WEST v. SAUL

CourtDistrict Court, E.D. Pennsylvania
DecidedNovember 8, 2022
Docket2:20-cv-05649
StatusUnknown

This text of WEST v. SAUL (WEST v. SAUL) is published on Counsel Stack Legal Research, covering District Court, E.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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WEST v. SAUL, (E.D. Pa. 2022).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA

KEIRA ROSE WEST, : CIVIL ACTION Plaintiff, : : vs. : NO. 20-cv-5649 : ANDREW SAUL, : Commissioner of Social Security, : Defendant. :

MEMORANDUM OPINION

LYNNE A. SITARSKI UNITED STATES MAGISTRATE JUDGE November 8, 2022 Plaintiff Keira Rose West brought this action seeking review of the Acting Commissioner of Social Security Administration’s decision denying his1 claim for Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act, 42 U.S.C. § 1381–1383f. This matter is before me for disposition upon consent of the parties. For the reasons set forth below, Plaintiff’s Request for Review (ECF No. 14) is DENIED.

I. PROCEDURAL HISTORY Plaintiff filed for SSI, alleging disability since August 1, 2018, due to mental illness, depression, anxiety and autism. (R. 230). Plaintiff’s application was denied at the initial level, and he requested a hearing before an Administrative Law Judge (ALJ). (R. 139-46). Plaintiff, represented by counsel, and a vocational expert testified at the October 10, 2019 administrative hearing. (R. 96-126). On December 26, 2019, the ALJ issued a decision unfavorable to Plaintiff. (R. 78-94). Plaintiff appealed the ALJ’s decision, and the Appeals Council denied

1 “[P]laintiff has gender dysphoria and identifies as being male.” (Pl.’s Br., ECF No. 14, at 2 n.2). Plaintiff’s request for review on September 18, 2020, thus making the ALJ’s decision the final decision of the Acting Commissioner for purposes of judicial review. (R. 1-7). On November 12, 2020, Plaintiff filed a complaint in the United States District Court for the Eastern District of Pennsylvania. (Compl., ECF No. 1). On November 16, 2020, Plaintiff

consented to my jurisdiction pursuant to 28 U.S.C. § 636(C). (Consent Order, ECF No. 4). On October 8, 2021, Plaintiff filed a Brief and Statement of Issues in Support of Request for Review. (Pl.’s Br., ECF No. 14). On November 8, 2021, the Acting Commissioner filed a Response, to which Plaintiff filed a Reply on December 22, 2021. (Resp., ECF No. 18; Reply, ECF No. 21).

II. FACTUAL BACKGROUND The Court has considered the administrative record in its entirety and summarizes here the evidence relevant to the instant request for review. Plaintiff was born on October 20, 1998, and was 20 years old on the alleged disability

onset date. (R. 226). He graduated from high school in a gifted program and attended some community college. (R. 104-05, 231, 405). Plaintiff previously worked as a retail stocker and education tutor. (Id.). A. Medical Evidence On February 4, 2016, Plaintiff was referred to Central Montgomery Mental Health as part of his Individualized Education Plan (IEP) “[i]n order to succeed more at home, mostly in relationship with Mother.” (R. 691). The intake assessment indicates diagnoses for mild autism, depression, anxiety, “borderline traits” and a history of cutting, with the last instance in July 2015. (Id.). Prescriptions for Lexapro, Abilify, Topomax and Xanax were noted. (R. 696). A

psychological evaluation from July 2016 noted a December 2014 through November 2015 partial hospitalization, a March 2016 hospitalization after an overdose of medication, and a May 2016 inpatient hospitalization after Plaintiff told his therapist that he wanted to hurt himself, although Plaintiff described it as “a bid to get into a partial program.” (R. 704, 706; see also R. 383-404). In July 2019, Plaintiff was noted to be compliant with medication and to have a stable mood. (R.

747). Plaintiff returned in October 2019 to facilitate the transition to adult support services once he turned 21 at the end of the month. (R. 715). Another prior partial hospitalization in 2017 was also noted. (Id.; see also R. 405-13). Plaintiff reported a “much more stable mood in the last several years” although with a recent resumption of cutting without suicidal intent after no cutting for a year. (R. 715). While treating at Central Montgomery Mental Health, Plaintiff repeatedly had normal mental status examinations. (R. 718, 725, 729, 731, 733, 735, 737, 739, 743, 745). Plaintiff received psychological evaluations in January and July 2017 from Child and Family, Focus, Inc., in Valley Forge, Pennsylvania, to evaluate the appropriate level of behavioral healthcare. (R. 592-93, 617). Diagnoses for major depressive disorder, autism

spectrum disorder and generalized anxiety disorder were noted, as were two prior suicide attempts, recent self-cutting and an instance of stabbing himself with a pencil. (R. 592, 594). Plaintiff expressed a long-term goal of earning a doctorate and becoming a professor in political science or English. (R. 596). He discussed having a poor relationship with his mother, but that he gets along well with peers and has a few close, supportive friends. (R. 598). Plaintiff was reevaluated on January 12, 2018, to determine whether there was a need for continued services, although it was also noted that he was struggling in his current program. (R. 603, 606). The evaluator noted difficulties “with differentiating legitimate mental health issues from Henry [Plaintiff’s preferred masculine name] using his diagnoses and symptoms as possible excuses for

avoiding responsibility.” (R. 606). On February 11, 2019, State agency psychological consultant Richard Small, Ph.D., opined that Plaintiff was moderately limited in maintaining attention and concentration for an extended period, interacting with the public, and accepting instructions and responding appropriately to criticism from supervisors. (R. 134-35). He further determined that Plaintiff is

not significantly limited in any other area of mental health functioning. (Id.). The reasons for his findings included Plaintiff’s high school education, with emotional support in an IEP; enrollment in college classes after a transitional year; past work as a tutor for three years; and activities of daily living (ADLs) including using public transportation, shopping, making simple meals, cleaning and socializing with friends, albeit with some isolation and difficulty focusing. (R. 136). Plaintiff presented to Christina Wohleber, PsyD, at CW Psychological Services on May 22, 2019, with anxiety, depressed mood and energy, and impulsivity, all rated as “mild.” (R. 641). Positive relationships with his father and siblings and a poor relationship with his mother were noted. (R. 643). At their weekly visits, Plaintiff and Dr. Wohleber often discussed

Plaintiff’s relationship with his family, coping strategies for his mental health issues, and his gender dysphoria, including legally changing his name, “top surgery” and how to pay for it. (R. 641-89). At a June 28, 2019 visit, Plaintiff also noted an intention to resume work shortly and “discussed impact working had on him and how he took on too much with work and school at the same time.” (R. 658). On August 17, 2019, Plaintiff reported “working on becoming more consistent with being responsible in order to move forward with surgery.” (R. 684). At the following visit, Plaintiff reported being excited to resume college classes, although he subsequently reported suffering a panic attack in class. (R. 678, 681). On December 12, 2019, Plaintiff presented to Onward Behavioral Health in Radnor,

Pennsylvania. (R. 43). He explained his reason for the visit as: “I just feel like I have a pretty expansive history of [mental health] issues, and though it’s been better recently, I noticed a decrease in my general quality of life and mood and wanted to nip it in the bud.” (R. 43).

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