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Shannon W. v. Commissioner of Social Security

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

May 3, 2019

SHANNON W., Plaintiff,


          Marsha J. Pechman United States District Judge.

         Plaintiff seeks review of the denial of her application for Supplemental Security Income. Plaintiff contends the ALJ erred by discounting two medical opinions, her testimony, and her mother's lay witness statement and by failing to find she met a listed impairment. Dkt. 9. As discussed below, the Court REVERSES the Commissioner's final decision and REMANDS the matter for an award of benefits under sentence four of 42 U.S.C. § 405(g).


         Plaintiff is currently 42 years old, has a high school education, and has no past relevant work. Dkt. 7, Administrative Record (AR) 31-32. Plaintiff applied for benefits in July 2015, alleging disability as of November 28, 2013. AR 132. Plaintiff's applications were denied initially and on reconsideration. AR 141, 151. After the ALJ conducted a hearing in August 2017, the ALJ issued a decision finding Plaintiff not disabled. AR 83, 16-33.


         Under the five-step disability evaluation process set forth in 20 C.F.R. § 416.920, the ALJ found:

Step one: Plaintiff has not engaged in substantial gainful activity since the application date.
Step two: Plaintiff has the following severe impairments: psychotic disorder, non-specified; and substance abuse disorder.
Step three: These impairments do not meet or equal the requirements of a listed impairment as set forth in 20 C.F.R. Part 404, Subpart P, Appendix 1.
Residual Functional Capacity: Plaintiff can perform work at all exertional levels. She can understand, remember, and carry out simple instructions, and make judgments commensurate with unskilled work. She can respond appropriately to supervision but cannot work in close coordination with coworkers where teamwork is required. She can deal with occasional changes in the work environment. Her work cannot require contact with the general public to perform work tasks.
Step four: Plaintiff has no past relevant work.
Step five: As there are jobs that exist in significant numbers in the national economy that Plaintiff can perform, she is not disabled.

         AR 18-33. The Appeals Council denied Plaintiff's request for review, making the ALJ's decision the Commissioner's final decision. AR 1. The rest of the procedural history is not relevant to the outcome of the case and is thus omitted.


         This Court may set aside the Commissioner's denial of Social Security benefits only if the ALJ's decision is based on legal error or not supported by substantial evidence in the record as a whole. Trevizo v. Berryhill, 871 F.3d 664, 674 (9th Cir. 2017). Each of an ALJ's findings must be supported by substantial evidence. Reddick v. Chater, 157 F.3d 715, 721 (9th Cir. 1998). “Substantial evidence” is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. Richardson v. Perales, 402 U.S. 389, 401 (1971); Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989). The ALJ is responsible for determining credibility, resolving conflicts in medical testimony, and resolving any other ambiguities that might exist. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). While the Court is required to examine the record as a whole, it may neither reweigh the evidence nor substitute its judgment for that of the ALJ. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). When the evidence is susceptible to more than one interpretation, the ALJ's interpretation must be upheld if rational. Burch v. Barnhart, 400 F.3d 676, 680-81 (9th Cir. 2005). This Court “may not reverse an ALJ's decision on account of an error that is harmless.” Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012).

         A. Medical Opinions

         A treating physician's opinion is generally entitled to greater weight than an examining physician's opinion, and an examining physician's opinion is entitled to greater weight than a non-examining physician's opinion. Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014). An ALJ may only reject the uncontradicted opinion of a treating or examining doctor by giving “clear and convincing” reasons. Revels v. Berryhill, 874 F.3d 648, 654 (9th Cir. 2017). Even if a treating or examining doctor's opinion is contradicted by another doctor's opinion, an ALJ may only reject it by stating “specific and legitimate” reasons. Id. The ALJ can meet this standard by providing “a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings.” Id. (citation omitted). “The ALJ must do more than offer his conclusions. He must set forth his own interpretations and explain why they, rather than the doctors', are correct.” Reddick, 157 F.3d at 725.

         1.Dr. Barkin

         Plaintiff's treating psychiatrist, Karin Barkin, M.D., filled out a Medical Source Statement in May 2016. AR 407-09. Dr. Barkin opined that Plaintiff was moderately to markedly limited in most work-related abilities. Id. The ALJ gave Dr. Barkin's opinions “little weight.” AR 29. The Commissioner concedes that some of the ALJ's reasons were erroneous. Dkt. 12 at 11. The ALJ discounted Dr. Barkin's opinions for lack of “reference to specific treatment encounters or more specific objective findings” but, as the Commissioner acknowledges, Dr. Barkin's treatment notes must be considered in connection with her opinions. AR 29; see Revels, 874 F.3d at 663. At the end of Dr. Barkin's opinions, Plaintiff's “care-coordinator” added a paragraph of observations. AR 709. The ALJ stated that this “complicat[ed] any analysis” of the opinions. AR 29. However, if the ALJ felt that the added sentences created ambiguity, the ALJ had a duty to develop the record to clarify the treating doctor's opinions. See Mayes v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001) (“An ALJ's duty to develop the record further is triggered only when there is ambiguous evidence or when the record is inadequate to allow for proper evaluation of the evidence.”).

         The Commissioner maintains, however, that the ALJ permissibly discounted Dr. Barkin's opinions because they conflicted with treatment notes stating Plaintiff was doing “well” or “stable” and because Plaintiff was capable of appropriate behavior in a courtroom for her child custody case. Dkt. 12 at 11-12; AR 29.

         a) Treatment Notes

         Incongruity between a treating physician's opinions and her own medical findings can be a “specific and legitimate reason for rejecting” the opinions. Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008). Here, however, the treatment notes that the ALJ cited reference only Plaintiff's self-reports that she was doing well. These contrast with her husband's and mother's accounts, her own admissions that she continued to experience auditory hallucinations, and Dr. Barkin's consistent conclusions that Plaintiff lacked insight into her condition.

         On April 23, 2015, Plaintiff reported she had been “doing well” but Dr. Barkin concluded she was doing worse than in the previous visit. AR 356, 358. Dr. Barkin observed that Plaintiff continued to respond to nonexistent voices and Plaintiff's mother reported that Plaintiff had stopped visiting her father because “the voices” told her not to visit him. AR 356. Dr. Barkin assessed Plaintiff's insight into her condition as “limited.” AR 358. At the next appointment, on May 7, 2015, Dr. Barkin concluded Plaintiff seemed better because, for the first time that year, she was not responding to nonexistent voices; however, Plaintiff missed the voices. AR 359, 361. By the time Plaintiff returned on June 11, 2015, she was hearing voices again despite, as her husband confirmed, taking her medication reliably every day. AR 362. Dr. Barkin concluded that Plaintiff's insight was “impaired.” AR 364. The ALJ does not refer to the next few treatment notes, which recount Plaintiff being reported to Child Protective Services for physically abusing her children. AR 365-68. In the next treatment note the ALJ cited, from August 26, 2015, Plaintiff continued to have auditory hallucinations, although she reported that her husband and mother felt she was “doing well.” AR 373. On September 8, 2015, Plaintiff reported her mood had been “stable” but she still heard voices, although rarely, and she missed the voices. AR 379.

         Plaintiff's self-reports that she had been doing well or was stable do not contradict Dr. Barkin's opinions, especially in light of Dr. Barkin's assessment that Plaintiff lacked insight into her condition.

         b) ...

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