CATHERINE M. SALINAS, Magistrate Judge.
Plaintiff Cleon Thelton Day III ("Plaintiff") brings this action pursuant to the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration (the "Commissioner") denying Plaintiff's application for a period of disability, disability insurance benefits ("DIB"), and supplemental security income ("SSI"). For the reasons set forth below, I
A claimant is considered disabled if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that is expected to result in death or has lasted or is expected to last for a continuous period of not less than twelve months.
At step one, the claimant must prove that he has not engaged in substantial gainful activity.
The issue in this appeal is whether the ALJ committed reversible error in failing to evaluate the following evidence in her decision: (1) the records of Christine Lloyd, MHA, a mental health technician at Grady Hospital and Plaintiff's case manager from September 2013 through December 2014; and (2) the records of Dana Abraham, LMSW, a senior licensed mental health clinician at Grady Hospital and the facilitator of Plaintiff's weekly outpatient depression group from September 2013 through November 2013.
Plaintiff and the Commissioner have set forth details of Plaintiff's medical history in their respective briefs. Each has emphasized different aspects of that history; however, neither party has objected to the facts as set forth by the other. I have considered all of these facts and do not find it necessary to repeat the medical evidence in the same level of detail as Plaintiff and the Commissioner. The relevant points are discussed below.
On October 12, 2012, Plaintiff applied for SSI benefits. [Doc. 8, Transcript ("Tr.") 224-32]. On October 30, 2012, Plaintiff applied for a period of disability and DIB. [Tr. 217-23]. In both applications, Plaintiff alleged a disability onset date of June 1, 2010. [Tr. 217, 224]. Plaintiff applied for these benefits based on the allegation that he was suffering from diabetes, high blood pressure, and depression. [Tr. 62, 74, 88, 102]. The Social Security Administration denied Plaintiff's applications initially on January 30, 2013, and upon reconsideration on April 4, 2013. [Tr. 60-115]. On April 18, 2013, Plaintiff requested a hearing before an administrative law judge ("ALJ") [Tr. 137], and the ALJ held a hearing on July 21, 2015, in Atlanta, Georgia [Tr. 32-56]. At the hearing, the ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from Joe Mann, a Vocational Expert. [Tr. 32-56].
On October 20, 2015, the ALJ issued her decision, finding that Plaintiff was not disabled under the Social Security Act. [Tr. 13-31]. Applying the sequential process required under 20 C.F.R. § 416.920, the ALJ made the following findings. At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since June 1, 2010, the alleged onset date. [Tr. 18]. At step two, the ALJ determined that Plaintiff had the following severe impairments: major depressive disorder, anxiety disorder, diabetes mellitus, hypertension, obesity, and gastroesophageal reflux disease. [Tr. 18-19]. At step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that meets or medically equals the severity of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1. [Tr. 19-21].
The ALJ went on to determine that Plaintiff had the RFC to perform less than a full range of medium work as defined in 20 C.F.R. §§ 404.1567(c) and 416.967(c), with the following limitations: occasionally lift fifty pounds and frequently lift twenty-five pounds; never climb ropes, ladders, and scaffolds due to symptoms of fatigue and medication side effects; occasionally climb ramps and stairs; occasionally stoop, kneel, crouch, crawl, and balance; avoid concentrated exposure to extreme vibrations, hazardous machinery, and unprotected heights; perform simple, routine, repetitive tasks in a work environment free of fast-paced production requirements; make simple work decisions (with few, if any, workplace changes); occasionally interact with co-workers, supervisors, and the public; and be off task up to ten percent of the workday. [Tr. 21-25]. In doing so, the ALJ evaluated the credibility of Plaintiff's statements regarding the intensity, persistence, and functionally limiting effects of his pain and other symptoms. [
The record evidence shows that Plaintiff consistently met in-person with Christine Lloyd, a mental health technician at Grady Hospital and Plaintiff's case manager, twice a month from September 2013 through December 2014. [Tr. 518-19, 522-24, 528-30, 568-72, 584-86, 592-95, 600-01, 605-06, 619-22, 625-42, 646-50, 656-61, 670-83, 689-90, 695-96]. Ms. Lloyd's role, in part, was to "educate [Plaintiff] on how to develop more effective coping skills and better manage behavioral health symptoms through the effective utilization of community resources, individual therapy and/or group therapy/training." [Tr. 523, 585, 605, 619, 632, 634, 639-40, 682]. Ms. Lloyd also noted that she would "provide necessary services to assist [Plaintiff] in his efforts to obtain community services, such as financial, transportation and support to help reduce environmental stressors[.]" [Tr. 594, 621, 625, 627-28, 641]. At each visit, Ms. Lloyd documented Plaintiff's mental and physical state and provided a short summary of their discussions. [Tr. 518-19, 522-24, 528-30, 568-72, 584-86, 592-95, 600-01, 605-06, 619-22, 625-42, 646-50, 656-61, 670-83, 689-90, 695-96]. At various visits, Ms. Lloyd noted that Plaintiff was sweating [Tr. 529, 637], his speech was pressured [Tr. 529, 569, 594, 600, 605, 619, 621, 627, 631, 637, 639], he presented with poor concentration and poor memory [Tr. 594, 628, 640-41], he made limited or poor eye contact [Tr. 529, 592, 600, 605, 631], and his mood appeared depressed or anxious at times. [Tr. 569, 571, 592, 600, 619, 628, 635, 650, 659, 689]. Ms. Lloyd and Plaintiff often discussed the status of his disability case [Tr. 519, 523, 689], education on diabetes and hypertension [Tr. 529, 586, 619-20, 626], housing options [Tr. 529, 592, 600, 606, 619-20, 626-29, 638, 647, 649-50, 658], and other issues with respect to obtaining food stamps, identification cards, and medication [Tr. 519, 571, 621-22, 633].
The record evidence also shows that Plaintiff attended a weekly outpatient depression group that was led by Dana Abraham, a senior licensed mental health clinician with Grady Hospital, between September 2013 and November 2013. [Tr. 515-17, 519-22, 524-25, 530-31, 541-50, 553-55, 560-61]. Ms. Abraham noted that Plaintiff "expressed difficulty with [the] ability to maintain positive thoughts related to [his] current living environment." [Tr. 516]. Ms. Abraham noted that Plaintiff was "regarded to have difficulty with interpersonal interactions[.]" [Tr. 517]. On November 11, 2013, Ms. Abraham noted that Plaintiff "was observed to be sad with blunted affect." [Tr. 545]. The following day, Ms. Abraham again noted that Plaintiff "was observed to be sad with blunted affect." [Tr. 546]. During that session, Ms. Abraham noted that Plaintiff "required frequent redirection regarding treatment goals as he was circumstantial in his thoughts and speech." [Tr. 547]. Ms. Abraham noted that Plaintiff had "a history of challenges with interpersonal relationships and is regarded to have some significant [n]arcicisstic [sic] traits as evidenced by his report of interactions and behavior in group setting (i.e. [e]xploitative of others, arrogant, grandiose re past titles and work experience, regards himself as special, entitled)." [Tr. 547]. That same day, Plaintiff reported "experiencing frequent thoughts of suicide and death" over the last one to two years. [Tr. 548, 550]. Ms. Abraham explained that Plaintiff's symptoms of depression were "exacerbated by his personality structure re his beliefs about himself and the world." [Tr. 549].
The ALJ did not mention Ms. Lloyd or Ms. Abraham's records in her decision, simply stating that "there were few treatment records" with respect to Plaintiff's mental impairments. [Tr. 22].
In light of her RFC finding, the ALJ noted that Plaintiff "is unable to perform any past relevant work" but that "there are jobs that exist in significant numbers in the national economy that the claimant can perform[.]" [Tr. 25]. Accordingly, the ALJ concluded that Plaintiff was not disabled from June 1, 2010, his alleged disability onset date, through the date of the ALJ's decision. [Tr. 26]. Following the ALJ's October 20, 2015 adverse decision, Plaintiff requested that the Appeals Council review the ALJ's decision, arguing that the decision contained errors of law and fact. [Tr. 10-12]. On November 22, 2016, the Appeals Council denied Plaintiff's request for review, declining to review the ALJ's decision. [Tr. 1-6]. When the Appeals Council denied Plaintiff's request, the ALJ's decision became the final decision of the Commissioner.
Affirmance of the Commissioner's decision is mandatory if her conclusions are supported by substantial evidence and based upon an application of correct legal standards.
On appeal, Plaintiff argues, among other things, that the ALJ erred in concluding that there were "few treatment records" with respect to Plaintiff's mental impairments, because the ALJ disregarded the records containing Ms. Lloyd and Ms. Abraham's impressions and notes. [Doc. 15 at 16-19]. Plaintiff argues that the ALJ was required to consider those records when assessing Plaintiff's mental limitations and that her failure to do so constitutes reversible error. [
The plaintiff has the burden of providing medical and other evidence about his impairments for the ALJ to use in reaching her conclusions.
At issue here are the records of Ms. Lloyd and Ms. Abraham. Plaintiff argues that these are "non-acceptable other medical source[s]" that the ALJ improperly ignored in her decision. [Doc. 15 at 18]. The Commissioner disagrees, arguing that "no acceptable medical source at Grady opined that Plaintiff had disabling mental limitations." [Doc. 18 at 13]. I conclude that even if Ms. Lloyd and Ms. Abraham are non-medical sources, the case must be remanded. The Regulations and rulings require that an ALJ consider all relevant evidence in the case record, including opinion evidence from non-medical sources.
20 C.F.R. § 416.902(j).
It is evident from the record that Ms. Lloyd helped Plaintiff manage his affairs, assisted Plaintiff with finding housing, and educated Plaintiff on his medical conditions. [Tr. 519, 523, 529, 571, 586, 592, 600, 606, 619-22, 626-29, 633, 638, 647, 649-50, 658, 689]. The record also shows that Ms. Abraham facilitated at least ten depression group sessions that Plaintiff attended. [Tr. 515-17, 519-22, 524-25, 530-31, 541-50, 553-55, 560-61]. As a mental health technician and a senior licensed mental health clinician, Ms. Lloyd and Ms. Abraham appear to qualify as people employed by a "social welfare agency," which would make them acceptable non-medical sources whose opinions may be considered.
"While an ALJ is not required to discuss every piece of evidence on the record, [s]he must nonetheless `develop a full and fair record,' which, at least, means that h[er] opinion must describe h[er] analysis with enough detail to satisfy a reviewing court that [s]he gave all of the relevant evidence before h[er] its due regard."
In this case, the ALJ stated that there were "few treatment records" with respect to Plaintiff's mental impairments, and she did not explicitly mention the records of either Ms. Lloyd or Ms. Abraham in her decision. [Tr. 22]. Plaintiff argues this is reversible error. [Doc. 15 at 17-19]. Although the Commissioner concedes that Ms. Lloyd "occasionally noted [Plaintiff's] mental health symptoms in her records," the Commissioner argues, in part, that the ALJ's failure to discuss Ms. Lloyd and Ms. Abraham's records does not constitute error because Ms. Lloyd and Ms. Abraham were not medical health care providers and were thus not acceptable medical sources. [Doc. 18 at 13-14]. This argument, however, ignores the fact that non-medical sources can be used to show the severity of a claimant's impairments as well as a claimant's functional capabilities.
Ms. Lloyd met with Plaintiff in-person twice a month for fifteen months, from September 2013 through December 2014. [Tr. 518-19, 522-24, 528-30, 568-72, 584-86, 592-95, 600-01, 605-06, 619-22, 625-42, 646-50, 656-61, 670-83, 689-90, 695-96]. Plaintiff attended Ms. Abraham's weekly outpatient depression group from September 2013 through November 2013. [Tr. 515-17, 519-22, 524-25, 530-31, 541-50, 553-55, 560-61]. Both Ms. Lloyd and Ms. Abraham provided assessments of Plaintiff's mental condition after each visit or session, and they both documented any notable observations, including when Plaintiff exhibited a depressed or anxious mood [Tr. 569, 571, 592, 600, 619, 628, 635, 650, 659, 689] or when Plaintiff appeared sad with blunted affect [Tr. 545-46]. Importantly, Plaintiff reported "experiencing frequent thoughts of suicide and death" to Ms. Abraham during one of their sessions. [Tr. 548]. The ALJ, however, failed to even mention Ms. Lloyd and Ms. Abraham's impressions and notes in her decision, much less evaluate their assessments. Although these records provide some evidence that Plaintiff suffered from mental limitations that could have affected his ability to work during the relevant period, the ALJ stated that the there were "few treatment records" with respect to Plaintiff's mental impairments, making it likely that the ALJ simply overlooked the records. [Tr. 22]. While the ALJ could have discounted these records, it is unclear whether that is what happened. The ALJ's failure to acknowledge the existence of these non-medical sources suggests an oversight on the part of the ALJ, requiring remand.
While I recognize that the ALJ is not required to specifically refer to every piece of evidence in her decision,
The Eleventh Circuit has determined that "[w]hen . . . an incorrect application of the regulations results in harmless error because the correct application would not contradict the ALJ's ultimate findings, the ALJ's decision will stand."
Because it is impossible for the Court to determine whether the ALJ considered all of the evidence in the record, this case must be remanded. On remand, the ALJ must consider the opinions of all of Plaintiff's examining and treating medical sources, as well as the opinions of appropriate non-medical sources, and give the proper weight to the testimony and statements of each as required by the law of this Circuit.
Plaintiff has raised other challenges to the ALJ's decision, including, but not limited to, Plaintiff's arguments regarding the ALJ's assignment of only "some weight" to the opinion of consultative examiner Anne Moore, Psy.D. and the ALJ's adverse credibility finding. [Doc. 15 at 14-24]. Because this case is due to be remanded for the reasons discussed above, the analysis of the ALJ may change. Therefore, I do not find it necessary, at this stage of the review process, to address Plaintiff's other arguments. Those arguments, however, should be considered by the ALJ on remand.
When making a credibility determination on remand, the ALJ is reminded that the GAF scale has been abandoned as a measurement tool and recognized to have questionable value.
For the foregoing reasons, I