MICHAEL A. PONSOR, District Judge.
Plaintiff, Antonio Arzola, appeals the final decision of Defendant, Carolyn W. Colvin, Acting Commissioner of the Social Security Administration, denying his application for disability benefits. Defendant has moved to affirm her decision. The issues are, first, the weight to be accorded to the opinion of Plaintiff's therapist and, second, the inclusion of a prior job that has an exertional level outside of Plaintiff's residual functioning capacity. For the reasons stated below, the court will deny Plaintiff's motion and allow Defendant's motion.
At the time of his initial application, Plaintiff was a 51-year-old male (d.o.b. 09/27/1960) claiming disability due to human immunodeficiency virus (HIV), hepatitis C, low back pain, high blood pressure, anxiety, and depression. He attended high school until 10th grade and then obtained a GED. Plaintiff previously worked doing sewing on a production line and as a warehouse worker. He was incarcerated from 2006 until 2010 for drug-related crimes. (A.R. 307.)
Because Plaintiff's challenge to the ALJ's decision is limited to her determinations with respect to Plaintiff's mental health, the court will focus on that area of the evidence. The following recitation of facts is drawn from the Administrative Record. (SSA Admin. R. of Soc. Sec. Proceedings, Dkt. No. 14 (hereinafter "A.R.").)
On May 20, 2010, Plaintiff sought treatment for his mental health issues at the River Valley Counseling Center. Catherine Gressler, a licensed mental health counselor, conducted his initial evaluation and prepared his treatment plan. (A.R. 306-10.) As part of the initial intake, Ms. Gressler reported on the "Brief Psychiatric Rating Scale" section of the intake form that Plaintiff had extremely severe symptoms of somatic concern,
On August 26, 2010, Ms. Gressler completed a form on Plaintiff's behalf for the Massachusetts Rehabilitation Commission Disability Determination Services. (A.R. 335-338.) She identified Plaintiff's psychiatric diagnosis as PTSD and polysubstance dependence, and she described his mental status at that time as "severely depressed, guilty, anhedonic." (A.R. 336.) With respect to his daily activities and interpersonal relationships, Ms. Gressler stated that Plaintiff could take care of himself independently, but that he could "not focus sufficiently to read a newspaper" and he "requires assistance with complex serial tasks." (
Ms. Gressler also reported that Plaintiff could not sustain his concentration and attention for extended periods because his thoughts distracted him. However, in response to the form's query about Plaintiff's memory, Ms. Gressler answered that his ability to remember instructions and work-related tasks was within normal limits ("WNL"). (A.R. 336.) She remarked that Plaintiff would handle routine stress poorly because he "has low frustration tolerance and is irritable," but his ability to get along with others in both work and home situations was within normal limits. (A.R. 337.)
Though Plaintiff attended psychotherapy twice a month and had been referred for a psychopharmacology medication evaluation, Ms. Gressler did not conduct any psychological testing. She opined that Plaintiff's prognosis was good and that she did not expect the duration of his episode of significant impairment to last beyond 12 to 18 months. (A.R. 338.) Because she was not an M.D. or a licensed psychologist, Ms. Gressler's report was co-signed by Dr. Donna Cohen, as required by the instructions on the Massachusetts Rehabilitation Commission's form. (A.R. 338.)
In September 2010, Ms. Gressler filled out another disability assessment form for Plaintiff. She listed his diagnosis as severe depression, marked by anhedonia, sleep disturbance, feelings of guilt or worthlessness, and thoughts of suicide. (A.R. 618.) She found him to have marked restrictions in the activities of daily living and in maintaining social functioning, as well as deficiencies in concentration, persistence, and pace. (A.R. 619.)
Sometime later, Ms. Gressler completed a third assessment of Plaintiff's mental impairments, in which she identified Plaintiff's diagnosis as PTSD. (A.R. 564.) She listed his depression under "clinical findings" and labeled his prognosis as "guarded." (
On May 18, 2011, Ms. Gressler revisited Plaintiff's treatment plan. (A.R. 548-53.) She reiterated the diagnoses as major depressive disorder and polysubstance dependence and noted that his GAF of 45 remained unchanged throughout the year. Ms. Gressler noted Plaintiff's pleasant and cooperative attitude, coupled with his engagement in the "therapeutic alliance," as his strengths, and emphasized his severe medical issues as his barriers to treatment. (A.R. 548.) On the "Brief Psychiatric Rating Scale," she rated his anxiety and depression as improved — now "moderate" instead of "extremely severe." (A.R. 553.) Plaintiff's emotional withdrawal and tension were "very mild." (
In addition to his sessions with Ms. Gressler, Plaintiff also saw Sharlene Hernandez, APRN, for medication management approximately every two months during this time period. (A.R. 380-83, 496-97, 540-47, 554-62.) Plaintiff first visited Ms. Hernandez for a "Psychopharm Diagnostic Assessment" on August 16, 2010. Ms. Hernandez found Plaintiff's dress and grooming, speech, and thought process to be within normal limits. (A.R. 496.) She marked his judgment, insight, and concentration as fair and his eye contact and rapport as good. Plaintiff's depressive symptoms were moderate, though he experienced tearfulness, reduced interest, and psychomotor retardation. His symptoms of anxiety were also moderate most of the time, with some nightmares, intrusive memories, and panic attacks. (
Plaintiff returned for medication management roughly every eight weeks for the following year. Most of Ms. Hernandez's observations from the previous visit were either unchanged or improved. For example, on October 5, 2010, she found Plaintiff to be "full range/appropriate" with respect to his affect, and his judgment, insights, and concentration improved from fair to good. (A.R. 380.) Ms. Hernandez indicated that both Plaintiff's depressive and anxiety symptoms were mild to moderate.
Though Plaintiff's condition fluctuated between the moderate and mild symptom range, his presentation with respect to affect, cognitive functioning, and thought process remained largely unchanged throughout his appointments in October 2010 (A.R. 560-61), December 2010 (A.R. 558-59), February 2011 (A.R. 556-557), April 2011 (554-55), June 2011 (A.R. 546-47), August 2011 (A.R. 543 & 545), October 2011 (A.R. 542 & 544), and December 2011 (A.R. 540-41). In this period, his biggest challenges were his difficulties falling asleep, the multiple awakenings a night, his panic attacks, nightmares, and intrusive memories — for which Ms. Hernandez adjusted his medications several times — as well as his increased guilt and anxiety associated with a few relapses in his substance dependence. (A.R. 559.) Despite these setbacks, Plaintiff never reported, and Ms. Hernandez never assessed, depression or anxiety symptoms greater than moderate; moreover, Plaintiff consistently denied ever having suicidal thoughts.
On October 26, 2010, as part of a consultative examination requested by the Massachusetts Rehabilitative Commission, Leon Hutt, Ph.D., examined Plaintiff. (A.R. 344-46.) Dr. Hutt reported that Plaintiff presented as polite and cooperative, fully alert and well oriented to time and place, and with clear, relevant, and coherent speech. However, the doctor found Plaintiff's attention capacity to be mildly impaired and quantitative reasoning to be well below average. Further, he estimated that Plaintiff performed in the low average range of adult intellectual function. (A.R. 345.) Dr. Hutt diagnosed Plaintiff with opioid dependence in full remission and major depressive disorder, recurrent, while assigning him a GAF score of 65.
On November 2, 2010, Ginette Langer, Ph.D., completed a consultation form, based on Plaintiff's treatment records at River Valley, as well as Dr. Hutt's evaluation, regarding Plaintiff's disability application. (A.R. 347-59.) She assessed Plaintiff as having mild restrictions in the activities of daily living and in maintaining social function and as having moderate difficulties in maintaining concentration, persistence, or pace. (A.R. 357.) After reviewing the application, Dr. Langer specifically noted that, though Plaintiff's claim of depression was supported by the records, Ms. Gressler's PTSD diagnosis differed from the major depressive disorder diagnosis and was not consistently supported by the medical providers. (A.R. 359.)
On the "Mental Residual Functional Capacity Assessment" completed by Dr. Langer, she found Plaintiff only moderately limited in the areas of ability to carry out detailed instructions, to maintain attention and concentration for extended periods, and to interact appropriately with the general public. (A.R. 375-76.) Additionally, Dr. Langer marked Plaintiff as moderately limited in the "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." (A.R. 376.) In sum, Dr. Langer concluded that Plaintiff had no significant limitations.
On May 4, 2010, Plaintiff filed his application for Supplemental Security Income (SSI), alleging a disability onset date of April 30, 2010.
On January 10, 2012, Plaintiff appeared with counsel at a hearing in front of the ALJ. Plaintiff testified at the hearing that he suffered from depression and anxiety. (A.R. 96 & 105.) He described feelings of occasional panic attacks when out shopping, along with days when he felt nervous and cried a lot. Plaintiff also spoke of his insomnia and problems remembering things. (A.R. 106.)
The vocational expert, Jeffrey Blank, Ph.D., testified that Plaintiff's previous work experience would be classified as unskilled and at either a sedentary or medium exertional level. (A.R. 111.) Given certain restrictions in exertion and movement, and with limitations to unskilled positions with occasional interaction with the public, Dr. Blank concluded that an individual with Plaintiff's age, education, and past work experience could return to his past work and perform other work as a small products assembler or packer. (A.R. 111-12.) However, when the ALJ added the limitation that Plaintiff might be absent more than three days a month, the vocational expert stated that Plaintiff could not return to past work and would be unable to perform any other work.
On January 26, 2012, the ALJ issued an unfavorable decision to Plaintiff, finding that he was not disabled.
The ALJ followed the five-step sequential disability determination. 20 C.F.R. § 416.920. At step one, she determined that Plaintiff had not been engaged in substantial gainful activity since May 4, 2010, the application date. At step two, she found that Plaintiff had the severe impairments of HIV, hepatitis C, low back pain, post-traumatic stress disorder, and depressive disorder. (A.R. 69.)
At step three, the ALJ found that Plaintiff's impairments did not meet or medically equal an entry on the List of Impairments, 20 C.F.R. § 416.920(d), -.925 & -.926. At step four, the ALJ found that Plaintiff had a residual functional capacity (RFC) to perform light work, except that Plaintiff would be
(A.R. 71.) Considering these limitations, the ALJ determined that Plaintiff was capable of returning to his past work as a temporary worker, a sewer on a production line, and a warehouse worker.
Proceeding nonetheless to step five, the ALJ found that there were a significant number of jobs in the local and national economies that Plaintiff could perform, such as a small products assembler or a packer. Thus, the ALJ determined that Plaintiff was not disabled.
On March 16, 2012, Plaintiff appealed this decision to the Appeals Counsel, which denied his request. Consequently, the ALJ's decision became final and subject to judicial review.
The Social Security Act sets forth the requirements for receiving disability insurance:
42 U.S.C. § 423(d)(2)(A). In applying this standard, the plaintiff "has the burden of showing a disability serious enough to prevent him from working at his former jobs, at which point the burden shifts to the [Commissioner] to show the existence of other jobs in the national economy that the [plaintiff] can nonetheless perform."
In reviewing a decision by the Commissioner, the findings "as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). The court must defer to the Commissioner on the resolution of conflicts in the evidence and uphold the Commissioner's decision "if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support [the] conclusion."
Plaintiff presents two challenges to the ALJ's decision. First, Plaintiff argues that the ALJ erred in according Ms. Gressler, his treating clinician, little credibility.
It is true that, in determining Plaintiff's mental RFC, the ALJ granted little weight to the opinions of Ms. Gressler, Plaintiff's therapist. The ALJ offered six reasons for this, two of which Plaintiff challenges. Plaintiff first asserts that the ALJ's rejection of Ms. Gressler's opinion as a treating source on the sole basis that the therapist is not an "acceptable medical source," 20 C.F.R. § 404.1513(a), was improper. Technically, Plaintiff is correct that an ALJ may not reject outright evidence from therapist solely because it is not from an "acceptable medical source."
While an ALJ must give controlling weight to treating sources who are acceptable medical sources (as long as the opinion is well supported by the evidence), an ALJ may use her discretion in assigning the weight to opinions of "other medical sources."
With respect to those remaining five reasons, Plaintiff objects to the ALJ's conclusion that Ms. Gressler's assessment relied too heavily on Plaintiff's self-reporting (which was inconsistent with the medical record), and to the ALJ's conclusion that Ms. Gressler's opinion was contradicted by that of Ms. Hernandez. Plaintiff further contends that in citing discrepancies between Plaintiff's testimony of his limitations and the medical evidence, the ALJ failed to actually identify those inconsistencies.
These arguments are unpersuasive. To begin with, other than the intake form (A.R. 307), the initial treatment plan (A.R. 301), and the annual treatment plan update (A.R. 548), the only other medical records by Ms. Gressler are the three administrative forms she completed on behalf of Plaintiff for his applications for disability income. There are no notes or summaries of his twice-monthly visits with Ms. Gressler, nor are there any reports of any testing or other assessments Plaintiff might have undergone during his treatment. Thus, the ALJ had to look elsewhere in search of support for Ms. Gressler's conclusions.
Turning to the rest of the medical record, however, there is little support for Ms. Gressler's opinion about the severity of Plaintiff's impairments, as the ALJ noted in her thorough review of the evidence she considered. In the records of the eight medication management visits Plaintiff had with Ms. Hernandez,
Furthermore, the ALJ noted that the conclusions of the state agency consultants were consistent with Ms. Hernandez' assessments. This included the in-person evaluation conducted by Dr. Hutt.
Finally, Plaintiff urges the court to remand his case because the ALJ included warehouse work as a past job Plaintiff could still perform despite an RFC limiting him to light exertional work. Defendant concedes that warehouse work is, in fact, considered to be medium exertional work and that including it was an error. Nonetheless, Plaintiff's other past work as a sewer falls within his RFC.
Moreover, even if the ALJ had concluded that Plaintiff could not return to his past work, at step five of the analysis the ALJ identified the jobs of small products assembler and packer — both work that exists in significant numbers in the local and national economy — that Plaintiff could perform with modest accommodation. 20 C.F.R. § 416.920(g). Plaintiff does not challenge this finding. There is no basis, therefore, for remand.
This court, were it reviewing the case de novo, might reach a conclusion different from the ALJ's. But where there is substantial evidence justifying the result that was reached, as there was here, the court is obliged to affirm her decision.
For the foregoing reasons, Plaintiff's motion is DENIED (Dkt. No. 17), and Defendant's motion is ALLOWED (Dkt. No. 25). The clerk shall enter judgment for Defendant, and this case may now be closed.
It is So Ordered.
