Reid v. Berryhill

          RULING ON CROSS-MOTIONS FOR JUDGMENT ON THE PLEADINGS

          Stefan R. Underhill United States District Judge.

         In the instant Social Security appeal, Verla Jean Reid (“Reid”) moves to reverse the decision by the Social Security Administration (“SSA”) denying her claim for disability insurance benefits or, in the alternative, to remand the case for a new hearing. Mot. to Reverse, Doc. No. 23. The Commissioner of the Social Security Administration^[1] (the “Commissioner”) moves to affirm the decision. Mot. to Affirm, Doc. No. 27. For the reasons set forth below, I grant Reid's motion and deny the Commissioner's.

         I. Standard of Review

         The SSA follows a five-step process to evaluate disability claims. Selian v. Astrue, 708 F.3d 409, 417 (2d Cir. 2013) (per curiam). First, the Commissioner determines whether the claimant currently engages in “substantial gainful activity.” Greek v. Colvin, 802 F.3d 370, 373 n.2 (2d Cir. 2015) (per curiam) (citing 20 C.F.R. § 404.1520(b)). Second, if the claimant is not working, the Commissioner determines whether the claimant has a “‘severe' impairment, ” i.e., an impairment that limits his or her ability to do work-related activities (physical or mental). Id. (citing 20 C.F.R. §§ 404.1520(c), 404.1521). Third, if the claimant does have a severe impairment, the Commissioner determines whether the impairment is considered “per se disabling” under SSA regulations. Id. (citing 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526). If the impairment is not per se disabling, then, before proceeding to step four, the Commissioner determines the claimant's “residual functional capacity” based on “all the relevant medical and other evidence of record.” Id. (citing 20 C.F.R. §§ 404.1520(a)(4), (e), 404.1545(a)). “Residual functional capacity” is defined as “what the claimant can still do despite the limitations imposed by his [or her] impairment.” Id. Fourth, the Commissioner decides whether the claimant's residual functional capacity allows him or her to return to “past relevant work.” Id. (citing 20 C.F.R. §§ 404.1520(e), (f), 404.1560(b)). Fifth, if the claimant cannot perform past relevant work, the Commissioner determines, “based on the claimant's residual functional capacity, ” whether the claimant can do “other work existing in significant numbers in the national economy.” Id. (citing 20 C.F.R. §§ 404.1520(g), 404.1560(b)). The process is “sequential, ” meaning that a petitioner will be judged disabled only if he or she satisfies all five criteria. See id.

         The claimant bears the ultimate burden to prove that he or she was disabled “throughout the period for which benefits are sought, ” as well as the burden of proof in the first four steps of the inquiry. Id. at 374 (citing 20 C.F.R. § 404.1512(a)); Selian, 708 F.3d at 418. If the claimant passes the first four steps, however, there is a “limited burden shift” to the Commissioner at step five. Poupore v. Astrue, 566 F.3d 303, 306 (2d Cir. 2009) (per curiam). At step five, the Commissioner need only show that “there is work in the national economy that the claimant can do; he need not provide additional evidence of the claimant's residual functional capacity.” Id.

         In reviewing a decision by the Commissioner, I conduct a “plenary review” of the administrative record but do not decide de novo whether a claimant is disabled. Brault v. Soc. Sec. Admin., Comm'r, 683 F.3d 443, 447 (2d Cir. 2012) (per curiam); see Mongeur v. Heckler, 722 F.2d 1033, 1038 (2d Cir. 1983) (per curiam) (“[T]he reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn.”). I may reverse the Commissioner's decision “only if it is based upon legal error or if the factual findings are not supported by substantial evidence in the record as a whole.” Greek, 802 F.3d at 374-75. The “substantial evidence” standard is “very deferential, ” but it requires “more than a mere scintilla.” Brault, 683 F.3d at 447-48. Rather, substantial evidence means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Greek, 802 F.3d at 375. Unless the Commissioner relied on an incorrect interpretation of the law, “[i]f there is substantial evidence to support the determination, it must be upheld.” Selian, 708 F.3d at 417.

         II. Facts

         Reid applied for supplemental security income (“SSI”) and social security disability insurance (“SSDI”) benefits on October 27, 2014, alleging that she suffered from a disability since May 1, 2012. Ex. 3 to Ans., R. at 11. As set forth more fully below, Reid's application was denied at each level of review. She now seeks an order reversing the decision or in the alternative, remanding for a new hearing.

         A. Medical History^[2]

         Reid's medical problems date back to her early childhood. As a young child, Reid was physically abused by her mother and stepfather. Exs. 3, 8 to Ans., R. at 56-59, 74, 308. The beatings were severe, and on one occasion resulted in stitches. Ex. 3 to Ans., R. at 56. Reid consequently lived with her grandparents, during which time her aunt's boyfriend attempted to rape her. Exs. 3, 8 to Ans., R. at 57-58, 305.

         At age thirteen, Reid started to regularly use marijuana, alcohol, and nicotine. Ex. 8 to Ans., R. at 299. Reid was sexually active by age fifteen and pregnant with her first child by age sixteen. Ex. 8 to Ans., R. at 300. When Reid was eighteen, her infant son died from Sudden Infant Death Syndrome. Id. She turned to crack cocaine and continued to use crack “fairly consistently” for twenty-two years. Id. Reid ultimately had five children, whom various family member raised due to Reid's drug and alcohol problems. Exs. 3, 8 to Ans., R. at 75, 300.

         On September 24, 2007, when Reid was forty-one years old, Reid sought psychiatric treatment at the Greater Bridgeport Community Mental Health Center, also referred to in the record as Southwest Connecticut Mental Health System (“Southwest”). Ex. 8 to Ans., R. at 311. She was seen by psychiatrist Judith Wolf, M.D., whom Reid continued to see through the date of the Administrative Law Judge (“ALJ”) hearing on January 24, 2017. Exs. 8, 13 to Ans., R. at 291, 1256-61. According to Dr. Wolf's notes from the initial meeting, Reid suffered from decreased sleep, decreased appetite, an extremely labile mode, impaired recent memory, a rapid flow of thoughts, paranoid ideations, and on and off auditory hallucinations. Ex. 8 to Ans., R. at 291, 309. Dr. Wolf also observed that Reid was depressed, anxious, disorganized in her thinking, and easily angered. Id. At that point, Reid's substance abuse had been in remission for two years. Ex. 8 to Ans., R. at 307.

         Dr. Wolf diagnosed Reid with psychosis, polysubstance abuse in remission two years, and with a current GAF^[3] score of 45 and a high GAF score in the past year of 65. Ex. 8 to Ans., R. at 295, 310. In February 2008, the diagnosis was modified to Schizoaffective Disorder and Polysubstance Dependence, cocaine and alcohol, in remission for two years. Ex. 8 to Ans., R. at 329. Dr. Wolf prescribed Lithium and Invega to treat Reid's schizophrenia. See Stipulation of Facts, Doc. No. 29-1, at ¶ 13.

         From 2011 through 2013, Reid was inconsistent with her treatment. Stipulation of Facts, Doc. No. 29-1, at ¶¶ 14, 15. On May 16, 2012, Reid relapsed on alcohol and cocaine, and was hospitalized at Yale New Haven Hospital for an attempted suicide by overdose on prescription medications. Ex. 9 to Ans., R. at 501.

         Beginning in 2014 and through the relevant time period, Reid became relatively consistent with her treatment program, which consisted of weekly meetings with her therapist, weekly group therapy sessions, and meetings with an employment specialist. Ex. 8 to Ans., R. at 424-25; Stipulation of Facts, Doc. No. 29-1, at ¶ 16. In addition, Reid started to participate in Southwest's peer support program. Stipulation of Facts, Doc. No. 29-1, at ¶ 16. Through the program, Southwest offered participants “jobs” and paid them a small stipend. Ex. 3 to Ans., R. at 35, 53; Stipulation of Facts, Doc. No. 29-1, at ¶ 16. Reid's “job” was to serve as a greeter. Ex. 3 to Ans., R. at 35, 53; Stipulation of Facts, Doc. No. 29-1, at ¶ 16. As such, Reid was responsible for greeting other patients as they arrived for Southwest activities and for preparing coffee. Stipulation of Facts, Doc. No. 29-1, at ¶ 16.

         As Reid's attendance improved, so did her functioning. Stipulation of Facts, Doc. No. 29-1, at ¶ 16. Although Reid continued to experience intermittent auditory hallucinations and started to experience panic attacks throughout 2014, she reported that she was otherwise functioning adequately. Stipulation of Facts, Doc. No. 29-1, at ¶ 16; Ex. 8 to Ans., R. at 379. Throughout 2015, Reid continued to experience intermittent auditory hallucinations, and suffered from depression and short-term memory loss. Exs. 8, 11 to Ans., R. at 343, 385, 917; Stipulation of Facts, Doc. No. 29-1, at ¶¶ 17, 18. On July 1, 2015, however, Reid reported that she felt good and had stopped hearing voices for the time being. Ex. 11 to Ans., R. at 926. She continued to report longstanding short-term memory problems and residual paranoia related to her history of trauma. Id.

         In 2016, Reid's treatment plan included group therapy facilitated by at least one and typically two MHC mental health providers, psycho-education groups, Consumer Council meetings, meetings with guest speakers, Tai Chi classes, group psychotherapy for Integrated Dual Disorders Treatment, groups to plan holiday events, meetings with employment specialists, weekly one-on-one meetings with a therapist, medication management sessions every one or two months, and collaboration meetings to participate in refilling her medication. Stipulation of Facts, Doc. No. 29-1, at ¶ 24; Exs. 12, 13 to Ans., R. at 1061, 1173, 1177, 1179.

         The Three-Month Recovery Plan Review dated January 12, 2016, signed by Dr. Wolf, therapist Stephen Brown, and others, provided that Reid had demonstrated “[g]ood progress with recovery goals over the recent period.” Ex. 13 to Ans., R. at 1161. Her auditory hallucinations were at “very low levels, ” and she had been “less volatile and in better control over her mood.” Id. Although the assessment reported that Reid had “struggled to incorporate attendance at [Narcotics Anonymous] meetings into her routine, ” her attendance at treatment appointments was around 70% - an increase from a rate of approximately 50% in 2015. Exs. 12, 13 to Ans., R. at 1088, 1161. The review concluded that Reid “appears free of major mental health [symptoms] about 75% of her time.” Ex. 13 to Ans., R. at 1161.

         According to subsequent reviews in July and October 2016, Reid continued to make “good progress” with her recovery goals. Ex. 12 to Ans., R. at 1072 (July 2016 Review Plan); R. at 1144 (October 2016 Review Plan). Staff comments, however, indicated that “when not doing well, [Reid] experiences auditory hallucinations, paranoia, extreme irritability, and mood disturbance.” Ex. 12, 13, R. at 1074, 1146. In October 2016, Dr. Wolf diagnosed Reid with Schizoaffective disorder and a current GAF score of 55. Ex. 13 to Ans., R. at 1150.

         B. Medical Opinions

         As discussed further below, the record includes the following medical opinions:

a. Consultative Examination Report, dated March 4, 2015, from Melissa Artiaris, Pys. D. Dr. Antiaris evaluated Reid on March 4, 2015. Ex. 10 to Ans., R. at 865- 69.

b. Opinion, dated March 25, 2015, from DDS consultant Deborah Stack, Ph.D. Dr. Stack neither examined nor treated Reid. Ex. 4 to Ans., R. at 94-105.

c. Mental Medical Source Statement, dated July 22, 2015, from Linda Wolf, M.D. Dr. Wolf treated Reid from 2007 through the date of the hearing, January 24, 2017. Ex. 11 to Ans., R. at 956-61.

d. Mental Medical Source Statement, dated January 18, 2017, from Dr. Wolf. Ex. 13 to Ans., R. at 1256-61.

e. Psychological Evaluation Report, dated January 23, 2017, from Derek Franklin, Psy. D. Dr. Franklin examined Reid on January 23, 2017. Ex. 3 to Ans., R. at 72-80.

         i. Dr. Antiaris's Consultative Examination Report, dated March 4, 2015

         On March 4, 2015, Melissa Antiaris, Psy. D., performed a psychological evaluation of Reid for DDS as a consultative examiner. Ex. 10 to Ans., R. at 865-69. Dr. Antiaris diagnosed Reid with Schizoaffective disorder, and cocaine and alcohol use disorder in full remission. Id. The prognosis was “guarded, ” and Dr. Antiaris advised Reed to “continue with her current psychiatric and psychological treatment as provided.” Ex. 10 to Ans., R. at 868.

         As provided in her report, Dr. Antiaris observed that Reed was “cooperative, ” that her speech was “fluent and clear, ” and that her expressive and receptive language were “adequate.” Ex. 10 to Ans., R. at 867. Dr. Antiaris noted that Reid was “[c]oherent and goal directed, ” and found “no evidence of hallucinations, delusions, or paranoia” that day. Id. Dr. Antiaris stated that Reid is “able to dress, bathe, and groom herself, ” and “can cook, clean, do laundry, and shop.” Ex. 10 to Ans., R. at 868. Further, Reid “can manage her funds and take public transportation.” Id. Reid reported that she gets along well with her children and her sister, although she does not see her sister often. Id.

         Dr. Antiaris judged Reid's cognitive functioning to be in the “borderline range.” Ex. 10 to Ans., R. at 867. Dr. Antiaris noted that her “[g]eneral fund of information” was “appropriate to experience, ” that her insight was “fair, ” and that her judgment was “poor.” Id. She opined that Reid's attention and concentration were “[m]ildly impaired due to limited intellectual functioning, ” and that Reid's recent and remote memory skills were also “[i]mpaired due to limited intellectual functioning.” Id. Dr. Antiaris further assessed Reid to be “moderately limited” in her ability to: (i) “maintain attention and concentration and a regular schedule;” (ii) “learn new tasks and perform complex tasks independently;” and (iii) “make appropriate decisions and relate adequately with others.” Ex. 10 to Ans., R. at 868. Dr. Antiaris observed that Reid was “markedly limited” in her ability “to appropriately deal with stress, ” but that there were “no limitations” in Reid's “ability to follow and understand simple directions and instructions or perform simply tasks independently.” Id. Dr. Antiaris determined that Reid “does require supervision.” Id.

         ii. Dr. Stack's Opinion, dated March 25, 2015

         On March 25, 2015, Dr. Stack rendered an opinion on Reid's work capacity. Ex. 4 to Ans., R. at 94-105. She did not examine Reid, and appears to have given equal weight to Dr. Antiaris's report and Dr. Wolf's records in formulating her opinion. See Ex. 4 to Ans., R. at 99 (noting “[w]eight distributed between psy examiner and TP”). Based on the following limitations, Dr. Stack concluded that Reid was restricted to unskilled work and determined that Reid was not disabled. Ex. 4 to Ans., R. at 104.

         With respect to understanding and memory, Dr. Stack found “not significantly limited” Reid's ability to remember locations and work-like procedures, or her ability to understand or remember very short and simple instructions. Ex. 4 to Ans., R. at 101. Dr. Stack opined that Reid's ability to understand, remember, and carry out detailed instructions was “moderately limited, ” as was her ability to “maintain attention and concentration for extended periods.” Ex. 4 to Ans., R. at 101. She also concluded that Reid had “sustained concentration and persistence limitations.” Id.

         With respect to concentration and persistence, Dr. Stack found Reid “not significantly limited” in her ability to “perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances.” Ex. 4 to Ans., R. at 102. Her ability to: i) sustain an ordinary routine without special supervision; ii) carry out very short and simple instructions; and iii) make simple work-related decisions was likewise found to be “not significantly limited.” Ex. 4 to Ans., R. at 101, 102. In contrast, Reid was considered to be “moderately limited” in her ability to: i) carry out detailed instructions; ii) maintain attention and concentration for extended periods; and iii) work in coordination with or in proximity to others without being distracted by them. Id. Reid's ability to complete a normal workday and workweek without interruptions from psychologically-based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods was similarly found to be “moderately limited.” Id. at 102.

         With respect to social interactions, Dr. Stack found that Reid's ability to interact appropriately with the general public, as well as her ability to accept instructions and respond appropriately to criticism from supervisors, was “moderately limited.” Id. Reid's ability to ask simple questions, request assistance, and get along with coworkers or peers without distracting them or exhibiting behavioral extremes was found to be “not significantly limited, ...