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5 UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 ANDREA T., 8 Plaintiff, CASE NO. C22-5841-BAT 9 v. ORDER REVERSING THE 10 COMMISSIONER’S DECISION COMMISSIONER OF SOCIAL SECURITY, 11 Defendant. 12
13 Plaintiff appeals the ALJ’s finding that she is not disabled. She contends the ALJ 14 erroneously discounted (1) the April 2021 opinion of examining psychologist Terilee Wingate, 15 Ph.D.; (2) Plaintiff’s testimony; and (3) a lay statement. Dkt. 13 1. For the reasons below, the 16 Court REVERSES the Commissioner’s final decision and REMANDS the matter for further 17 administrative proceedings under sentence four of 42 U.S.C. § 405(g). 18 BACKGROUND 19 Plaintiff is currently 48 years old, has an 11th-grade education and GED, and has worked 20 as a cashier, caregiver, and babysitter. Tr. 74, 150-58, 425. In December 2014, she applied for 21 benefits, alleging disability as of February 14, 2012. Tr. 387-402, 882. Her applications were 22 denied initially and on reconsideration. Tr. 263-69, 281-92. The ALJ conducted hearings in 23 2016 and 2017 (Tr. 135-204), and subsequently found Plaintiff not disabled. Tr. 60-83. 1 The Appeals Council denied Plaintiff’s request for review (Tr. 1-7), and Plaintiff sought 2 judicial review. The U.S. District Court for the Western District of Washington reversed the 3 ALJ’s decision and remanded for further administrative proceedings. Tr. 977-91. On remand, 4 the ALJ held another hearing (Tr. 915-39), and subsequently issued a decision finding Plaintiff
5 not disabled. Tr. 882-904. The Appeals Council declined to assume jurisdiction of the case, and 6 the ALJ’s decision is therefore the Commissioner’s final decision. Tr. 857-64. 7 DISCUSSION 8 A. Dr. Wingate’s Opinion 9 Dr. Wingate examined Plaintiff multiple times and completed DSHS form opinions in 10 October 2017, September 2019, and January 2021. See Tr. 1579-86, 1705-11, 1938-42. In April 11 2021, Dr. Wingate conducted additional cognitive testing, rated Plaintiff’s full-scale IQ as 63, 12 and prepared a narrative report describing Plaintiff’s symptoms and limitations. Tr. 1944-53. At 13 that time, Dr. Wingate concluded, in pertinent part: 14 [Plaintiff] cannot sustain attention to tasks throughout a daily or weekly work schedule without interruption from anxiety, depressed mood, fatigue, and 15 inattention. She has extremely poor stress tolerance and when pressures are placed upon her, she will withdraw and isolate. She has sufficient judgment to 16 avoid hazards and make work decisions. Due to severe social anxiety and marked social isolation, she rarely even leaves her home and she never leaves her home 17 alone. She cannot interact appropriately with supervisors, coworkers or the pub[l]ic. 18 Tr. 1949. 19 The ALJ gave little weight to each of Dr. Wingate’s opinions finding her description of 20 disabling mental limitations was inconsistent with Plaintiff’s treatment notes, which document 21 “generally stable mental health symptoms with conservative treatment of medication and 22 counseling.” Tr. 900. 23 1 Plaintiff contends the grounds the ALJ provided to discount Dr. Wingate’s April 2021 are 2 erroneous. Plaintiff did seek treatment for her mental conditions and some of her symptoms 3 improved with conservative treatment, but most of Plaintiff’s symptoms did not improve. 4 Clinicians repeatedly described Plaintiff’s isolation, inability to leave her home alone, and social
5 anxiety, and indicated Plaintiff did not progress in this area.1 Most of the treatment notes also 6 reference some normal mental status findings, but those findings do not pertain to Plaintiff’s 7 social functioning and when the notes are considered as a whole, they are not inconsistent with 8 Dr. Wingate’s opinions regarding Plaintiff’s disabling social limitations. The ALJ erred in 9 focusing only on normal mental status findings and ignoring the significant social limitations 10 recorded in those notes, thereby mischaracterizing the notes as documenting improvement and 11 symptom stability. See Reddick v. Chater, 157 F.3d 715,722-23 (9th Cir. 1998) (“In essence, the 12 ALJ developed his evidentiary basis by not fully accounting for the context of materials or all 13 parts of the testimony and reports. His paraphrasing of record material is not entirely accurate 14 regarding the content or tone of the record. We conclude that his approach and conclusions do
15 not fully account for the nature of CFS and its symptoms.”). 16 17
1 See Tr. 845 (Plaintiff reports she is “not ready to leave house to socialize”), 1264 (Plaintiff 18 reports she does not leave her house for fear of triggering her PTSD), 1278 (Plaintiff describes feeling content with staying home), 1280 (Plaintiff reports continuing to isolate), 1281 (Plaintiff 19 not ready to attempt socializing outside her family), 1284 (Plaintiff reports spending all of her time at home; therapist observes that Plaintiff is “stable, however no progress in therapy”), 1286 20 (Plaintiff not ready to join group therapy session; not sure she wants to leave her home for activities), 1288 (therapist discusses Plaintiff’s lack of progress in therapy regarding social 21 isolation), 1297 (Plaintiff reports she is unable to leave her home except for appointments), 1335 (Plaintiff still unwilling to try group therapy), 1659 (Plaintiff describes socializing “mostly with 22 family”), 1664 (Plaintiff not ready to try group therapy), 1672 (same), 1687 (same), 1689 (Plaintiff stated she was ready to start group therapy, but then failed to attend any of the sessions 23 (Tr. 1690-91, 1693, 1694)), 1698 (Plaintiff reports leaving her home twice in the past month with her sisters). 1 Normal mental status findings are reasonably inconsistent, however, with the disabling 2 concentration/attention deficits that Dr. Wingate described, and the ALJ therefore did not err in 3 discounting that part of Dr. Wingate’s opinion, but that evidence is not inconsistent with the 4 disabling social limitations Dr. Wingate indicated. Thus, the ALJ failed to provide a legally
5 sufficient reason to discount the social limitations referenced in Dr. Wingate’s April 2021 6 opinion. 7 Although Plaintiff requests, in the alternative, that this error warrants a remand for a 8 finding of disability (Dkt. 22 at 18), Plaintiff fails to establish this remedy is appropriate. See 9 Leon v. Berryhill, 880 F.3d 1044, 1045 (9th Cir. 2017) (“An automatic award of benefits in a 10 disability benefits case is a rare and prophylactic exception to the well-established ordinary 11 remand rule.”). Thus, the Court orders this case be remanded for further administrative 12 proceedings to allow reconsideration of the social limitations identified in Dr. Wingate’s April 13 2021 opinion. 14 B. Plaintiff’s Testimony
15 The ALJ discounted Plaintiff’s testimony of disabling limitations on the grounds: (1) 16 Plaintiff’s activities are inconsistent with her alleged limitations, (2) the objective evidence does 17 not corroborate Plaintiff’s allegations, (3) Plaintiff’s knee condition improved with conservative 18 treatment, and (4) some of Plaintiff’s mental impairments improved with treatment. Tr. 891-96. 19 Absent evidence of malingering, an ALJ must provide clear and convincing reasons to discount a 20 claimant’s testimony. See Burrell v. Colvin, 775 F.3d 1133, 1136-37 (9th Cir. 2014). 21 Plaintiff does not challenge the ALJ’s assessment of her physical allegations, but disputes 22 whether her conditions improved over time, and contends that her “critical problems” were 23 cognitive and therefore unlikely to improve with treatment. Dkt. 13 at 17.
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5 UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 ANDREA T., 8 Plaintiff, CASE NO. C22-5841-BAT 9 v. ORDER REVERSING THE 10 COMMISSIONER’S DECISION COMMISSIONER OF SOCIAL SECURITY, 11 Defendant. 12
13 Plaintiff appeals the ALJ’s finding that she is not disabled. She contends the ALJ 14 erroneously discounted (1) the April 2021 opinion of examining psychologist Terilee Wingate, 15 Ph.D.; (2) Plaintiff’s testimony; and (3) a lay statement. Dkt. 13 1. For the reasons below, the 16 Court REVERSES the Commissioner’s final decision and REMANDS the matter for further 17 administrative proceedings under sentence four of 42 U.S.C. § 405(g). 18 BACKGROUND 19 Plaintiff is currently 48 years old, has an 11th-grade education and GED, and has worked 20 as a cashier, caregiver, and babysitter. Tr. 74, 150-58, 425. In December 2014, she applied for 21 benefits, alleging disability as of February 14, 2012. Tr. 387-402, 882. Her applications were 22 denied initially and on reconsideration. Tr. 263-69, 281-92. The ALJ conducted hearings in 23 2016 and 2017 (Tr. 135-204), and subsequently found Plaintiff not disabled. Tr. 60-83. 1 The Appeals Council denied Plaintiff’s request for review (Tr. 1-7), and Plaintiff sought 2 judicial review. The U.S. District Court for the Western District of Washington reversed the 3 ALJ’s decision and remanded for further administrative proceedings. Tr. 977-91. On remand, 4 the ALJ held another hearing (Tr. 915-39), and subsequently issued a decision finding Plaintiff
5 not disabled. Tr. 882-904. The Appeals Council declined to assume jurisdiction of the case, and 6 the ALJ’s decision is therefore the Commissioner’s final decision. Tr. 857-64. 7 DISCUSSION 8 A. Dr. Wingate’s Opinion 9 Dr. Wingate examined Plaintiff multiple times and completed DSHS form opinions in 10 October 2017, September 2019, and January 2021. See Tr. 1579-86, 1705-11, 1938-42. In April 11 2021, Dr. Wingate conducted additional cognitive testing, rated Plaintiff’s full-scale IQ as 63, 12 and prepared a narrative report describing Plaintiff’s symptoms and limitations. Tr. 1944-53. At 13 that time, Dr. Wingate concluded, in pertinent part: 14 [Plaintiff] cannot sustain attention to tasks throughout a daily or weekly work schedule without interruption from anxiety, depressed mood, fatigue, and 15 inattention. She has extremely poor stress tolerance and when pressures are placed upon her, she will withdraw and isolate. She has sufficient judgment to 16 avoid hazards and make work decisions. Due to severe social anxiety and marked social isolation, she rarely even leaves her home and she never leaves her home 17 alone. She cannot interact appropriately with supervisors, coworkers or the pub[l]ic. 18 Tr. 1949. 19 The ALJ gave little weight to each of Dr. Wingate’s opinions finding her description of 20 disabling mental limitations was inconsistent with Plaintiff’s treatment notes, which document 21 “generally stable mental health symptoms with conservative treatment of medication and 22 counseling.” Tr. 900. 23 1 Plaintiff contends the grounds the ALJ provided to discount Dr. Wingate’s April 2021 are 2 erroneous. Plaintiff did seek treatment for her mental conditions and some of her symptoms 3 improved with conservative treatment, but most of Plaintiff’s symptoms did not improve. 4 Clinicians repeatedly described Plaintiff’s isolation, inability to leave her home alone, and social
5 anxiety, and indicated Plaintiff did not progress in this area.1 Most of the treatment notes also 6 reference some normal mental status findings, but those findings do not pertain to Plaintiff’s 7 social functioning and when the notes are considered as a whole, they are not inconsistent with 8 Dr. Wingate’s opinions regarding Plaintiff’s disabling social limitations. The ALJ erred in 9 focusing only on normal mental status findings and ignoring the significant social limitations 10 recorded in those notes, thereby mischaracterizing the notes as documenting improvement and 11 symptom stability. See Reddick v. Chater, 157 F.3d 715,722-23 (9th Cir. 1998) (“In essence, the 12 ALJ developed his evidentiary basis by not fully accounting for the context of materials or all 13 parts of the testimony and reports. His paraphrasing of record material is not entirely accurate 14 regarding the content or tone of the record. We conclude that his approach and conclusions do
15 not fully account for the nature of CFS and its symptoms.”). 16 17
1 See Tr. 845 (Plaintiff reports she is “not ready to leave house to socialize”), 1264 (Plaintiff 18 reports she does not leave her house for fear of triggering her PTSD), 1278 (Plaintiff describes feeling content with staying home), 1280 (Plaintiff reports continuing to isolate), 1281 (Plaintiff 19 not ready to attempt socializing outside her family), 1284 (Plaintiff reports spending all of her time at home; therapist observes that Plaintiff is “stable, however no progress in therapy”), 1286 20 (Plaintiff not ready to join group therapy session; not sure she wants to leave her home for activities), 1288 (therapist discusses Plaintiff’s lack of progress in therapy regarding social 21 isolation), 1297 (Plaintiff reports she is unable to leave her home except for appointments), 1335 (Plaintiff still unwilling to try group therapy), 1659 (Plaintiff describes socializing “mostly with 22 family”), 1664 (Plaintiff not ready to try group therapy), 1672 (same), 1687 (same), 1689 (Plaintiff stated she was ready to start group therapy, but then failed to attend any of the sessions 23 (Tr. 1690-91, 1693, 1694)), 1698 (Plaintiff reports leaving her home twice in the past month with her sisters). 1 Normal mental status findings are reasonably inconsistent, however, with the disabling 2 concentration/attention deficits that Dr. Wingate described, and the ALJ therefore did not err in 3 discounting that part of Dr. Wingate’s opinion, but that evidence is not inconsistent with the 4 disabling social limitations Dr. Wingate indicated. Thus, the ALJ failed to provide a legally
5 sufficient reason to discount the social limitations referenced in Dr. Wingate’s April 2021 6 opinion. 7 Although Plaintiff requests, in the alternative, that this error warrants a remand for a 8 finding of disability (Dkt. 22 at 18), Plaintiff fails to establish this remedy is appropriate. See 9 Leon v. Berryhill, 880 F.3d 1044, 1045 (9th Cir. 2017) (“An automatic award of benefits in a 10 disability benefits case is a rare and prophylactic exception to the well-established ordinary 11 remand rule.”). Thus, the Court orders this case be remanded for further administrative 12 proceedings to allow reconsideration of the social limitations identified in Dr. Wingate’s April 13 2021 opinion. 14 B. Plaintiff’s Testimony
15 The ALJ discounted Plaintiff’s testimony of disabling limitations on the grounds: (1) 16 Plaintiff’s activities are inconsistent with her alleged limitations, (2) the objective evidence does 17 not corroborate Plaintiff’s allegations, (3) Plaintiff’s knee condition improved with conservative 18 treatment, and (4) some of Plaintiff’s mental impairments improved with treatment. Tr. 891-96. 19 Absent evidence of malingering, an ALJ must provide clear and convincing reasons to discount a 20 claimant’s testimony. See Burrell v. Colvin, 775 F.3d 1133, 1136-37 (9th Cir. 2014). 21 Plaintiff does not challenge the ALJ’s assessment of her physical allegations, but disputes 22 whether her conditions improved over time, and contends that her “critical problems” were 23 cognitive and therefore unlikely to improve with treatment. Dkt. 13 at 17. As noted above, the 1 ALJ erred in rejecting Dr. Wingate’s opinion about Plaintiff’s social functioning, and thus 2 likewise erred in rejecting Plaintiff’s testimony about this limitation. On remand the ALJ shall 3 reconsider Plaintiff’s allegations in light of the updated record on remand as necessary. 4 C. Lay Evidence
5 Plaintiff’s mother, Pamela W. completed a third-party function report in 2015. See Tr. 6 432-39. The ALJ found this report was inconsistent with Plaintiff’s self-reported activities and 7 abilities, inconsistent with the opinions of certain non-examining providers, and inconsistent 8 with a treating nurse’s opinion regarding Plaintiff’s physical exertion abilities. Tr. 901. The 9 ALJ can reject the testimony of lay witnesses only upon giving germane reasons. See Dodrill v. 10 Shalala, 12 F.3d 915, 919 (9th Cir. 1993) (“If the ALJ wishes to discount the testimony of the 11 lay witnesses, he must give reasons that are germane to each witness.”). 12 Plaintiff states that “plaintiff’s physical impairments are not at issue,” Dkt. 13 at 15, and 13 thus the Court does not disturb the ALJ’s findings as to these limitations. However, Ms. W. also 14 stated Plaintiff has “difficulty communicating with strangers.” Tr. 432. Again, as noted above,
15 the ALJ erred in rejecting Dr. Wingate’s opinion about Plaintiff’s social functioning. Thus, on 16 remand the ALJ shall reconsider Plaintiff’s allegations in light of the updated record on remand 17 as necessary. 18 CONCLUSION 19 For the foregoing reasons, the Commissioner’s decision is REVERSED, and this case is 20 REMANDED for further administrative proceedings under sentence four of 42 U.S.C. § 405(g). 21 On remand, the ALJ shall reassess the social limitations identified in Dr. Wingate’s April 22 2021 opinion, and in any testimony as to this limitation provided by Plaintiff and the lay witness, 23 1 Ms. W., develop the record and redetermine residual functional capacity as necessary, and 2 proceed to the remaining steps of the disability evaluation process as needed. 3 DATED this 3rd day of April, 2023. 4 A
5 BRIAN A. TSUCHIDA United States Magistrate Judge 6
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