United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
JOHN M. BODENHAUSEN, Magistrate Judge.
Plaintiff Laura Fletcher ("Plaintiff") brings this action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the Commissioner's final decision denying her applications for Supplemental Security Income ("SSI"), under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. All matters are pending before the undersigned United States Magistrate Judge, with consent of the parties, pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the decision of the Commissioner shall be reversed and the matter is remanded for proceedings consistent with this Memorandum and Order.
I. PROCEDURAL HISTORY & SUMMARY OF DECISION
Plaintiff filed an application for SSI benefits in January 2011, alleging a disability onset date of January 1, 2011. After her application was denied on June 28, 2011, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"), which was held on November 27, 2012. Two witnesses testified at the hearing - Dr. Gerald Belchick, a vocational expert ("VE"), and Plaintiff. Prior to the hearing, Plaintiff amended her onset date to June 18, 2012. On April 9, 2013, the ALJ issued an unfavorable, written decision, finding that Plaintiff was not under a disability, as defined by the Social Security Act. (Tr. 10-19)
In denying Plaintiff's claim of disability, the ALJ followed the familiar five-step sequential evaluation process for determining whether Plaintiff was disabled within the meaning of the Act. (Tr. 10-12) See 20 C.F.R. §§ 404.1520(a) and 416.920(a). At step one, the ALJ found that Plaintiff was not engaged in substantial gainful activity since her alleged onset date. At step two, the ALJ found that Plaintiff suffered from two severe impairments - psychotic disorder (NOS) and polysubstance abuse. No physical impairments were noted. (Tr. 12-13) At step three, the ALJ concluded that Plaintiff's mental impairments did not meet or equal the criteria for a listed impairment. (Tr. 13-15) The ALJ found that Plaintiff had only mild restrictions relative to the activities of daily living, moderate difficulties relative to social functioning, and moderate difficulties with concentration, persistence, or pace. (Tr. 14)
At step four, the ALJ assessed Plaintiff's residual functional capacity ("RFC") as follows:
[T]he claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: the claimant is able to understand, remember, and carry out at least simple instructions and non-detailed tasks and to respond appropriately to supervisors and co-workers in a task oriented setting where contact with others is casual and infrequent. The claimant cannot have constant/regular contact with the general public and cannot perform work which includes more than infrequent handling of customer complaints. The claimant cannot perform work in an environment in close proximity to alcohol/controlled substances.
(Tr. 15) In making this RFC assessment, the ALJ declined to give any weight to a medical source statement completed by Dr. Jaron Asher on October 31, 2012. (Tr. 16-17) Dr. Asher was Plaintiff's treating psychiatrist. The ALJ also found Plaintiff's credibility to be "weakened." (Tr. 17-18)
Plaintiff filed a timely request for review by the Appeals Council. On March 14, 2014, the Appeals Council denied Plaintiff's request (Tr. 1), leaving the ALJ's April 9, 2013, decision as the final decision of the Commissioner in this matter. Plaintiff has exhausted her administrative remedies and the matter is properly before this Court.
In her request for judicial review, Plaintiff contends that the ALJ erred in declining to give any weight to the medical source statement of Dr. Asher. (ECF No. 19 at 13) In her argument, Plaintiff notes that the ALJ apparently misunderstood some of Dr. Asher's observations regarding the frequency of Plaintiff's auditory hallucinations. (Id. at 23) The Commissioner agrees that the ALJ made this mistake. (ECF No. 22 at 5-6) The Commissioner contends, however, that the mistake does not require a remand.
Having reviewed the record, and in light of controlling legal standards, the Court concludes that substantial evidence does not support the Commissioner's decision. As explained in detail below, the ALJ's mistake regarding the frequency of Plaintiff's hallucinations is significant. The ALJ's misunderstanding regarding Dr. Asher's observation resulted in a finding of an inconsistency where there was none. Correcting that mistake has the potential to impact the proper weight to be given to Dr. Asher's medical source statement, as well as the proper assessment of Plaintiff's credibility. Accordingly, the matter must be remanded for further proceedings.
II. SUMMARY OF RECORD
A. General History and Characteristics of Plaintiff
At the time of her hearing, Plaintiff was 26 years old. Plaintiff has a lengthy history of mental illness, dating back to when she was approximately ten years old. The record indicates that Plaintiff was initially diagnosed with depression. Over the years, Plaintiff has also been diagnosed with schizophrenia. Plaintiff has a significant history of polysubstance abuse, including the use of heroin, marijuana, and alcohol. Plaintiff completed high school at an alternative high school. Plaintiff completed some college, as well as an EMT course. Plaintiff has scant work history - working briefly in 2008 and again in 2009, with lifetime earnings of less than $4, 000. (Tr. 118, 120)
As reflected the record, Plaintiff has been treated by a number of psychiatrists over the years. Plaintiff has also been hospitalized due to her mental illness and substance abuse. For example, Plaintiff was hospitalized in September 2008 at St. John's Mercy Medical Center due to a "recent exacerbation of auditory hallucinations and social withdrawal." (Tr. 194-214) In June 2012, Plaintiff was hospitalized for acute opiate withdrawal. Upon her discharge, Plaintiff received out-patient treatment and assistance at Places for People. Plaintiff amended her alleged disability onset date to coincide with her discharge in June 2012.
B. Summary of Administrative Hearing
On November 27, 2012, the ALJ conducted a hearing on Plaintiff's case. Plaintiff was represented by counsel at the hearing. Two witnesses testified during the hearing - Plaintiff and Dr. Gerald Belchick, a VE. Plaintiff testified that she had about two years of college education. (Tr. 26-27) Plaintiff explained that she had never worked a full-time job for six months or longer. (Tr. 27) Plaintiff had completed opiate detox, followed by rehab in June 2012. (Tr. 27-28) Plaintiff testified that she began seeing Dr. Asher after her prior psychiatrist had medical problems. (Id.) Plaintiff explained that she has been "schizophrenic for years, " with symptoms including visual, auditory, and tactile hallucinations. (Id.) At the time of her hearing, Plaintiff advised she had not used opiates since ...