If you’re from a country that doesn’t have emotional support animals, here’s how it works.

Sometimes places ban or restrict animals. For example, an apartment building might not allow dogs. Or an airline might charge you money to transport your cat. But the law requires them to allow service animals, for example guide dogs for the blind. A newer law also mandates that, in some circumstances, they allow emotional support animals, ie animals that help people with mental health problems (like depression or anxiety) feel better. So for example, if you’re depressed, and having your dog nearby makes you feel better, then a landlord has to let you keep your dog in the apartment. Or if you’re anxious, but petting your cat calms you down, then an airline has to take your cat free of charge.

Clinically and scientifically, this is great. Many studies show that pets help people with mental health problems. Depressed people really do benefit from a dog who loves them. Anxious people really do feel calmer when they hold a cute kitten.

Legally, it’s a racket. In order to benefit from these rules, you need for a psychiatrist to write you an “emotional support animal letter”, saying that your pet is actually an emotional support animal. In theory, the psychiatrist should evaluate you carefully, using their vast expertise to distinguish between an emotional support animal and a normal pet. In practice, nobody has a rubric for this evaluation that makes sense. I’m not saying there aren’t long, scholarly-sounding papers with tiles like A Rubric For The Emotional Support Animal Evaluation That Makes Sense and twenty-seven authors from the psychiatry departments of top medical schools. I’m saying that when you take out all the legalese, the executive summary is “think really hard about whether this animal really helps this person, then think really hard about whether it will cause trouble, and if it helps the person and won’t cause trouble, sign the letter”.

Here’s a typical case: you’ve been seeing a patient with depression for three years. You prescribe them medication, maybe they get a little better, maybe they go up and down randomly in the way of all depression patients. Then they say “My roommate is leaving, so I need to move to a new apartment. But almost nowhere allows dogs, and the only place that does allow them charges more than I can afford. Please write me an emotional support animal letter or else I’ll lose my beloved Fido, the light of my life.”

So you say, okay, I’ve got to do an evaluation to see if you’re really depressed. They say “You’ve been treating me for depression for three years, you’ve prescribed me six different antidepressants, come on.” You say okay, fine, I’ll skip that part, but I’ve got to do an evaluation to see if your animal really helps you. They say “I feel so much better whenever I’m with Fido, he really brightens up my day.” You ask the same question several times, in the manner of all psychiatrists, and your patient always gives the same answer. Then you say “I’ve got to evaluate whether your animal is safe,” and he says “Oh yeah, Fido is such a good boy, he would never hurt a fly.” Now what?

You could keep evaluating harder. You could make them bring Fido into your office (good luck!) and observe him. The observation would look like your patient petting a dog for a half-hour appointment, for which you charge them $200. You could get “collateral history” from friends and family: “Is Fido really a good boy? Does your cousin seem happier when Fido is around?” At some point this becomes insane and humiliating. Good luck figuring out which point that is.

Or you could do the ultra-responsible thing and deny the letter. You could say “As your psychiatrist, I inherently have a conflict of interest; I know you, I like you, I can’t be objective in this determination.” Now your patient will hate you forever. Every other doctor gives their patients emotional support animal letters. The only other psychiatrist in town charges $500 per appointment and demands at least ten appointments before they will write an ESA letter, they’ll never be able to make it work, they’ll lose Fido. They’ll lose Fido and it will be your fault and they’ll hate you forever and they will never take any of the medication you recommend ever again even if they’re suicidally depressed and you’re the last psychiatrist in the world.

Or you could wash your hands of it. You could say “I’m going to be ultra-responsible and demand you see a third party. But just between you and me, that third party could be Pettable - Get Your ESA Letter In 24 Hours. Or maybe CertaPet - Get Your ESA Letter In 3 Easy Steps. Or even ExpressPetCertify - Same Day ESA Approval, Guaranteed Landlord Acceptance. Or how about ESADoctors - Get Your Legitimate ESA Letter? Or any of their one thousand competitors. You don’t have to feel conflict-of-interest-y. Your patient will only be out $100 or so, and only slightly pissed at you. And you get the warm glow of knowing this will definitely work, because these services have never, ever turned anyone down.

Or you could stop dithering and just write the damn emotional support animal letter. It doesn’t have to be more than a few sentences. If you Google “emotional support animal letter”, it autocompletes to “…template”. There are hundreds of them!

This option has basically no downsides and is the one that most psychiatrists end up taking.

And it’s harmless enough with Fido - he really is a good boy. But I’ve had patients with ADHD ask me to certify their snake. Sorry, I refuse to believe a snake can help you with ADHD, unless it’s one of those talking snakes from Harry Potter and it whispers “Concccccentrate . . . conccccccentrate” in your ears every time you start slacking off. Still, some patients argue very eloquently: “Taking care of the snake helps me keep to a routine, and makes me feel more confident, and she’s my only friend in the world, and I feel like I’d be stressed and lost without her.” It’s a little weird. But do you really want your patient to lose their beloved Nagini just because you refused to write a letter that has no legal requirements and no downsides?

Probably it’s bad that society is so hostile to pets. Probably it’s bad that we’ve reached the level of housing shortage where landlords don’t need to compete for tenants, and they might as well ban all pets if it makes their lives even slightly easier. Probably the emotional support animal loophole makes things better rather than worse.

But the process runs into the same failure mode as Adderall prescriptions: it combines an insistence on gatekeepers with a total lack of interest into whether they actually gatekeep. The end result is a gatekeeping cargo cult, where you have to go through the (expensive, exhausting) motions of asking someone’s permission, without the process really filtering out good from bad applicants. And the end result of that is a disguised class system, where anyone rich and savvy enough to engage with the gatekeeping process gets extra rights, but anyone too poor or naive to access it has to play by the normal, punishingly-restrictive rules.

I have no solution to this, I just feel like I incur a little spiritual damage every time I approve somebody’s ADHD snake or autism iguana or anorexia pangolin or whatever.