United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
ANDREA
R. WOOD UNITED STATED DISTRICT JUDGE
This is
a Social Security disability appeal from an adverse decision
by an Administrative Law Judge (“ALJ”).
See 42. U.S.C. § 405(g). Plaintiff Falicia T.
alleges that she is disabled based on both physical and
mental impairments, but this appeal only concerns the latter.
Plaintiff's central argument is that the ALJ erred by not
giving controlling (or any) weight to the opinion of
Plaintiff's psychiatrist who, in 2012, diagnosed
Plaintiff with posttraumatic stress disorder
(“PTSD”) stemming from childhood sexual abuse.
The ALJ rejected this opinion, as well as another similar
opinion from Plaintiff's therapist, because Plaintiff
only sought treatment for her mental problems in 2012 and
because Plaintiff quickly experienced significant improvement
after taking two medications. The ALJ also found that
Plaintiff's testimony was materially contradicted by her
husband's testimony. The Court finds that the ALJ's
rationales, as currently explained, are insufficient to
affirm the decision.
BACKGROUND
Plaintiff
initially proceeded pro se at the administrative
level. On November 5, 2010, she filed her application for
Title II disability benefits. She was then 43 years old and
had a spotty work history.[1] On the initial intake form, her
impairments were described in vague terms. (See
Admin. R. (“R.”) at 307 (“1. Nervous
condition-asthma-emotional problem/back spasm; 2. back
pain.”).) At this time, Plaintiff was not receiving any
mental health treatment.
From
2010 until April 2012, Plaintiff visited many doctors and
went to the emergency room multiple times to address physical
problems. The ALJ's decision contains a long summary of
these visits. Plaintiff's problems, which were not always
tied to a specific diagnosis, included abdominal pain,
uterine fibroids, fractures in her hand and fingers,
dizziness, back pain, chest pain, muscle spasms, knee pain,
and urinary tract infections. Because the physical problems
are not germane to this appeal, the Court will not further
discuss them.
In
2011, the ALJ asked a psychologist, Ellen Rozenfeld, to
answer interrogatories. Dr. Rozenfeld found that Plaintiff
had no mental impairments, explaining as follows:
[Plaintiff] has been seen on numerous occasions for physical
issues and there is no suggestion of consideration of a
somatoform disorder. No. mental health concerns were noted
and no dxes were made. She is not prescribed psych meds. Clmt
was seen for chest pain, yet there was no mention of anxiety
sxs despite the allegation on reconsideration of frequent
anxiety attacks. Allegations of a “nervous
condition” and anxiety attacks are not supported by the
objective file evidence.
(Id. at 1136.) Because Dr. Rozenfeld found that
Plaintiff did not have any mental impairment, much less a
severe one, as required at Step Two, she did not offer any
opinion on whether Plaintiff could meet a listing at Step
Three.
In
April 2012, Plaintiff began counseling with a social worker
named Barbara Daubenspeck. In June, she began treatment with
a psychiatrist named Tanya Anderson. Plaintiff saw Ms.
Daubenspeck five or six times from April to September 2012.
(See Id. at 1302-22.) Plaintiff saw Dr. Anderson
four times from June to September 2012.
Plaintiff
first saw Ms. Daubenspeck on April 21, 2012. In the initial
assessment, Ms. Daubenspeck noted that Plaintiff's
symptoms included depressed mood, hopelessness, irritability,
anxiousness, and somatic complaints. (Id. at 1308.)
Plaintiff reported that she was unhappy in her marriage (she
had been married for 23 years and her husband was 15 years
older than she was), that she was isolated from her family,
and that she gets upset about things. (Id. at 1308.)
Ms. Daubenspeck diagnosed Plaintiff with depressive disorder.
(Id. at 1309.)
In
subsequent visits, Plaintiff and Ms. Daubenspeck discussed
various issues. Plaintiff complained that she was “very
unhappy” in her marriage and that there “has been
physical abuse and police involvement.” (Id.
at 1311.) She stated that she has trouble keeping a job but
“does not know why.” (Id.) She described
sexual abuse by three different people during her childhood.
In Dr.
Anderson's initial assessment, she diagnosed Plaintiff
with PTSD, noting that she had a “chaotic childhood
filled with multiple traumas that she has never resolved or
found treatment for.” (Id. at 1378.) Plaintiff
reported that she was sexually abused and raped multiple
times growing up, including being molested by an uncle when
she was 5 to 9 years old, raped by her mother's boyfriend
when she was 15, and raped by her sister's boyfriend when
she was 16. (Id. at 1377.) Dr. Anderson prescribed
two medications, Zoloft and Klonopin. Over the next three
visits, Plaintiff discussed how she was feeling and how her
medications were working.
Both
Dr. Anderson and Ms. Daubenspeck provided medical opinions.
Dr. Anderson completed two forms. The first was a medical
source statement dated July 17, 2012. (Id. at 1299-
1301.) On September 19, 2012, Dr. Anderson completed another
similar questionnaire. (Id. at 1356-61.) On these
forms, she rendered opinions which, if accepted, would
establish that Plaintiff could not work.
Ms.
Daubenspeck provided two opinions. On July 9, 2012, she
completed a Physical Residual Functional Capacity
Questionnaire. She noted that she had seen Plaintiff four
times in a three-and-a-half month period and had diagnosed
her with depressive disorder and rated her prognosis as
“fair.” (Id. at 1290.) She estimated
that Plaintiff's symptoms would interfere
“frequently” during a normal work day.
(Id.) On September 7, 2012, Ms. Daubenspeck prepared
a one-page letter, stating that Plaintiff attended a total of
six psychotherapy sessions. She noted that Plaintiff
“had a difficult childhood and several traumas from
which she is trying to process.” (Id. at
1321.) The letter was mostly a factual summary, but it
included the following assessment at the end: “It
appears at this time that between her mood disorder with
confusion and her medical condition combined she is not able
to work at this time.” (Id.)
In the
summer of 2012, Plaintiff was still proceeding pro
se. She appeared twice before the ALJ for a hearing but
got continuances each time so that she could find an
attorney. She eventually retained her present counsel and a
hearing was held on October 12, 2012. On the day of the
hearing, counsel faxed the ALJ a letter brief. (See
Id. at 398-401.) In this brief, counsel noted that
Plaintiff previously “was on disability from January
1992 to December 1997 until her benefits ceased.”
(Id. at 399.) Counsel then explained that Plaintiff
“did not help herself” when she applied for
benefits in 2010 because, first of all, she confusingly
stated that she stopped working because she had no car to get
to work when the real reason was her impairments. Counsel
argued that Plaintiff further undermined her own case by
initially presenting it as
“not involving mental
illness.” (Id. at 401 (emphasis added).)
Counsel summarized as follows: “As a mentally ill
person it is not surprising that [Plaintiff] presented her
case in such an undisciplined and fragmented manner. That
helps to confirm her disability rather than to distract from
it.” (Id.)
At the
start of the hearing, the ALJ referred to this letter brief
and discussed it with counsel. Counsel again argued that the
ALJ should try to obtain Plaintiff's disability file from
the early 1990s because this might address any concerns about
whether Plaintiff had a long-term mental illness.
(Id. at 45-46.) Counsel also acknowledged that
Plaintiff's mental illness was not “highly
documented” but suggested that the pain medication
Plaintiff took for her various physical ailments made her
sleep more, which in turn lessened the frequency of her
psychological symptoms. (Id. at 46.)
Plaintiff
then testified about her work history, health problems, daily
activities, and other matters. Plaintiff's husband
testified about similar matters. A vocational expert
testified but no medical expert was called.
On
January 24, 2013, the ALJ issued a 15-page decision finding
that Plaintiff was not disabled. The ALJ applied the
five-step process and concluded that Plaintiff had the
residual functional capacity (“RFC”) to do light
work subject to certain restrictions.
Plaintiff
filed an appeal to the Appeals Council, raising many of the
arguments she raises here. (Id. at 402-03.) Counsel
complained that the ALJ never sought to obtain the earlier
disability file. Responding to the ALJ's assertion that
Plaintiff improved with medications, counsel noted that
Plaintiff's symptoms “can reoccur and wane
periodically.” (Id. at 402.) Counsel also
complained that the ALJ's analysis of the medical
opinions was flawed because the ALJ “criticizes each
opinion individually not allowing for the cumulative effect
of the opinions.” (Id. at 403.)
DISCUSSION
A
reviewing court may enter judgment “affirming,
modifying, or reversing the decision of the Commissioner of
Social Security, with or without remanding the cause for a
rehearing.” 42 U.S.C. § 405(g). If supported by
substantial evidence, the Commissioner's factual findings
are conclusive. Id. Substantial evidence exists if
there is enough evidence that would allow a reasonable mind
to determine that the decision's conclusion is
supportable. Richardson v. Perales, 402 U.S. 389,
401 (1971). Accordingly, the reviewing court cannot displace
the decision by reconsidering facts or evidence, or by making
independent credibility determinations. Elder v.
Astrue, 529 F.3d 408, 413 (7th Cir. 2008). However, the
Seventh Circuit has emphasized that review is not merely a
rubber stamp. Scott v. Barnhart, 297 F.3d 589, 593
(7th Cir. 2002) (stating that a “mere scintilla”
is not substantial evidence). A reviewing court must conduct
a critical review of the evidence before affirming the
Commissioner's decision. Eichstadt v. Astrue,
534 F.3d 663, 665 (7th Cir. 2008). Even when adequate record
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