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Kenlasha M. v. Saul

United States District Court, N.D. Illinois, Eastern Division

November 19, 2019

KENLASHA M., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff, Kenlasha M., [3] applied for Social Security Income benefits on May 18, 2015, alleging she became disabled on May 6, 2015. (R. 191.) After a hearing, an administrative law judge ("ALJ") issued a written opinion denying her application for benefits. (R. 17-26.) The Appeals Council denied Plaintiffs request for review of the ALJ's decision (R. 1), making the ALJ's decision the final decision of the Commissioner. Jozefyk v. Berryhill, 923 F.3d 492, 496 (7th Cir. 2019). Plaintiff now asks the Court to remand the Commissioner's decision denying her application (D.E. 16), and the Commissioner has filed a motion asking the Court to affirm the decision. (D.E. 26.) The matter is now fully briefed. For the following reasons, the Court grants Plaintiffs request for remand and denies the Commissioner's motion to affirm.

         I. Administrative Record

         Plaintiff was born on March 4, 1980. (R. 25.) She did not finish sixth grade and has never worked a regular job; she received no earnings from 2007 through 2016. (R. 44, 202-03.) From February 2014 through May 5, 2015, Plaintiff was serving time in a Texas jail for assault. (R. 621-22.) Upon her release, Plaintiff lived in Texas with a relative and received medical care from Metrocare. In May and June 2015, she met with a clinician at Metrocare for treatment of her diagnoses of schizoaffective disorder and depression. (R. 622.) Plaintiff presented with withdrawn behavior, blunted affect and fair judgment and insight, and she reported having racing thoughts and seeing visions of powdered footprints. (R. 622, 625-26, 738.) The clinician prescribed risperidone (an antipsychotic used to treat schizophrenia and bipolar disorder), bupropion (an antidepressant) and hydroxyzine (an anti-anxiety medication). (Id.) Plaintiff also took medication for high blood pressure, diabetes and nerve pain in her hands (gabapentin). (R. 245.) Plaintiff reported side effects from her medications including dizziness, headaches, nausea and sleepiness. (Id.) She indicated that she cared for her hygiene, cleaned her room, did dishes, and prepared simple meals, but she did not go to the store because she could not be around people. (R. 224-26.)

         On June 29, 2015, Michael P. Dolan, Ph.D., performed a mental status examination on Plaintiff related to her claim for benefits. Plaintiff reported experiencing auditory and visual hallucinations, racing thoughts, anger, anxiety attacks, trouble sleeping, tearfulness, depression and decreased energy, and she said she was often agitated and easily distracted. (R. 630-31.) Plaintiff stated that she could perform some household duties, but her sister helped with most things, and Plaintiff seldom left her home. (R. 631.) Dr. Dolan observed that Plaintiffs concentration was "poor," her speech was "slow and mumbled, but understood," she was "guarded and gave vague responses," and she was often distracted and played with children's toys during the interview. (R. 631-32.) In addition, he found Plaintiffs mood was apathetic, her affect was labile (characterized by uncontrollable laughing or crying), and she had poor judgment, a below-average fund of knowledge and memory deficiencies. (R. 632-33.) Dr. Dolan listed her primary diagnosis as Bipolar I Disorder, severe, with psychotic features. (R. 633.)

         In July 2015, a non-examining state agency consultant opined that Plaintiff had severe mental impairments that caused her mild restriction in her activities of daily living ("ADLs") and moderate difficulties in maintaining social functioning and maintaining concentration, persistence or pace. (R. 81-83.) Specifically, he found Plaintiff could "understand, remember, and carry out simple instructions, . . . concentrate for extended periods, interact w[ith] others and respond to changes." (R. 85.) Another non-examining state agency consultant found Plaintiff did not have severe physical impairments. (R. 95-96.)

         Plaintiff continued receiving regular treatment from Metrocare through June 2016. (R. 764.) In June or July 2016, Plaintiff moved to Chicago with help from the Salvation Army Human Trafficking program. (R. 57.) In Chicago, Plaintiff was assigned a licensed clinical social worker, Jennifer Harvey, to meet with her regularly and provide her with emotional and other support, including assisting her in managing her finances and accompanying her on errands. (R. 62, 64-65, 68.) Plaintiff first lived at Breakthrough Women's Shelter, where she received medical care from Susan J. Erlenborn, M.D., of the Lawndale Christian Health Center ("LCHC"). (R. 975.) On August 2, 2016, Dr. Erlenborn filled out a "Physician's Statement," listing Plaintiffs diagnoses as schizoaffective disorder, bipolar type, and post-traumatic stress disorder ("PTSD"), and she checked a box indicating Plaintiff was unable to work due to her disability. (R. 1050.)

         On September 23, 2016, Dr. Erlenborn noted Plaintiff had not been taking her medications regularly, and she hoped a pill box would help Plaintiff take them consistently. (R. 978-80.) In addition to medication for asthma, hypertension and diabetes, Plaintiff was prescribed bupropion, risperidone, gabapentin and extra strength acetaminophen. (R. 985-86.) At that visit, Plaintiffs weight was 335 pounds, up 22 pounds since June. (R. 981, 986.) On September 29, 2016, Plaintiffs weight had risen further, and she complained of pain in her wrists and thumbs that made it hard for her to grip and lift things. (R. 984-85.) In addition, Plaintiffs feet were swollen, possibly due to her other impairments or prolonged standing at cooking school.[4] (R. 987.)

         On October 4, 2016, Plaintiffs thumb pain was improved with splints, but her weight was up to 351 pounds. (R. 1000.) Dr. Erlenborn's psychological examination showed Plaintiff was sleepy but cooperative, with a slightly depressed affect and normal attention span and concentration. (R. 997-98.) The doctor noted Plaintiff was taking her antipsychotic medication regularly. (R. 999.) On October 20, 2016, Dr. Erlenborn recommended Plaintiff discuss with psychiatry changing to a different antipsychotic due to her marked weight gain. (R. 1007.)

         In December 2016, Plaintiff moved to subsidized housing at Marah's, [5] but she continued to be treated by Dr. Erlenborn at Breakthrough. (R. 1115, 1021.) On December 5, 2016, Plaintiff met with psychiatrist, Medeia Gartel, M.D., at Sinai Psychiatry and Behavioral Health. Dr. Gartel did not complete a planned psychiatric evaluation because Plaintiff became "verbally confrontational" toward her. (R. 1109-13.) Eventually, Plaintiff was rescheduled to have an evaluation with a different psychiatrist on March 3, 2017; she was not interested in therapy because it conflicted with her schooling. (R. 1116.) Later, Sinai called Plaintiff to postpone the psychiatric evaluation to May 2017; Plaintiff got angry and hung up the phone. (R. 1117.)

         On December 6, 2016, Plaintiff told Dr. Erlenborn she felt more depressed, had little energy and had difficulty concentrating. (R. 1013.) Plaintiff reported that the medication prazosin was helping her sleep, but she still had occasional flashbacks due to PTSD.[6] (R. 1015.) Dr. Erlenborn increased her dose of bupropion and continued her antipsychotic medications. (R. 1013.) Physically, Plaintiffs wrist and hand pain was mild and intermittent, her diabetes was fairly well-controlled, her hypertension was controlled, and she had lost a few pounds. (R. 1013-14.) However, Plaintiff continued to have foot pain due to flat feet. (R. 1017.) On December 27, 2016, Plaintiff reported that she did not feel any less depressed with the increased bupropion. (R. 1024.)

         On March 2, 2017, Plaintiff told Dr. Erlenborn that she was not sleeping well and was waking up "feeling haunted. She gets up to go to the bathroom and then can't go back to sleep -sees men in her room, and smells her prior abuser," and she was "[u]nable to travel on public transportation by herself because she is afraid." (R. 1028.) Dr. Erlenborn noted that Plaintiff often felt depressed, hopeless, anxious, edgy, restless and irritable, and she had trouble concentrating and getting along with other people. (R. 1029-30.) Dr. Erlenborn increased Plaintiffs prazosin at bedtime to address her nightmares from PTSD and referred Plaintiff for a psychiatric evaluation. (R. 1033.) Physically, Plaintiff continued to have pain in her feet, "especially [the] bottoms of her heels that makes it hard to stand and walk in morning," so Dr. Erlenborn ordered custom orthotics and prescribed extra strength acetaminophen. (R. 1035.) Plaintiffs hypertension and asthma were controlled. (R. 1034, 1028.)

         On April 4, 2017, Ms. Harvey arranged for Plaintiff to participate in Growing Home. (R. 58.) Growing Home is a "unique supportive employment model," which provides participants with job readiness classroom lessons, peer support, group therapy, wraparound social services, and job skills at an urban farm. (R. 301, 303.) Plaintiff was supposed to participate about 24 hours per week (R. 303); however, after completing one week in the classroom, Plaintiff did not return to the program after one day at the urban farm. (R. 57-58.) She testified that she had trouble bending down to pick the vegetables, and she did not like having so many people (about 37) standing around her. (R. 57-59.) Plaintiff said "[i]t was just too much" for her. (R. 59.)

         On April 10, 2017, Plaintiff received a psychiatric diagnostic evaluation at Cook County Health Systems.[7] (R. 1124.) She was prescribed a new antipsychotic medication (aripiprazole), a new antidepressant (sertraline) and prazosin. (Id.)

         On May 15, 2017, Kim Davidson, LCSW, the director of clinical services at Deborah's Place (which runs Marah's), wrote a letter "To Whom It May Concern" to "confirm" that Plaintiff:

regularly participates in meetings with program staff and has worked to improve her health and well being. She has provided verification to medical appointments and meets with the Health Services Coordinator regularly to discuss her progress. She has had four individual appointments over the last few months to discuss her mental health in detail. Through her participation in services, Kenlasha has also demonstrated improved mental health and wellbeing [sic].

(R. 1187.) Notes from these individual appointments are not in the administrative record.

         II. ...

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