Do You Need A Doctor's Note For A Service Dog

It happens almost as soon as Emily steps through the door of the grocery store. "What do you think you're doing in here with that?" an employee demands loudly while moving to block her path. He's pointing in anger at the black Labrador retriever beside her. As Emily comes to a halt, her service dog, Todd, automatically sits. He's braced slightly against her leg to help her balance.

"We don't allow dogs," the employee states emphatically. "It's a health code violation."

"This is a service animal. He provides medical alert to assist me with my disability and is permitted to accompany me by the Americans with Disabilities Act [ADA]." The well-rehearsed line flows from Emily's mouth even as she feels herself flushing, aware that people are staring as they pass. She wants desperately to move farther into the store, out of the way.

"Well, what about your papers or ID? I need to see some proof," the employee insists, crossing his arms and looking at Emily in clear disbelief.

Emily replies, trying to stay calm. "The ADA doesn't permit businesses to ask for proof of disability, and there are no registries or certifications for service animals."

As the employee blusters and scoffs, Emily signals to Todd, who stands and walks with her around the employee. Thankfully, he does not follow them, but Emily still pushes down a wave of panic that he might call the police or that someone else might try to make her leave the store before she can get what she needs.

It's the end of a long day, but partway to the checkout counter, Emily realizes that she forgot to grab bread to go with tonight's dinner, so she and Todd head down the front aisle to the bakery. Along the way, Emily does her best to block out the delighted cries, sounds of surprise and conversations that break out as she and Todd pass. Emily hears one couple wondering whether she is a dog trainer because she doesn't look like she's blind. What could be wrong with her?

While looking at the choices of dinner rolls on display, Emily is startled by a shrill voice behind her. "Oh, what an adorable puppy! Can I pet him?"

Emily turns to see a woman already reaching toward Todd, who, on cue, backs partially behind Emily as she steps forward in front of him. "No, ma'am, please don't distract him. He's working."

"Oh, it's all right. I love dogs," says the woman, now trying to reach around Emily's leg to get to Todd.

"He is working," says Emily firmly. "Please leave us alone."

"Well, there's no need to be so rude about it. Why would you bring a dog if you didn't want people to pay attention to it?" exclaims the woman, glaring at Emily as she walks off in a huff.

Emily goes directly to a self-checkout to avoid more interactions with employees. By the time she reaches the car, Todd is alerting her that her heart rate is elevated. Emily sits in the car for a few minutes, shaking and breathing heavily before she feels safe to head home.

This is a common experience for people with disabilities who require service animals. For these individuals, their service animals are their lifeline, but all too often, they experience disproportionate discrimination, invasive questioning and other unwanted attention. Service dogs are becoming more common, particularly for people who have invisible disabilities. Consequently, it is more important than ever that counselors become comfortable working with service dog teams and know how to respond when clients ask whether a service dog would be helpful for them.

Defining a service animal

It is helpful to first understand what a service animal is not. Service animals are frequently confused with emotional support animals and with therapy animals.

Emotional support animals are pets that are permitted to live with or travel with someone who has a disability. They are not required to be trained in any specific way, and animals other than dogs can be designated as emotional support animals.

Many counselors are already familiar with therapy animals because they are often used in animal-assisted therapy. Therapy animals are simply animals that are used by their handlers to assist others, frequently in mental health or medical settings, but also in courtrooms and during crisis or disaster response scenarios. Often, the facility in which the handler works will impose general training or temperament requirements for therapy animals, but these animals are not expected to do specific tasks.

When it comes to service animals, there are a number of misconceptions. One of the most common myths is that service animals require a special certification or license or official documentation. In reality, there is no registry or certification for service animals that has any legal meaning. Another myth is that service dogs must be a certain breed or size, but there are actually no restrictions. In fact, many small breeds make excellent medical alert dogs and don't require the space considerations that larger breeds do.

So, what is the definition of a service animal? According to the ADA, a service animal is a dog that has been individually trained to work or perform tasks for a person with a disability. A disability as defined by the ADA is a legal term, not a medical one. Under the ADA, a person with a disability is someone who has a physical or mental impairment that substantially limits one or more major life activities.

Service animals are not pets; under the law, they are considered to be necessary medical equipment. They can be in public with their handler because their handler has a right to equal public access under the law, and the service animal performs tasks required by the handler to achieve that access. This means that outside of a few specific limitations, service animals are allowed to go anywhere that a wheelchair, walker or other assistive device can go. Just as wheelchairs are custom fit for their users, service animals are specifically trained for an individual's needs through a set of trained tasks.

Trained tasks are not actually defined by the ADA. The only thing the ADA clearly states is that comfort is not a task. This is very important, so let me elaborate. Counselors may have cause to think about and discuss with a client whether a service dog would be helpful for that client. However, if after researching categories of tasks, the answer to the question of "What would a service dog do for my client?" is anything like, "It would make them feel better when they experience anxiety," then the client cannot utilize a service animal.

Because the ADA defines only what a trained task is not, organizations such as the International Association of Assistance Dog Partners provide lists of common tasks. Generally, these tasks are broken down into categories on the basis of what the tasks accomplish (hearing, mobility, guide, medical alert, psychiatric assistance, etc.) or what "kind" of service animal might perform them. Because counselors are not typically experienced in training dogs, it is easier to start with determining broad categories of tasks that counselors believe might be helpful for their client. It is best to focus on tasks that would help the client in public because the point of public access with a service dog is that the dog is actively mitigating the client's disability and is therefore required. Counselors are likely to find several "bonus" tasks that would provide great additional benefit, but these are best added once it is clear that a service dog is necessary for the client to successfully function independently in public places.

Working with prospective handlers

In assessing whether a service animal is a good fit for a client, a simple first test is to ask:

1) Is my client disabled under the definition set forth by the ADA?

2) Is my client a suitable candidate for a service animal?

3) Are there trained tasks a service dog could perform that would help mitigate my client's disability?

Often, the first question will provide counselors with the overall answer. If the client isn't disabled, then that person won't be able to use a service animal. If the client is disabled, then the focus moves to the question of whether the client is a suitable candidate for using a service animal.

Some basic considerations for arriving at an answer to the second question include whether the client is physically and financially able to care for a dog, whether the client can handle major life changes at this point and the client's overall degree of resiliency. Service dog programs agree that potential contraindications include suicide attempts by the client in the past year, severe paranoia or psychosis and any other situation that might put the dog's safety at risk. A good candidate might have a history of bonding strongly with canines. It is also important to determine whether the client is in a stable enough position to be able to effectively use a service animal.

Then we arrive at the question of trained tasks, which is essentially, can the client be helped by a service dog? In assessing a client, a counselor might ask what the client's disability is preventing the person from doing. A possible answer would be that the client has posttraumatic stress disorder and is hypervigilant. The client experiences flashbacks and becomes stuck in place. Sometimes the client becomes disoriented and cannot remember where he parked. Additionally, at home the client disassociates without warning and cannot get to his medication. He also has nightmares and disrupted sleep.

For this client, possible trained tasks to be used in public might include a "watch my back" command, in which the service dog would alert the handler to people approaching from behind, and a "search" command, in which the dog could search an enclosed area such as an office for other people. The dog would also be trained to respond to and eventually alert the handler to flashbacks by sensing shifts in breathing and body language or other cues specific to the client. For example, the dog could be trained to lick the handler's face if it does not receive a response from the handler. It could also alert other known people, such as the client's spouse or co-workers, that the client needs assistance. In responding to a flashback or other episode, the dog could be trained to lead the handler to the exit of the building, either automatically or upon receiving a "find the way out" command. In instances in which the handler can't locate his car, the dog could be trained to "find the car" and lead the handler there.

Some bonus tasks performed at home by the service dog might include waking the handler from nightmares and retrieving medication from a known location. The dog could also use the known "search" command upon returning home if the handler was concerned that an intruder might be present. Perhaps the handler also has a secondary concern of mobility issues from knee and back problems. In that case, more mobility tasks such as balance feedback and bracing to help the handler get out of chairs could be added to the service dog's responsibilities, along with some named items for retrieval such as "phone," "remote" and "keys."

This service animal would clearly be a huge comfort to the client, but we can recognize that it would be performing many tangible trained tasks beyond comfort, thus setting it apart from a regular pet or an emotional support animal. This is what justifies the animal working with its handler in public as medical equipment under the law.

Getting a dog

What steps should be taken after determining that a client would be helped by a service animal? Most handlers are best served getting their first dog from a program rather than attempting to train the dog themselves, unless they possess extensive training experience or have connections to the right people to provide the training. The organization providing the service animal will likely want documentation and a release of information from the counselor if the client's disability is related to a mental health-based diagnosis rather than a concern that is primarily medical. Be aware that scam programs do exist. It is important to look for red flags, such as programs that want a large sum of money upfront or that won't allow prospective clients to visit a training or to be connected with current clients.

Accreditation bodies such as Assistance Dogs International can help limit the risk in choosing an organization. These accreditation bodies assist training programs by setting standards for the required level of obedience training, thus helping to ensure that the animal will be safe to work in public. They also have agreements concerning their obligations to clients should needs change or challenges arise.

When choosing a service animal organization, clients should read and understand the contract as well as the policies and practices of the program thoroughly before committing because there may be fundraising requirements or extensive policies regarding gear, care, travel and so on. Generally, clients will have custody through an organization that maintains ownership of the dog. Therefore, it is important to ask for information concerning who makes the call on when a dog retires, whether animals retire into handler care and what the process is for getting a successor dog, in addition to all of the requirements for being a handler through the organization.

The experiences of handlers

Very little research is available on the experiences of service dog handlers. There is prevalent stigma against service animals, however. In her 2017 study of just under 500 handlers, sociologist Meghan Mills found that the majority of participants (68 percent) reported discrimination during daily tasks. Mills also reported that 77 percent of respondents indicated the legitimacy of their service dog had been questioned, and nearly half said they had not used their service dog in public "sometimes" because of unwanted attention.

The experiences of handlers appear to be affected by factors such as gender, race, age and geographic location. It is common for handlers to experience negative reactions from their friends, family members and communities. This can be especially true for those with invisible disabilities who may already have the legitimacy of their illness questioned regularly. Service dogs are not as common as other assistive devices, and this can draw additional attention. The social norm in the United States of pet dogs being prohibited in most public spaces compounds this experience. Even when handlers start with strong support networks, the constant discrimination they face over time can lead either to their exclusion by others or to self-imposed isolation to avoid these experiences.

Because people tend not to understand public access laws or how to interact appropriately with service dog teams, handlers are often characterized as demanding or rude for protecting their legal rights or safety. In online service dog forums, handlers regularly ask how to be strategic about telling strangers not to distract a dog who needs to be watching for medical alert (for example, a dog trained to give early warning for a seizure). These handlers do not want to endanger themselves, but they have been told that they are being unreasonable to expect strangers not to talk to, bark at or call their dog.

New handlers in programs or on their own will practice being assertive and calm, repeating the law and educating in the face of people yelling and threatening to call the police. As a result, handlers can put unreasonable expectations on themselves and their dogs to be flawless. Handlers may be concerned that an off day or a small mistake could make their access and the access of other teams more difficult.

Working with teams

Counselors who understand the role of service dogs have a unique opportunity to model positive social interactions for handlers. Showing respect through appropriate etiquette to service dog teams is a simple step that will communicate understanding and put service dog handlers at ease.

The core of service dog etiquette is not interfering with the animal's focus by talking to, petting or otherwise engaging the dog. In the same way one would not comment on a person's wheelchair or cane, it is rude to focus too much on a service dog or to ask too many questions. The presence of a service dog, as necessary medical equipment, is not an invitation for conversation about the client's disability or about service dogs (either in general or about the handler's in particular). Handlers may be sensitive to these questions because they commonly are asked by others in inappropriate settings. As with any other client, it is best to build rapport first, then ask more probing questions once a relationship is established. In support of building a therapeutic relationship, I'd recommend that counselors say something along the following lines: "I'm not going to ask you things I don't need to know about your service animal, but is there anything you would like to tell me about how you want me to interact with you as a team while we're working together?" This would be a polite way for counselors to align themselves with these clients while also signaling understanding of and respect for their boundaries.

If counselors are aware that a client is a service dog handler, it is important to think in advance about the potential barriers the team may face in a counseling setting. For example, if the waiting room becomes uncomfortable because another client is being too curious or is distracting the service dog, consider whether there is another location where the client could go to wait for the session. Educating other counselors and staff in the practice on basic etiquette is also important because it removes the responsibility from the client. If a client who is a handler is going to participate in a group, spend time beforehand discussing how the client would like to be supported in setting boundaries with the other group members. This step could improve the outcome.

As previously noted, many service dog teams experience frequent discrimination. Over time, some handlers become fearful of entering new environments because of the potential of access concerns or other negative interactions. Some handlers have been threatened or experienced violence simply for having a service animal. Conflict may also result from the handler not allowing people to pet or interact with the service animal or from refusing to be illegally removed from a building. Many teams have been attacked by pet dogs or by dogs that are claimed to be service animals. It is worth counselors evaluating for trauma responses within this demographic because, over time, the constant alienation can build up, even without the experience of acute incidents.

Handlers may also have lost the support of family or friends or access to some of their spaces because of this treatment decision. Loss of access can be due to lack of ADA coverage (as is the case in religious spaces) or due to elements of specific environments in which the social cost of advocacy may outweigh the gain of access. It is important that counselors not place the burden of education exclusively on handlers and understand that in some situations, there is no clear path forward to gain access once it has been denied. This means that counseling with handlers may involve elements of grief counseling.

There are interventions used in training programs that can deepen the bond in a team and help handlers be more effective in using their service dogs. Some of these interventions target specific symptoms, whereas others address interpersonal and environmental processing through the team bond. Counselors working with long-term clients who are handlers may be served by seeking consultation and supervision in this area.

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K. Lynn Pierce recently started her counselor education and supervision doctoral program at Pennsylvania State University. She is a service animal handler of four years and provides consultation and workshops for mental health and related professions around service dog inclusion and integration. Contact her through her website at klynnpierce.com.

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