipolar Disorder	2	18
Schizoaffective	1	9
Schizoaffective + PTSD	1	9
Pet Type
Cat	6	55
Dog	5	45
	n	Mean	SD	Min	Max
Age	11	52.46	7.51	40	74

Hypotheses and Design

To explore how living with ESAs impacted aspects of mental recovery for adults with SMI, research hypotheses were derived from the related literature delineated in the previous section. To explore these hypotheses, our team developed a research evaluation plan comprised of three components: 1) evaluation of any changes in bonding and stress biomarkers; 2) evaluation of any changes in depression, anxiety, and loneliness; and 3) qualitative interviews to obtain lived experience data.

Biomarker Hypotheses

H1: Participants will experience a significant increase in oxytocin after 10-minute interactions with ESAs

H2: Participants will experience significant decreases in cortisol and alpha amylase after 10-minute interactions with ESAs

Depression, Anxiety and Loneliness Hypotheses

H3: Participants will experience a significant decrease in anxiety symptoms at 12 months post-ESA placement

H4: Participants will experience a significant decrease in depression symptoms at 12 months post-ESA placement

H5: Participants will experience a significant decrease in loneliness at 12 months post-ESA placement

Data Collection and Measures

A 12-month longitudinal, mixed method case study design was utilized. All study protocols and processes were reviewed and approved by the University of Toledo Institutional Review Board prior to commencing. Participants adopted shelter animals (dogs or cats) through HARP as ESAs, remained enrolled in HARP, and were followed for a twelve-month period from their respective ESA adoption dates. All study procedures were reviewed and approved by the University of Toledo Institutional Review Board prior to the study commencing. As with all ESAs placed through HARP, animal welfare was monitored on an ongoing basis through the HARP Program, in accordance with HARP’s operation policies. Data was collected from participants at their homes by the principal investigator and/or a trained research assistant via: salivary biomarker samples (pre-ESA placement and 1, 3, 6, 9, and 12 months post-ESA placement); depression, anxiety and loneliness scales (pre-ESA placement and 12 months post-ESA placement); and open-ended questions comprising a qualitative interview (12 months post-ESA placement).

Biomarker Data Collection

To see whether physical interactions with the ESAs were associated with oxytocin release and subsequent decreases in cortisol and/or alpha amylase, biomarker data was collected. Oxytocin activity was measured using a RayBio Enzyme Immunoassay Kit (RayBiotech, EIA-OXT, Norcross, GA). Cortisol activity was determined using Salimetrics Enzyme Immunoassay Kit (Salimetrics, I-3002, State College, PA). Alpha-amylase activity was measured using a kinetic enzyme assay kit (Salimetrics, I-1902, State College, PA). Prior to ESA placements, saliva samples were collected from each participant to establish a baseline in each of these biomarkers. The passive drool approach was used for all saliva collection. One-month post ESA placement, a home visit was conducted to: 1) obtain a saliva sample at the beginning of the visit; 2) have the participant do a focused pleasant interaction (stroke, hold, play with, talk to) their respective ESA for a period of ten minutes, and; 3) obtain a second saliva sample following ten minutes of focused interaction with the ESA. Samples were stored in a mobile cooler and transported to the University X Cardiopulmonary and Metabolism Research Laboratory (CMRL) for storage and analysis. This process was repeated at three months, six months, nine months, and twelve months from ESA placement. Samples were stored at -80 °C until the analysis. The time of day of saliva was collected varied due to participant schedule constraints. This was a methodological weakness, as due to a circadian rhythm cortisol peaks in the morning and declines throughout the day (Mohd Azmi et al, 2021).

Data Collection on Depression, Anxiety, and Loneliness

To examine whether the presence and severity of depression, anxiety, and loneliness changed over time after ESA adoption, standardized measures with strong psychometric data – the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), and the University of California Los Angeles (UCLA) Loneliness Scale Version 3 – were used to respectively operationalize these concepts. In an evaluation and meta-analysis of psychometric properties of the BDI, a mean coefficient alpha of .81 for nonpsychiatric patients was found; mean correlations of BDI with clinical ratings were .72 for psychiatric patients (Beck et al, 1988). Within a meta-analysis, the BAI was found to have high internal consistency (.91) and good test-test reliability (.66) in clinical samples (Bardhoshi, Duncan, & Erford, 2016). In an evaluation of the UCLA Loneliness Scale Version 3 psychometrics, Russell (1996) found that the measure was internally consistent (.89 to .91) with good test-rest reliability (.73); convergent validity was found through strong correlations with other measures of loneliness. The BDI, BAI, and UCLA Loneliness Scale Version 3 were completed by participants at their homes prior to ESA adoption and at 12 months post-ESA adoption. All information was entered into SPSS 24.0.0.0 for analysis.

Qualitative Data Collection

At 12 months post-ESA placement, the principal investigator completed in-person, semi-structured, digitally recorded interviews with participants. Interviews were completed in each participant’s home and lasted between forty minutes and two hours. The interview question format was derived from a qualitative questionnaire developed by Charmaz (2003) to generate a data-driven explanation of how phenomena occur through concrete experience and social processes. Questions were adapted for this specific study through qualitative data from a previous unpublished study with 3 HARP participants. All interviews were professionally transcribed and uploaded into ATLAS.ti.8 for analysis.

Results

Biomarker Analysis and Findings

All biomarker salivary analysis was conducted in the Cardiopulmonary and Metabolism Research Laboratory at the University of Toledo by Dr. Barry Scheuermann, co-investigator on this evaluation. Oxytocin concentration was determined using a RayBio Enzyme Immunoassay Kit (RayBiotech, EIA-OXT, Norcross, GA) with an inter-assay CV of 15%, a minimal detectable concentration of 3.6 ng/ml and a range of 0.1 to 1,000 ng/ml. Cortisol concentration was determined using Salimetrics Enzyme Immunoassay Kit (Salimetrics, I-3002, State College, PA) with an inter-assay CV of 20% and a functional sensitivity concentration of 0.028 ug/dl. Alpha-amylase activity was measured using a kinetic enzyme assay kit (Salimetrics, I-1902, State College, PA) with an inter-assay CV of 5.8%. The lower limit of sensitivity was determined by the change in absorbance corresponding to 2.0 U/ml. A calibration curve was determined for each plate and used to calculation the final concentrations (cortisol, oxytocin) or activities (alpha-amylase). Each saliva sample was measured in duplicate and the average optical density (OD) for the paired samples was used for further calculations.

Values for each individual measure at each time point was entered into a spreadsheet for statistical analysis. A two-way analysis of variance with two repeated measures (time vs. before and after focused interaction) was used to examine possible differences. A significant F-ratio was further analyzed using the Student-Neuman Keuls post hoc test, when appropriate. While there were observable patterns of decrease in cortisol and increase in oxytocin after focused ten-minute ESA interactions, and the highest oxytocin increase occurred at 12 months (see Figures 1 and 2), results of the analysis indicated these changes were not statistically significant, nor were there significant differences across the duration of the study (i.e. no main effect for time). Analyses were also run using a non-parametric test, e.g., the Friedman test, and no statistically significant differences were detected.

Figure 1

Figure 2

There was no consistent pattern in alpha-amylase level changes (see Figure 3).

Figure 3

Data Analysis and Findings on Depression, Anxiety, and Loneliness

Paired sample t-test were conducted to explore whether there was a relationship between the intervention (adopting and living with ESA for 12 months) and participants’ scores of loneliness, depression, and anxiety on the respective instruments. Analysis conducted to examine the impact of intervention on participants experiences of loneliness indicated that there was a statistically significant decreases in UCLA Loneliness Scale scores from Time 1 (M=59.20, SD=9.47) to Time 2 [M=49.90, SD=13.66, t(10)=3.80, p=.004]. The eta-squared statistic (.62) indicated a large effect size. Results further showed that 18 of 20 items on the loneliness scale scored a lower mean value after intervention; of these, 4 were statistically significant. See Table 2. The loneliness scale item in Table 2 pertaining to finding companionship was reverse-scored, and who companionship was found from (e.g., from humans, the ESA, or both) was not defined beyond what was presented on the scale instrument. While the UCLA instrument has been widely utilized in studying the effects of animal companionship on people, such vagaries having been increasingly identified as issues, and it was recently recommended that a new instrument be developed to explicitly measure such (Gilby & Tanni, 2020).

Table 2. UCLA Loneliness Scale

Scale Item	Time 1	Time 2	t(p)
	Mean (SD)	Mean (SD)
Feel that you lack companionship	3.81(.40)	2.18(.98)	5.87(p=.001)
Feel alone	3.36(.67)	2.18(.75)	4.48(p=.001)
Feel isolated	3.63(.67)	2.54(1.12)	3.18(p=.01)
Feel can find companionship	2.90(.83)	2.09(1.13)	2.32(p=.04)
UCLA Loneliness Scale	59.20(9.47)	49.90(4.32)	3.80(p=.004)

Paired sample t-test conducted to examine the impact of intervention on participants experiences of depression indicated that there was a statistically significant decrease in Becks Depression Inventory (BDI) total scores from Time 1 (M=21.09, SD=8.43) to Time 2 [M=14.64, SD=7.03, t(10)=2.48, p=.03]. The eta-squared statistic (.41) indicated a large effect size. Results indicated that on the BDI scale 19 out of 21 items scored a lower mean value after intervention; 5 of which were statistically significant. See Table 3.

Table 3. Significant Items and Total Score for Beck’s Depression Inventory (BDI)

Scale Item	Time 1	Time 2	t(p)
	Mean (SD)	Mean (SD)
Discouraged about future	.90(.83)	.36 (.50)	2.20 (p=.05)
Being punished	1.09(1.04)	.36 (.50)	2.39(p=.04)
Critical of myself	1.27(.64)	.90(.70)	2.39(p=.04;
Lost interest in other people	1.09(.70)	.54(.52)	3.46(p=.006)
Problem sleeping	1.63(1.02)	.63(1.02)	3.70(p=.004)
BDI Total Score	21.09(8.43)	14.64(7.03)	2.48(p=.03)

Paired sample t-test conducted to examine the impact of intervention on participants experiences of anxiety indicated that there was a statistically significant decrease in Becks Anxiety Inventory (BAI) scores from Time 1 (M=23.55, SD=9.81) to Time 2 [M=17.73, SD=11.79, t(10)=2.24, p=.049]. The eta-squared statistic (.36) indicated a large effect size. There were not statistically significant changes in individual mean item scores on BAI.

To examine whether there were significant differences in participants’ experiences of loneliness, depression, or anxiety in term of gender, ethnicity, pet type, age, and diagnosis, Mann-Whitney (IV 2 categories) and Kruskal-Wallis H Test (IV 3 categories) were conducted for pre-and-post intervention data. An examination of pre and post UCLA, BDI, and BAI scores indicated that after intervention there was a statistically significant difference in participants experiences of loneliness by gender (U =.50, p=.045) with a mean rank of 10.25 for males and 5.06 for females. That is, women reported lower levels of loneliness after the intervention as compared to men. There were no other significant mean rank differences in UCLA, BDI, and BAI scores related to gender for pre-post conditions.

The species of ESA was related to reported differences in depression levels of the participants. Twelve months after ESA adoption, there was statistically significant difference in participants experiences of depression by ESA species (U=26, p=.044) with a mean rank of 4.17 for cat and 8.20 for dogs. Individuals with feline ESAs experienced lower levels of depression twelve months after ESA placement. The type of ESA the participant interacted with did not have any other significant mean rank differences in UCLA, BDI, and BDA scores for pre-post conditions. Results suggest that prior to ESA placement, younger participants reported higher levels of loneliness as compared to older participants. Prior to intervention there was a statistically significant difference in loneliness by age [H (2) = 6.16, p=.046] with a mean rank of 10.50 for participants younger than 50, 5.50 for participants in the age category of 50-59, and 1 for participants who were greater than or equal to 60. Age did not have any other significant mean rank differences in UCLA, BDI, and BDA scores for pre-post conditions.

Results also suggest that the type of diagnosis affected depression levels among the participants prior to ESA placement. Individuals with co-occurring mood and anxiety disorders had higher levels of depression prior to ESA placement. There was a statistically significant difference in participants recordings on depression scale by diagnosis (U=24, p=.014] with a mean rank of 10.00 for participants diagnosed with mood and anxiety disorder and participants diagnosed with mood disorder reported a mean rank of 4.5, study participants did not have any other significant mean rank differences in UCLA, BDI, and BDA scores for pre-post conditions. There were no other significant mean rank differences in UCLA, BDI, and BAI scores for pre-post conditions by ethnicity.

Qualitative Data Analysis and Findings

According to Longhofer and colleagues (2013), substantive significance is defined as “… the consistency of a theme across and within study participants”. To identify themes of substantive significance related to the experience of having an ESA, a thematic analysis approach was used. Inductive open first-level coding was completed by the principal investigator, using in vivo language from the participants; e.g., “good listener” and “kept me on even keel”. After open coding was completed, codes were compared, sorted and coded into more abstract codes using both inductively derived higher level codes and the following “a priori” codes identified from the human-animal interaction (HAI) literature: psychological benefits; social benefits; emotional benefits; and physical benefits. Coding continued until all data had been accounted for and integrated into umbrella themes that provided an explanatory framework. Through integrating the vivo themes within the empirically established HAI benefits, processes emerged that served to help explain how HAI benefit were conveyed. While mental health recovery goes beyond traditional mental health outcomes such as symptom reduction, to limit scope and focus, themes and analysis related to psychological benefits are reported in this article. Additional qualitative findings related to broader mental health recovery outcomes will be presented in a future manuscript.

Five unique constructs related to psychological HAI benefits emerged from the qualitative interviews: Global mental health improvement, Behavior activation/motivation, Comfort/affection, Distraction from symptoms, and Soothing/calming (Table 5). All participants voiced experiencing overall global improvement in mental health, which they attributed to having their respective ESAs. Similarly, all participants reported that their ESAs served to motivate them and activate behaviors related to better self-care and daily routine, which they then associated with improvements in mental health. All participants also made a reference to their ESA as being a source of comfort which they reported helped them to “feel better”. Distraction from mental health symptoms through ESAs engaging their attention was referenced by six of eleven participants. Seven of the eleven participants reported that their ESAs were soothing/calming to them, which they associated with reductions in symptoms (anxiety, crying, feelings of sadness, agitation). These participants related the soothing/calming feeling with touching/cuddling/direct physical contact with their ESAs, who were engaging in proximity-seeking behavior with them.

Table 5 Qualitative findings of perceived psychological HAI Benefit

Construct	Sample quotes
Global mental health improvement	•“If it wasn’t for him, there’s no telling where I would be at right now. Mentally, physically, and emotionally, I’m better. That is how I feel about [ESA name]. [ESA name] has did what he was supposed to do and then some.’•“I still have anxiety and depression, but I have a lot more minutes during the day where I’m smiling. Because of him [the ESA]. I have a little more hope now. I actually look forward to things …”•“My mental health is much better than what it was before [getting the ESA]. I’m happier, more content. She makes me laugh.”•“She’s been really helpful over the past year. She’s helped with my depression, having her here.”
Behavior activation/motivation	•“… It was something to get up for when before I couldn’t get up, when I didn’t feel like getting up, when there wasn’t anything to get up for … There was no accountability. But she wakes me because she is hungry. It’s like oh yeah, okay kit. When she licks my ear or– I have to put a blanket over my face. If she licks my ear or eyebrow or something, it’s like yeah, I am getting up.”•“I am out more. I am at the park every day because I feel like he has to have a walk. He is the one that gets me out the door for that. I would never go to the park otherwise.”•“She made me love her to the point where yes, I want that responsibility. I see what it’s helping me do. It’s helping me get up and do things I can’t do for just myself. That is getting up and do more than get a cup of coffee. I have to get up and feed somebody else and make sure they got their coffee.”
Comfort/affection	•“She is comforting to me when I am feeling sad or don’t feel good.”•“He’s been a huge comfort to me, he really has, helps lift my spirits.”•“When I’m not feeling well, having a moment, she helps me feel better, gives love and attention.”
Distraction from symptoms	•“She knows I am sad. She will just come over and start nibbling and licking on my toes. Why are you biting me? I didn’t do anything, I am just sitting here. I am not even calling you or playing with you. But yeah, she does that. I say yes [ESA name], I know, I am better. I am not thinking about it, I am good. Without her I think I would have been locked up somewhere because I lost my mind. Depressed.”•“.because when my head is getting full and overwhelmed with things, I can’t get stuck in that because I have her to focus on, she comes up and it gets me out of my head.”
Soothing/calming	•“When I’m not feeling so good, mood- or nerve-wise, he gives me that cute little look and will cuddle his way next to me, and we chill.”•“She is helping keep me even keeled. I think about a year ago if I had been in the situation I have been in lately, a year ago I would probably be in the hospital right now, but she sits on me and keeps me even.”

Discussion

Given the lack of statistical significance in biofeedback measures, the statistically significant improvements on self-report measures of anxiety, depression, and loneliness, and the positive accounts of ESAs as beneficial for mental health within qualitative interviews, this study yielded mixed results. Insights from qualitative findings into the mechanisms for how ESAs were perceived to promote aspects of mental health recovery aligned with prior literature and provide positive support for ESA companionship as an intervention. Given the lack of design controls, the statistically significant decreases in participants’ BDI, BAI, and UCLA Loneliness Scale Scores can certainly be related to factors other than ESAs over the 12-month study period. These findings are consistent with prior research showing reductions in loneliness (Powell et al, 2019) and attenuated anxiety and depression symptoms (Hughes et al, 2020) associated with adult involvement with companion animals. As the first empirical study to quantify such as related to ESAs, there is no previous literature on ESA benefits with which to benchmark these findings. It is the authors’ hope that this data may serve as preliminary benchmarks for future related research. There were no controls within this study, and participants continued to utilize ongoing services with their respective mental health providers during this time. These quantitative findings thus need to be interpreted with caution, as a beginning step toward developing an empirical understanding of how ESAs can partner with humans to support mental health recovery.

Within the 12-month post-ESA adoption qualitative interview data, participants unanimously endorsed their respective ESAs as a pivotal factor in their self-reported mental health improvements, citing ESAs as both ameliorating specific symptom experiences and contributing to overall mental health improvement. Numerous examples were given in the qualitative data in which the participants experienced some form of anxiety and/or depression symptoms and obtained partial or at times total relief after interaction with their respective ESAs. In some instances participants reported initiating the contact with their ESAs, whereas at other times participants reported that their ESAs “knew” they were struggling and initiated contact with them without prompting, which distracted from psychiatric symptoms and/or offered direct physical contact that participants found comforting. Qualitative findings from this study are consistent with the previous literature on mental health recovery-related benefits of animal companionship reported by individuals with SMI; in addition to comfort and support, ESAs were perceived to provide a range of related benefits (Wisdom et al, 2009; Zimolag & Krupa, 2009; Brooks et al, 2016).

Biomarker data findings were not statistically significant; however, the data did demonstrate a pattern of increases in oxytocin and decreases in cortisol after participants engaged in 10-minute focused positive interactions with their ESAs. This pattern is supported by the literature which indicates an increase in oxytocin post human-animal interaction (e.g. Nagasawa, 2015; Vincent, 2019). The biomarker patterns displayed by the oxytocin and cortisol data can be situated within qualitative findings, e.g. participants reporting petting their ESAs (associated with oxytocin release) and then “feeling better” (associated with oxytocin increase and cortisol decrease).

Due to participant schedule constraints, biomarker data was collected at varying times during the day. Ideally, due to the daily diurnal rhythm cycle entailed in cortisol release, saliva samples of cortisol would be taken at the same time each day for a given participant; this may have served as a confound in cortisol measurement. The small sample may also have precluded detection of any significance in the observed changes in oxytocin and cortisol. Future research should utilize a larger sample and collect saliva samples at consistent times for participants. While widely considered a marker of sympathetic nervous system activation, reliability, and generality of salivary alpha amylase as an indicator have not been consistent (Petrakova et al, 2015). The lack of a pattern in alpha-amylase after ESA interactions might be related to the small sample size, and/or inconsistency issues reported in previous literature.

As an exploratory pilot study, limitations are numerous and important to keep in mind. Findings of this study are not generalizable; this was not a randomly selected or assigned sample, and there was no control or comparison group. Rather, findings from this study offer a rationale for additional and more nuanced research on ESA benefits. For instance, findings indicated differences in participant experiences based on demographics, diagnoses, and animal species; such warrant additional investigation. This study demonstrated feasibility of collaboration between a humane society, a human healthcare system, and a university to run an ESA placement program. Findings indicated improvements in human and animal well-being, consistent with the One Health approach; homeless animals from humane societies were reported to be excellent ESAs who conveyed benefits of HAI, and the people who benefited in turn provided caring homes for animals in need. Evaluation, replication, and expansion of partnership models such as HARP – which leverage mutually beneficial bonds between people and animals – offer promise for both human and animal well-being.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563823/

The service animal, usually a dog, is an animal that is specially trained to perform tasks for an individual with a disability. The disability can be psychiatric in nature, but the animal must be tasked trained to assist with that disability.

Some of these tasks include attending to an individual’s mobility and activities of daily living.

Helping to remind an individual to take their medication.

Assisting an individual during and /o after a seizure.

Supporting an individual with autism.

Applying sensory commands such as lying on the person or resting their head on the individual’s lap to help the individual regain behavioral control.

Service dog verification works via an honor system, which can be problematic, especially in the case of a psychiatric service dog where the disability may not be visible. In addition, their is no requirement for professional training. Under the Americans with Disabilities Act (ADA) individuals with disabilities, including those of a psychiatric nature, can bring their service animals into places where dogs may not be allowed. This does NOT include private clubs, religious organizations, or places of worship that ARE NOT open to the public.

Emotional Support Animals, or ESAs, DO NOT qualify as service animals under the ADA and are considered pets. They are no longer allowed in aircraft carrier cabins after the US Department of Transportation revised this act in December of 2020. They ARE still covered under the FAIR HOUSING Act.

Research has shown that service animals are able to help owners gain a greater degree of independence and participate in everyday outings that may otherwise had been a struggle. Overall, service animals are known to improve owners’ quality of life. ESAs, on the other hand are not evidence-based treatment for psychiatric disorders nor are they specifically trained to help with one. Pets however are known to benefit patients with mental conditions through the development of a strong bond and the contribution they make to emotional support in times of crisis.

Mental health professionals documentation?

A mental health professional can write a letter for a patient at their request, stating they have an emotional disability they are being treated for and the letter should be given to the patient to use as he / she /they deems fit. Patients should be encouraged to have the animal pass a standard basic obedience test as given by the AKC. You as a mental health professional can not vouch for the behavior of the animal.

If the letter is for documentation for a service animal, it can include how the animal helps alleviate symptoms of the patient’s condition. I strongly recommend referral to professional trainers that have a background in the mental health field so a coordinated treatment plan can be devised. The trainer is also able to write a letter stating how the animal is trained to assist.

Writing a letter for a patient confirming a dog is needed to assist with a disability does not make that animal a service animal. There are no current standards for conducting evaluations to determine the need for a service animal or ESA. This letter is your recommendation. If written, you should be able to defend your recommendation in a court of law. It is a crime to fraudulently certify an animal as a service animal in some jurisdictions, and such conduct could result in disciplinary action by your licensing board. There are cases where having an animal may be harmful or may worsen a psychiatric condition.

In summary, I am a strong advocate for canines in helping psychiatric patients both as ESA’s and psychiatric service dogs. I do believe there are certain situations where a dog is necessary for the most optimal functioning of a patient, especially where response to medication is only partially effective. In advocating for patients, animals must be tasked trained and should be able to pass basic obedience testing. If a patient has not been able to demonstrate this training, then a letter should not be written. The patient also must be responsible, and can care for the needs of the animal. In the case of an assistance animal helping a patient with dementia, arrangements need to be made for the care of the animal as well.

At Puppies with a Purpose we love to see articles written about Animal Assisted Therapy and its positive effects on humans.

The following is an article from TIME Magazine written by Alexandra Sifferlin. Thank you for reading!

During a couples-therapy session, therapist Ellen Winston of Lakewood, Colo., brought along her assistant, Sasha — who happens to be a dog.

The couple were dealing with behavioral problems in their children and, on top of that, getting a divorce. “The split was not entirely amicable, and there were very hurt and angry feelings all around,” Winston says. “The parents struggled to have a civil conversation and it often escalated into yelling, and then tears, on both sides.”

During the sessions, the couple would sit on complete opposite sides of the couch. Sasha would hop in the middle, curl up and fall asleep. Both partners would stroke Sasha at particularly emotional moments, and it helped them calm down. Still, they continued to get agitated, often letting therapy sessions intensify into screaming matches. When that happened, Sasha would quickly get up and walk to the door. Winston used those moments as teaching points.

“We [discussed] that if this is how they interact regularly, their children were likely also picking up on their moods and acting out as a result. This was one of the first times they realized that their children may be impacted by the parents own relationship.”

Winston’s sessions are one of the ways animal-assisted therapy is changing. Animal-assisted therapy is different from service animals who accompany someone dealing with anxiety or depression. Those are certified as emotional-support animals (ESA), who are daily companions and covered under the Americans With Disabilities Act. Therapy animals, on the other hand, are meant to be used in counseling, whether a professional session or an informal one. Although the American Psychological Association and the American Psychiatric Association have no formal position on animal-assisted therapy, there’s evidence that small practices and individuals are exploring it. Animals are appearing in all sorts of places: in emergency rooms, prisons, juvenile-detention centers, nursing homes and, increasingly, your therapist’s office. There are no official numbers yet, but Pet Partners, a nonprofit that registers animals for animal-assisted therapy use (the largest organization to do so in the U.S.), says there were more than 1 million reported interactions between registered animals and patients last year. This number includes everything from nursing-home visits to therapy sessions.

Kathryn Kimbley, director of HumAnima CIC, an animal-assisted therapy service in West Midlands, England, brings her therapy dog Flossie to individual sessions with clients, as well as to larger groups, to comfort patients with depression, behavioral problems or even mental-health issues like PTSD. “Dogs can act very much like a social catalyst. In various settings they will encourage people to interact with one another,” Kimbley says. “It lifts the mood and makes people feel better.”

Kimbley has found that her clients feel more at ease talking to her when they’re physically distracted. “If someone is talking, they might sort of tap their foot or fidget. They have this energy they want to redirect somewhere, and they have no outlet for it. So if Flossie is in this situation, it is much easier for them.”

A therapy pet can also modulate a relationship between a client and his or her counselor. “You are dealing with powerful and overwhelming emotions, but you can’t hug a client,” says Kimbley. “With a dog present, that need is therefore met.”

Emerging research confirms the benefits of pets on people. A 2009 study found that preschool kids with special needs were better able to follow directions during assigned tasks if they were with a trained poodle than when they were alone, with another human or with a stuffed animal dog. Other research has shown that animals are social facilitators: people tend to be viewed as more trustworthy if they have a pet, and pets are known to instigate more conversations among strangers. Animals can also lower a person’s anxiety level. “You can see some of the same changes in physiological response from looking at a fish tank as you do with petting a dog, cat or a horse,” says Sheryl Pipe, an adjunct professor of anthrozoology (the study of human-animal interaction) at Canisius College in Buffalo, N.Y. “But in terms of social facilitation, that is better suited for mammals.”

Of course, there are certain people who don’t respond well to animals in their sessions, and therapists need to distinguish between those who will benefit and those who need pet-free space. And not just any animal will work. Therapy animals are most successful when they’re a bit older and have more experience. There are no set guidelines for training animals used in therapy, and many groups use their own rubrics. Kimbley makes sure her animals are properly socialized and can react normally in a variety of situations.

But, Pipe warns, a therapy animal should be considered a partner rather than a tool. “We tend to have a greater willingness to consider the impact on our partner than our tools. We have to make sure an animal is happy participating and still has adequate time to behave like the animal that they are,” says Pipe.

“The field is still relatively in its infancy, but the data that’s beginning to come in is really encouraging in terms of how impactful this work can be.” Man’s best friend, it seems, can also be man’s best medicine

Campuses Debate Rising Demands for ‘Comfort Animals’

By JAN HOFFMANOCT. 4, 2015
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Mary McCarthy and Carl, her rabbit, with her roommate, Rachel Brill, and her dog Theo, in their campus apartment at St. Mary’s College of Maryland. Carl and Theo are emotional support animals, permitted by the college to live on campus. Credit Drew Angerer for The New York Times

ST. MARY’S CITY, Md. — Rachel Brill and Mary McCarthy are seniors and longtime roommates at St. Mary’s College of Maryland. This year, they share their four-bedroom campus apartment with two other female students. Also, Theo and Carl.

Theo, easygoing and unflappable, is a tawny, 103-pound, longhaired German shepherd. Carl, an energetic charm magnet, is a jet-black, 1.5-pound Netherland Dwarf rabbit.

House rules: Carl must reside in a pen under Ms. McCarthy’s raised bed; Theo snoozes in a crate in Ms. Brill’s bedroom. Carl cannot be let loose in the living room, where Theo likes to hang out. “We’re still very careful because we don’t want there to be an issue with Theo and Carl,” Ms. McCarthy said. “We’re both very anxious people.”

And that is exactly why Theo and Carl have permission to live in campus housing.

Like many schools across the country, St. Mary’s, a small, public liberal arts college, is figuring out how to field increasing requests for animals by students with diagnosed mental health problems. Last fall it began allowing “comfort animals” for students like Ms. Brill, Theo’s owner, who has anxiety and depression, and Ms. McCarthy, Carl’s owner, who gets panic attacks.
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“When I feel a panic attack coming on,” Ms. McCarthy said, “feeling his heartbeat helps me regulate my own.” Credit Drew Angerer for The New York Times

Anxiety, followed closely by depression, has become a growing diagnosis among college students in the last few years. The calming effect of some domesticated animals has become so widely accepted that many schools bring in trained therapy dogs to play with stressed students during exam periods.

But as students with psychiatric diagnoses are asking to reside on campus with their own animals, schools with no-pet housing policies are scrambling to address a surfeit of new problems. How can administrators discern a troubled adolescent’s legitimate request from that of a homesick student who would really, really like a kitten? If a student with a psychological disability has the right to live with an animal, how should schools protect other students whose allergies or phobias may be triggered by that animal?

The topic is being hotly debated by college housing and disability officials in the wake of discrimination lawsuits filed by students who were denied so-called emotional support animals. Last month, on the eve of a trial in a case closely watched by administrators, the University of Nebraska at Kearney settled with the Justice Department, agreeing to pay $140,000 to two students who had been denied support animals, and spelling out protocols for future requests. Recently, a federal judge refused to dismiss a similar case against Kent State University.

“The disabilities services people are all looking at what they need to do to make this work,” said Jane Jarrow, an educational disabilities consultant who is teaching “Who Let the Dogs In?” — an online course about emotional support animals — for the fourth time this year. “We’re way past pretending it’s not going to happen.”

In the years before support animal lawsuits, universities found it relatively easy to say no to requests for animals. But now, said Michael R. Masinter, an expert on disability law at Nova Southeastern University in Florida, “schools think it’s easier to say yes than no because property damage is cheaper than litigation.”

Perhaps that explains the 95-pound pig that a freshman was allowed to bring to her second-floor room at Washington State University. Unfortunately, when led to the stairs, the pig balked. The freight elevator made him anxious, too. So he stayed in the dorm room and used a litter box.

“The other students thought the pig was kind of cool, but less cool when it began to smell,” recalled Hannah Mitchell, the dorm’s residential director at the time. “We talked about bathing it. But dorm bathrooms aren’t built for washing animals.”
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A washing machine designated for students with animals protects students with animal allergies. Credit Drew Angerer for The New York Times

Pig and student transferred to a dorm with ramps. Eventually, both moved off campus. Custodians said the dorm room’s carpeting had been chewed-up, the furniture gnawed and closet doors knocked off.

The overwhelming majority of support animal requests are for dogs and cats. But schools have had requests for lizards, tarantulas, potbellied pigs, ferrets, rats, guinea pigs and sugar gliders — nocturnal, flying, six-ounce Australian marsupials.

Clearly, many requested animals are students’ pets. But what is the difference between an emotional support animal and a pet that also provides support?

The distinction depends less on the animal and more on the student: whether the student has a diagnosed psychiatric disorder, and can document that the animal is therapeutically necessary.

“Do we have people trying to get their pet across as an assistance animal? Sure,” said Jamie Axelrod, director of disability resources at Northern Arizona University, where requests for support animals rose to about 75 last year from a handful a few years ago. “Do we have people who legitimately require one? We do.”

“You have to rely on a treatment provider’s ethical sense that they’re doing what’s right for their patient,” Mr. Axelrod added. “But it’s a new gray area.”

Research on the therapeutic value of animals is limited. Some studies have shown that they can provide a short-term benefit, particularly in reducing anxiety and depression. A long-term therapeutic benefit, however, has not been definitively established by randomized control trials.

Joanne Goldwater, associate dean of students and director of residence life at St. Mary’s College of Maryland, is not concerned about objective evidence. “Having that animal has clearly helped to reduce stress and anxiety for some students,” she said, “which helps them progress towards their degree.”

Students concur. Ms. Brill, a film major, wrapped her arms around Theo’s neck. “Theo helps me when I’m feeling isolated and depressed,” she said. On wobbly days, he gives her structure, she added, because she must get out of bed to feed, brush and walk him. “All I have to do is look at Theo, squish his face a lot in the evenings, and he’s like, ‘Hey, I love you!’ ”

Her roommate Ms. McCarthy, a psychology major, tucked Carl into her neck, stroking his silky fur as he eagerly nuzzled her ear. “When I feel a panic attack coming on, feeling his heartbeat helps me regulate my own,” she said.

And animals have inspired creative compromises. At St. Mary’s, animal owners must do their laundry in designated washing machines and dryers to avoid cross-contamination with the clothing of students with animal allergies.

At Western Washington University, a student asked to keep her six-foot snake. But the school prohibits “live feeds,” said Karen M. Walker, the associate housing director. The solution? Frozen mice, served thawed — a solution amenable, so far, to the school, student, suite mates and snake.

Whether schools must permit support animals depends, generally, on federal housing law. The Nebraska suit was filed by the Justice Department in 2011 on behalf of Brittany Hamilton, whose four-pound miniature pinscher, Butch, would put his paws on her shoulders to quell her anxiety attacks. She wanted Butch to live in her university apartment. The university said no.

But in 2013, a federal judge ruled that the university’s residences were bound by the Fair Housing Act, which protects individuals with disabilities from discrimination. Among the act’s “reasonable accommodations” for residents with psychological disabilities are animals that provide emotional support.

While the consent order in the Nebraska case last month is not binding on other colleges, it lays out some guidelines. The university can deny a request if the animal is too big for the quarters or aggressive, or damages property.

And if a student’s documentation looks insufficient, a school can contact the student’s medical provider — a pushback against emotional support animal letters downloaded on the Internet or churned out by cybertherapists who, for fees of up to $150, will Skype with the student and then issue the document. Universities have been circulating a watch list of such practitioners.

Some institutions are managing the issue with a matter-of-fact attitude. “We use our code of conduct for animals as well as people,” said L. Scott Lissner, the Americans With Disabilities Act coordinator at Ohio State University. “We don’t let our students walk across campus and lick people unless it’s welcome, so we don’t let the dogs do it. We don’t let students howl all night.” And, he added, “they can’t go to the bathroom wherever they want.”

“Myles” of Service

     Until recently, my repertoire of life-skills gave me the ability to successfully manage my intermittent anxiety so that I could function normally in life. Like most people, I worked hard, enjoyed great times with friends and family, traveled, managed my finances, enjoyed hobbies, and was always looking for new ways to enrich my life. Anxiety was something that I had never actually identified with or considered to be an issue that required my attention. That is until my mind and body were bombarded with extreme symptoms of dreadful thinking, dizziness and unexplained panic that ultimately consumed me. My life as I knew it essentially stopped. I existed in a perpetual loop of stress hormones racing through my body causing unexplained bodily symptoms and, of course, generating more fear. Like most adverse things that I have faced in my life, I made a decision to approach this new condition in a logical, well-tested manner. Most evidence-based research at the time showed that psychotherapy, coupled with anti-depressant medicines (SSRIs), were the most effective treatment of anxiety, so I embarked on a newly found mission of putting this anxiety stuff behind me.

     I was familiar with the benefits of talk therapy, and had also seen the effectiveness of medicine in treating people with both depression and anxiety. These two approaches seemed acceptable to me so I embarked on my own individual therapy and scheduled an appointment with a psychopharmacologist. The well-known SSRI, Celexa, was prescribed to me and I began my regimen, as advised, with a very small dosage that was to be increased with time. Surprisingly, the side effects that I experienced after taking my very first dosage so severely increased my panic symptoms that I made a frantic call to my doctor and climbed into bed to ride out the storm. This led to a series of bi-weekly appointments – each offering a different prescription of intolerable anti-anxiety medication intended to calm down my central nervous system. As each new pill failed to provide relief, my doctor finally informed me that she had no other medication to offer me. Her intuition was that I had linked my anxiety to medication and it was the anxiety that was interfering with the effectiveness.

     One can only imagine the disappointment and terror that I felt when my doctor calmly looked at me and very directly said, “I don’t have any more medication to try.” I remember thinking that this meant I would forever live with these uncomfortable, overwhelming feelings of fear and panic that were stealing my life from me. For some reason, I remembered that in one of my many appointments with my doctor, she had casually mentioned her involvement with the organization, Puppies With A Purpose, and discussed how dogs had been proven to be an effective tool in helping people who were suffering with anxiety, and other psychiatric disorders. At the time, I didn’t really embrace the idea because I was living in a “no pet” building and didn’t understand the laws and rights associated with psychiatric service dogs. Later, when I asked her about it, she explained that my specific disorder would qualify me for a service dog, and provided me with details regarding my rights to obtain a service dog, even in a “no pet” building. I left her office that day on my newly altered mission, complete with contact information for local professionals who could help me locate and train a dog to help me.

     My individual psychotherapy continued as I began the process of finding a dog to help me cope, and my anxiety symptoms remained a constant presence in my day-to-day life. After meeting with a woman who specialized in training psychiatric service dogs, I located and adopted a dog who I quickly named Myles because he had traveled many miles from the “Shaggy-Dog Rescue” in Texas to his new home in New York City. I will always remember that day when my friend drove me north, about a half an hour out of the city, to pick up Myles, who was being delivered by way of semi-trailer truck along with many other rescue dogs from the south. As he sat on my lap for the first time on our way back to the city, he looked intently and questioningly into my eyes for an extended period of time. I remember feeling somewhat cautious, as I was trying to read him and watch his reactions, knowing very little about his temperament. After a minute or so, he sighed heavily and rested his head against my chest as if to say, “I’ll stay.”      

     Anyone who has experienced an anxiety disorder understands how pervasive one’s focus becomes on the anxiety itself. It is a vicious cycle of fearful thoughts—hormonal reactions—bodily symptoms— more fearful thoughts. It is, in fact, the symptoms brought on by the overstimulation of the central nervous system that causes many people, including myself, to withdraw from the outside world and remain in the safety zone of one’s home. Needless to say, having a dog to walk quickly breaks this pattern of avoidance, and this was the first accomplishment of Myles in his role as my unofficial service dog. I can still remember how uncomfortable and unsteady I felt during those first few weeks of walking Myles, wondering how I was ever going to survive this new responsibility.

     It didn’t take long for me to appreciate the distraction that walking Myles provided. It was hard to remain focused on my own anxiety when my new companion was exhibiting anxious signs of his own in response to his relocation – a loud, fast-moving city. Myles chased unfamiliar objects like motorized wheelchairs, lunged at dogs that he deemed threatening, and became crazed by the frolicking squirrels in Central Park. I feared that there was no way that he was ever going to be trainable, yet also noticed that I was beginning to look at life a bit differently. Nearly every walk with Myles brought a bit of new insight related to my anxiety. The controlling, perfectionistic nature of many anxiety sufferers, like myself, began to shift as Myles had his good days and his bad days. I found myself easing up on my expectations of him and relaxing more with life, in general. Change was now more acceptable for some reason. Unknowingly, Myles also reminded me that staying with him in the present moments of our walks together was a simple antidote to my fears of the future, which had previously haunted me.

     As my outlook on life improved and my anxiety symptoms began to subside a bit, Myles was enrolled in a rigorous behavior-training program designed to ready him for certification as a psychiatric service dog. Three days a week, his trainer picked him up early in the morning and worked with him, teaching commands that were easily transferrable. I learned how to reinforce his good behavior, respond to his negative behavior, and after several months of hard work, Myles finally earned a vest that allowed him to be at my side whenever I needed – restaurants, cross-country flights, doctor’s appointments and even at work.

     The recovery from my anxiety disorder has been a lengthy, ongoing process that has caused me to greatly change how I view life. By identifying the underlying factors of my anxiety in therapy, I have also been able to make some important behavioral changes in the way I have been living. I am convinced, however, that it is what Myles entered into the recovery equation that has been the most valuable. Along with helping me to exhale and relax as I began to increase my interaction with the outside world, his presence gently forced me to shift my focus to something outside of myself. Myles was probably the most helpful when I would struggle to contain the irrational fears that would unexpectedly surface. From the very beginning, he seemed to have an intuitive way about him and would come close to me when I was the most vulnerable and really locked into my fear. “Thankful” wouldn’t come close to expressing the feelings of gratitude that I have for Myles, and for the opportunity to experience such a connection with a dog, my psychiatric service dog. I am also thankful for an organization like Puppies With A Purpose that works hard to educate people on the undeniable usefulness of dogs as support for those who are struggling with emotional and psychiatric disorders.

My sister Katie is an extremely outgoing, funny, caring person who will talk to anyone for hours. She loves going out to the mall, watching movies and spending time with family and friends. However my sister Katie is very different from most other 27 year olds, she has Autism. Living with Katie is a very rewarding, but also a very challenging experience. Her funny, innocent personality can be a joy to be around but Katie also suffers from severe behavioral outbursts that my family has deemed “meltdowns”.

Her meltdowns can sometimes come out of the blue with no warning or can be a process that progressively gets worse. During a meltdown she will get very anxious and frustrated at first, which will then escalates into severe anger. She will begin screaming and acting out much like a young child having a temper tantrum. However, hers can get violent where she will throw and break things and she often tries to run away during the process.

Katie likes order and control, and a lot of her meltdowns are prompted by things not going as planned or her not getting her way. When this happens and she is about to meltdown she can sometime be calmed by having her attention averted elsewhere. Nothing is as calming and as effective at avoiding a meltdown as an interaction with a dog.

Katie has always adored dogs and they have always been a very important part of her life. When Katie is upset, being able to pet and talk with a dog is very therapeutic to her. She will talk to them and cry to them as if they are real people and this provides a channel for her anxiety to escape without having it escalate to a full meltdown. There have been many times when she is upset and she is unable to see the dogs, so she will call someone to talk to their dogs over the phone to express her emotions. The dogs don’t have to do anything but sit there and get pet, but Katie’s entire day can be positively transformed by even the slightest interaction with a dog.

Even when she is not having behavioral problems Katie is constantly thinking about the next time she will be able to see a dog. She even gets presents and cards for all the dogs she knows every Christmas. Anytime she sees someone walking on the street with a dog she stops to pet it, which allows her to have a calming social interaction in crowded places. She even began going to an animal shelter a few times a month to help take care of dogs, and we have noticed that it has helped her baseline anxiety directly after going to the shelter.

I have seen the importance that dogs have played in my sister’s life, and how beneficial they have been to helping her achieve greater happiness. There is something extremely special about the interaction of a dog and human that allows people to instantly feel better. They are a nonjudgmental, soothing, unconditional source of support. I believe therapy dogs can help so many people with a multitude of different issues and it is my hope that many more people will begin to use them.

Have you or someone you know been positively impacted by therapy dogs? We would love to hear about your experience and how it has helped you. If you would like to share your story in order to help raise awareness of the importance of therapy animals please  email puppieswithapurposeinc@gmail.com!