United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER [2]
GABRIEL A. FUENTES, UNITED STATES MAGISTRATE JUDGE
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presented with withdrawn behavior, blunted affect and fair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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