Falicia T. v. Saul

          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 ...