United States District Court, D. Connecticut
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, ...