JONATHAN W. FELDMAN, Magistrate Judge.
Plaintiff Rosalyn Fountaine ("plaintiff" or "Fountaine") brought this action pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3) seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI").
Plaintiff filed her applications for DIB on July 29, 2014 and for SSI on August 20, 2014, alleging disability beginning on March 1, 2014. Administrative Record ("AR"), Docket # 9, at 209-21. Plaintiff's applications were initially denied on November 24, 2014. AR at 114-49, 206-08. Plaintiff appeared at the hearing before Administrative Law Judge Michael Carr ("the ALJ") with counsel on March 8, 2016. AR at 41. Plaintiff, her daughter, and a vocational expert testified at the hearing. AR at 41-98.
The ALJ issued an unfavorable decision on August 19, 2016. AR at 12-30. Plaintiff timely filed a request for review by the Appeals Council ("AC").
This case presents a troubling administrative determination involving an applicant who undeniably suffers from disabling mental illness. The deferential standard of review that this Court is required to apply in this proceeding does not require it to turn a blind eye to what is readily apparent from a fair reading of this record: Rosalyn Fountaine is disabled from competitive full-time employment.
At step two of the familiar five-step sequential disability determination process, the ALJ acknowledged that Fountaine had the following severe impairments: generalized anxiety disorder, major depressive disorder, and post-traumatic stress disorder ("PTSD").
Indeed, virtually every medical report, note, or opinion in this record pays tribute to the severity of plaintiff's psychiatric issues. A sampling would include the following: In 2007, plaintiff was hospitalized for extreme depression and anxiety and admitted to self-medicating with alcohol. AR at 290. Her mood continued to be turbulent and depressed throughout 2010 and her thinking was disorganized and erratic. AR at 398-99. In 2011, she tried to kill herself by overdosing on medication. AR at 287. Two years later, plaintiff again tried to kill herself by repeatedly stabbing herself in her arm. AR at 33. In 2014, plaintiff attempted to shoot herself, but her suicide plan was foiled by her daughter. AR at 33. Fountaine's suicidal ideations and serious mental health issues continued despite repeated efforts to control them. In summer 2014, plaintiff was hospitalized due to severe depression and intrusive thoughts of suicide. AR at 328. Medical providers consistently noted that plaintiff had trouble organizing coherent, rational thoughts. AR at 463, 1233. In late July 2014, plaintiff was again hospitalized for hearing voices and self-harm. AR at 111. Her Global Assessment of Functioning ("GAF") was assessed at 40 (AR at 111, 300-01) and was 55 at discharge. AR at 326. Plaintiff's thought process continued to be disorganized, confused, and bizarre. She reported to medical appointments tearful and expressing feelings of anxiety and being overwhelmed. AR at 475, 478. On September 1, 2014, the police brought plaintiff to the hospital because plaintiff allegedly attempted, again, to overdose on medication. AR at 519, 714-15. Fountaine was admitted to the psychiatric ward where she was diagnosed with recurrent major depression and a GAF of 35. AR at 1026, 1156. The medical records list plaintiff's triggers as loud people, financial issues, aggression, and work-related stress. AR at 1130. When Fountaine was discharged less than a week later, her GAF was 65. AR at 983. Several months later, in December 2014, plaintiff again tried to overdose. AR at 524. Plaintiff reported anxiety and depression and was observed to have poor insight, judgment, attention span, and memory, as well as alcohol and opiate dependence. AR at 556, 629. Her GAF was 25. AR at 556. In June 2015, plaintiff continued to have anxiety, depression, racing thoughts, and insomnia. AR at 494. She repeatedly indicated her desire to end her life and tried group counseling but the counseling provoked panic attacks. AR at 505-09. Over a year later, in August 2016, plaintiff was yet again admitted after attempting to overdose on 15 tablets of Klonopin, six tablets of Xanax, and ten beers. AR at 32. Her risk was assessed to be moderate to high because she continued to have suicidal thoughts with a plan. AR at 33-34. Records from plaintiff's treating physician indicate that plaintiff appeared unkempt and hopeless and had a flat affect, depressed mood, and impaired memory, even despite weekly therapies. AR at 101-05.
At the time of the hearing before the ALJ, plaintiff did not have her own place to live, and alternated between staying at her daughter's apartment and with a "friend." AR at 62, 83. Being homeless also compounded plaintiff's stress. AR at 64-65, 75-76. Fountaine told the ALJ that she did not like to "burden" her daughter, but her daughter, who was studying to be a nurse, testified that she was concerned about Fountaine's mental health and perilous living situation. AR at 61, 79-88. Plaintiff's daughter further testified that her mother's PTSD, depression, and anxiety had been "very, very severe" in the months prior to her hearing. AR at 80. Her conditions resulted in "a lot of breakdowns" and multiple hospitalizations at St. Joe's Hospital Behavioral Science Unit. AR at 80, 517-1231. When plaintiff had breakdowns, she would get "very nervous, shaky, tearful, crying, emotional." AR at 86. The breakdowns would also sometimes "get out of hand" when plaintiff "tried to hurt herself."
Plaintiff's daughter told the ALJ that she observed her mother's sudden mood swings and her difficulties with comprehension and memory. AR at 81, 84. She testified that plaintiff struggles with "following directions and how to get places or appointments" and struggles to complete paperwork and recall events. AR at 80-84. Despite being sober for six months prior to the hearing, plaintiff admitted to struggling to maintain her sobriety. AR at 76, 83. When plaintiff experiences a depressive episode, she cannot shop, cook, do house chores, or do anything for herself. AR at 87. These "depressive fits" can last for up to a week. AR at 87.
In addition to the testimony of plaintiff and her daughter, which undeniably corroborated plaintiff's medical history, the ALJ also had the benefit of opinion evidence from plaintiff's treating mental health therapist. In an opinion letter dated February 2, 2016, plaintiff's treating therapist, Dr. Catherine Zaffarano informed the ALJ that she had been treating plaintiff weekly since November 2015 utilizing "several different modalities for coping with severe PTSD and Major Depressive Disorder." AR at 516. In Dr. Zaffarano's opinion, plaintiff was not "capable of being employed".
Based on this administrative record, the ALJ determined that plaintiff has the ability "to perform a full range of work at all exertional levels" so long as she is "limited to performing simple routine and repetitive tasks" and is limited to "simple work-related decisions." AR 19-20. Based on a hypothetical posed to a Vocational Expert ("VE"), the ALJ determined that plaintiff could find employment as a "warehouse worker", an "industrial cleaner", or a "kitchen helper." AR at 26.
The ALJ's decision is not supported by substantial evidence for several reasons. First, the ALJ decided to give "limited weight" to the only opinion in the record from a treating source, plaintiff's mental health therapist. The Commissioner advises disability applicants of the importance of submitting medical opinions from treating sources.
Our circuit has also been blunt on what an ALJ must do when deciding not to give controlling weight to a treating physician:
Here, the ALJ assigned what he described as "limited weight" to the medical opinions of the claimant's treating mental health providers. AR at 23. His justifications meet neither the letter nor the spirit of the treating physician rule. The ALJ accorded Dr. Zaffarano's opinion limited weight because of a lack of treatment notes and "objective clinical findings" to substantiate the opinion and because "[i]t would appear that if the claimant were able to do all of these [therapies] while attending outpatient services at Cloud Nine,
The ALJ's primary reasoning is that because plaintiff attended treatment, she must be able to work. First, it is not true that plaintiff regularly attends treatment. In fact, Fountaine's inability to engage in consistent treatment underscores her mental illness. Dr. Zaffarano's treatment notes document plaintiff's inability to maintain a schedule and demonstrate that she erratically appeared early at Cloud Nine Wellness, failed to attend classes at all, or intermittently did so. AR at 104-07. They also document plaintiff's inability to accept or follow instructions, and underscore that plaintiff needed constant reminders to make appointments with various medical professionals, take her medications, and was told month after month to follow a specific care plan that she seemingly could never comply with. AR at 101, 104-05, 107-08. Second, even if plaintiff attended treatment with some frequency, such attendance would not mean that she can mentally cope with a full-time job.
Even without Dr. Zaffarano's treatment notes, her opinions as expressed in her mental RFC report (AR at 1265-66) were well-supported by the extensive medical record and hearing testimony discussed above. These records unquestionably support and are fully consistent with Dr. Zaffarano's opinion that plaintiff's mental illness would prevent her from engaging in full-time employment in a competitive work environment. Moreover, the ALJ's reliance on a single comment from plaintiff that she felt "happy" or that she experienced some "improvement" as justification for a disability decision on
While assigning little weight to the treating source, the ALJ assigned "great weight" to the opinion of psychologist Sara Long. Long met with plaintiff On a single occasion in October 2014. In the context of this record, the ALJ giving "great weight" to the opinion of a non-treating source
Based on the evidence in the record, Rosalyn Fountaine is disabled. Remand for further record development and more administrative proceedings, or another hearing, would serve no useful purpose.
Accordingly, plaintiff's motion for judgment on the pleadings (Docket # 10) is