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Ford v. Berryhill

United States District Court, W.D. Washington, Seattle

April 30, 2018





         Plaintiff Charisse Ford seeks review of the denial of her application for disability insurance and supplemental security income benefits. Ms. Ford contends the Administrative Law Judge ("ALJ") misevaluated the medical opinion evidence concerning her mental impairments and her testimony. (Op. Br. (Dkt. # 8) at 1.) Ms. Ford contends these errors impacted the ALJ's residual functional capacity determination and the findings at Step Five of the disability evaluation process. (Id.) As discussed below, the court REVERSES the Commissioner's final decision and REMANDS the matter for further administrative proceedings under sentence four of 42 U.S.C. § 405(g).


         Utilizing the five-step disability evaluation process, [1] the ALJ found:

Step one: Ms. Ford has not engaged in substantial gainful activity since August 15, 2012.
Step two: Ms. Ford has the following severe impairments: degenerative disc disease; affective disorder; and anxiety disorder.
Step three: These impairments do not meet or equal the requirements of a listed impairment.[2]
Residual functional capacity: Ms. Ford can perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.97(b). Ms. Ford can stand and/or walk with normal breaks for about four hours in an eight-hour workday. She can sit with normal breaks for a total of about six hours in an eight-hour workday. Ms. Ford can frequently stoop and kneel. She can occasionally climb ramps, stairs, ladders, ropes, and scaffolds. Ms. Ford can occasionally crouch and crawl. Ms. Ford is capable of unskilled work involving short and simple tasks. She can have superficial contact with supervisors for work tasks, and can have occasional changes to the work environment. Ms. Ford is not able to perform at a production rate pace, but can perform goal-oriented work.
Step four: Ms. Ford cannot perform past relevant work, including institutional cook, receptionist, teacher assistant, home attendant, and packager.
Step five: Ms. Ford can perform jobs that exist in significant numbers in the national economy, including housekeeping. Therefore, Ms. Ford has not been disabled since August 15, 2012, the alleged disability onset date.

(Administrative Record ("AR") (Dkt. # 7) at 27-36.)[3] The Appeals Council denied Ms. Ford's request for review, thus rendering the ALJ's decision final. (AR at 5.)

         III. ANALYSIS

         A. Evaluation of the Medical Evidence Concerning Ms. Ford's Mental Impairments

         Ms. Ford contends that the ALJ erred in evaluating the medical evidence in the record concerning her mental impairments. (See Op. Br. at 2-9.) Questions of credibility and conflicts in the evidence are solely the ALJ's responsibility, so long as the medical evidence in the record is not conclusive. See Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982). The ALJ's findings resolving credibility and evidentiary issues "must be supported by specific, cogent reasons." See Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998).

         Where the ALJ rejects the opinion of an examining doctor, even if it is contradicted by another doctor, the ALJ must provide "specific and legitimate reasons that are supported by substantial evidence in the record" for rejecting the opinion. See Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1996) (citing Andrews v. Shalala, 53 F.3d 1035, 1042 (9th Cir. 1995)). The ALJ can satisfy this requirement "by setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings." Reddick, 157 F.3d at 725 (citing Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989)). The court may also draw "specific and legitimate inferences from the ALJ's opinion." Magallanes, 881 F.2d at755. The court now reviews the ALJ's evaluation of the relevant medical evidence.

         1. R.A. Cline, Psv.D.

         Dr. Cline examined Ms. Ford on December 6, 2012. (AR at 316-23.) During the examination, Dr. Cline conducted a clinical interview, during which she documented Ms. Ford's subject complaints and her own observations. (Id. at 316-17.) Dr. Cline noted Ms. Ford was "visibly anxious with her hands trembling and being very tearful throughout the initial portion of the interview." (Id. at 316.) Dr. Cline also remarked that she did not have records available to review. (Id.)

         Dr. Cline conducted several tests during her examination of Ms. Ford. (Id. at 317.) Ms. Ford's score on the Beck Anxiety Inventory ("BAI") "indicate[d] a marked to severe level of anxiety, " which Dr. Cline stated was congruent with Ms. Ford's presentation during the examination. (Id.) Dr. Cline further noted that Ms. Ford's score on the Beck Depression Inventory-II "indicate[d] a moderate to marked level of depression at this time and over the last two weeks." (Id.) Based upon her observations, Dr. Cline diagnosed Ms. Ford with depressive disorder, generalized anxiety disorder with features of panic disorder, and posttraumatic stress disorder. (Id. at 318.) Dr. Cline additionally concluded that Ms. Ford had marked limitations in both her ability to communicate and perform effectively in a work setting, and her ability to complete a normal work day or week without interruptions from her psychological symptoms. (Id. at 318-19.)

         The ALJ rejected Dr. Cline's opinions on Ms. Ford's mental limitations because (1) they were based on a single examination; and (2) Dr. Cline relied heavily on Ms. Ford's subjective report of symptoms. (Id. at 33.) The ALJ accepted Dr. Cline's opinion "that the most that the claimant can still do are unskilled tasks with reduced social interaction because of severe mental impairments." (Id.)

         The ALJ erred in rejecting Dr. Cline's opinions. He gave only two vague reasons, neither of which satisfies the "specific and legitimate" standard. First, the fact that Dr. Cline performed only a single examination is not a legitimate reason to reject her opinion. Examining doctors commonly conduct only a single examination. If the court were to reject medical opinions every time they were based on a single examination, then only opinions from treating doctors would be considered, contrary to federal regulation. See 20 C.F.R. § 416.927(c) (noting that the Social Security Administration ("SSA") "will evaluate every medical opinion we receive, " including opinions from non-treating doctors). Furthermore, the ALJ contradicted his own logic by placing "significant weight" on the opinions of the state-agency reviewers, Jan Lewis, Ph.D. and Patricia Kraft, Ph.D., neither of whom performed even a single examination. If an opinion should be rejected solely because it was based on a single examination, then one that was based on no examination at all should also be rejected. As that is not the law, the ALJ was not entitled to reject Dr. Cline's opinion on the basis of her having performed a single exam.

         Second, the ALJ's rejection of Dr. Cline's opinions because they were based on Ms. Ford's subjective complaints, without more, is insufficient. An ALJ does not provide clear and convincing reasons for rejecting an examining psychologist's opinion by questioning the credibility of the patient's complaints where the psychologist does not discredit those complaints, and supports her ultimate opinion with her own observations. Edlund v. Massanari, 253 F.3d 1152, 1159 (9th Cir. 2001). At no point does the record indicate that Dr. Cline discredited Ms. Ford's complaints. (See AR at 316-23.) To the contrary, the record indicates that Dr. Cline supported her opinions with her observations and testing. (See id.) Dr. Cline reported that Ms. Ford "achieved a score of 44 on the BAI[, ] which indicates a marked to severe level of anxiety, " and was "congruent with her presentation in the interview." (AR at 317.)

         The Ninth Circuit's recent opinion in Buck v. Berryhill,869 F.3d 1040 (9th Cir. 2017), is informative. The Buck Court noted that psychiatric evaluations "will always depend in part on the patient's self-report" because "unlike a broken arm, a mind cannot be x-rayed." Id. at 1049 (internal quotation marks omitted) (quoting Poulin v. Bowen,817 F.2d 865, 873 (D.C. Cir. 1987)). "Thus, the rule allowing an ALJ to reject opinions based on self-reports does not apply in the same manner to opinions regarding mental illness." Buck, 869 F.3d at 1049. The Ninth Circuit further noted that clinical interviews and mental status evaluations "are objective measures and cannot be discounted as 'self-report.'" Id. The ALJ thus erred in rejecting Dr. Cline's opinions as based on Ms. Ford's subjective ...

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