United States District Court, D. Minnesota
Lionel H. Peabody, Esq., Peabody Law Office, counsel for Plaintiff.
Ann M. Bildtsen, Esq., Assistant United States Attorney, counsel for Defendant.
REPORT AND RECOMMENDATION
JEFFREY J. KEYES, Magistrate Judge.
Pursuant to 42 U.S.C. § 405(g), Plaintiff Nathan Osai Williams seeks judicial review of the final decision of the Commissioner of Social Security ("the Commissioner"), who denied Plaintiff's application for supplemental security income. This matter is before the Court on the parties' cross-motions for summary judgment. (Doc. Nos. 12, 14.) This matter has been referred to the undersigned for a Report and Recommendation pursuant to 28 U.S.C. § 636 and D. Minn. L.R. 72.1. For the reasons stated below, this Court recommends that Plaintiff's motion for summary judgment be denied and Defendant's motion for summary judgment be granted.
I. Procedural History
Plaintiff protectively filed an application for a period of disability, disability insurance, and supplemental security income on March 17, 2011, alleging a disability onset date of October 3, 2003. (Tr. 160-67.) The Social Security Administration ("SSA") denied Plaintiff's claim initially and on reconsideration. (Tr. 75-96, 97-122.) Plaintiff timely requested a hearing before an Administrative Law Judge ("ALJ"), and the hearing was held on January 29, 2013. (Tr. 83-84, 34-61.) At the hearing, Plaintiff amended the alleged onset date of disability to March 11, 2013, waiving his applications for a period of disability and disability insurance benefits. (Tr. 33-34.) Accordingly, the ALJ dismissed the waived portion of Plaintiff's application and addressed only his pending application for supplemental security income, as of March 17, 2011, the amended alleged onset date of disability. (Tr. 13.) The ALJ issued an unfavorable decision on Plaintiff's application. (Tr. 10-22.) Plaintiff sought review of the ALJ's decision, but the Appeals Council denied the request for review on January 15, 2014. (Tr. 1-5.) Denial by the Appeals Council made the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 404.981.
II. Statement of Facts
Plaintiff, born on June 12, 1975, was thirty-five years old on the onset date of disability, March 17, 2011. (Tr. 160.) Plaintiff has a G.E.D. and has previously worked as a fork lift operator, a janitor, a sales representative, in shipping and receiving, and in a warehouse. (Tr. 204, 217-24.) He suffers from lumbar facet disease, major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder and a history of polysubstance abuse. (Tr. 574, 562-66.) Plaintiff's appeal concerns only his mental-health impairments.
Before applying for supplemental security income, Plaintiff had not received treatment for his mental impairments in his adult life. (Tr. 263.) To initiate his application, he completed a Disability Report for the SSA. (Tr. 201-08.) In the report, Plaintiff asserted that he was last employed as warehouse packager in 2003, but that his symptoms of post-traumatic stress disorder, depression, and anger problems limited his ability to work. (Tr. 203-04.) In February 2011, Accend Services evaluated Plaintiff and began providing him therapy; he had a pending evaluation scheduled with Nystrom and Associates. (Tr. 206-07.)
Plaintiff also completed a Function Report for the SSA. (Tr. 209-16.) He reported that his conditions impaired his ability to complete job applications, to follow orders from superiors, and to avoid aggressive or uncontrollable behavior at work. (Tr. 209.) He further reported that he had trouble getting a full night's rest due to night terrors. (Tr. 210.) His daily activities included eating breakfast, walking his kids to school, working on job applications, walking, and spending time with his kids again after school. (Tr. 210.) He reported caring for his kids by feeding them, playing games, and teaching them responsibility. (Tr. 210.) He was able to prepare his own meals and complete house and yard work when not angry or depressed, and when he was assisted by verbal reminders and encouragement. (Tr. 211.) He shopped once a week, for an hour or so, though he had difficulty following through on plans and budgeting. (Tr. 212-13.) He noted hobbies and interests in fishing, drawing, watching movies, and spending time with his children. (Tr. 213.) He reported limitations with talking, memory, completing tasks, concentration, understanding, following instructions, and getting along with others, all related to his mental health impairments; however, he was able to follow written instructions "well." (Tr. 214.) He described fear of confrontation and authority figures and a propensity to fight. (Tr. 215.) Finally, he reported observing violent behavior at home and experiencing physical and sexual abuse as a child. (Tr. 216.)
Plaintiff's Work History Report, completed for the SSA, describes former employment from 1996 until 2005 as a fork lift driver, in shipping, receiving and packaging, as a janitor, as a sales representative, and in warehouse tasks. (Tr. 217-24.) Among other responsibilities, his various positions required him to: stock, ship, and package merchandise; assist customers; and oversee cash registers. (Tr. 218-23.)
A. Medical Records
Initial evaluations, physical examinations, and ongoing treatment notes comprise the medical records relevant to Plaintiff's appeal. They contain both objective medical evidence and opinion evidence from treating and examining providers.
1. Evaluations and Diagnoses of Mental Impairments
Plaintiff completed an Adult Mental Health Services Assessment in February 2011 with Accend Services. (Tr. 263.) Plaintiff sought mental-health services due to his difficulty holding a job and a stable residence; he reported being homeless at the time. (Tr. 269.) To Accend Services, he expressed interest in stabilizing his income, either in the form of disability benefits or a longterm job. (Tr. 269.) Describing his symptoms, he noted social withdrawal, difficulty concentrating, racing thoughts, insomnia, irritability, and inability to control his violent reactions. (Tr. 265.) Accend Services noted that Plaintiff was scattered, tense, and distractible, but also oriented, cooperative, and logical. (Tr. 267.) Accend Services diagnosed him with Posttraumatic Stress Disorder and Bipolar I Disorder. (Tr. 268.)
Accend Services referred Plaintiff to Nystrom and Associates for psychological testing, which he completed over multiple evaluative sessions in June and July of 2011. (Tr. 325-43.) On assessment, Plaintiff was neatly dressed, calm, cooperative, and alert and oriented, though he stuttered at times during the interview portion. (Tr. 327.) Describing his current functioning, Plaintiff reported symptoms of depression, uncontrollable rage, disorganization, forgetfulness, and hypervigilence. (Tr. 332-33.) Throughout testing, Plaintiff appeared to understand the instructions given and sat quietly while completing the assessment. (Tr. 336-38.) Following the diagnostic results, Nystrom and Associates diagnosed him with: Major Depressive Disorder, Recurrent, Moderate; Generalized Anxiety Disorder; and Post-traumatic Stress Disorder. (Tr. 333, 342.) Upon receiving the results, he asked to begin individual therapy and was scheduled for weekly sessions. (Tr. 336.)
In July 2011, Plaintiff saw psychologist Marcus Desmonde for a Social Security consultative psychological evaluation. (Tr. 289-91.) Though he reported being homeless in February, by July he had secured housing at a local boarding house. (Tr. 263; 289.) Plaintiff reported that he maintained a regular schedule of waking up between 9:00am and 10:00am, spending time with his children at their mother's home, staying for lunch and dinner, and returning to the boarding house to get to sleep by 12:00am. (Tr. 289-90.) Dr. Desmonde reported that, on exam, Plaintiff was open, spontaneous, and uninhibited; he came casually dressed with good hygiene. (Tr. 290.) He reported past symptoms of depression, difficulty with anger and self-medication with cannabis; his current symptoms included occasional sleep disturbance and low frustration tolerance. (Tr. 290) Dr. Desmonde estimated Plaintiff's IQ as between 75 and 85. (Tr. 290) Ultimately, he diagnosed Plaintiff with Adjustment Disorder of adolescence and adulthood with mixed disturbance of emotions and conduct, Cannabis abuse by history, Posttraumatic stress disorder by history, and he noted moderate psychosocial stressors due to homelessness and difficulty obtaining full-time employment. (Tr. 291.) Dr. Desmonde found that Plaintiff was in touch with reality and oriented to day and month, though not the exact day. (Tr. 290.) Memory assessment showed that Plaintiff recalled five digits forward and three digits backward, he computed serial seven additions, and he recalled two out of three objects immediately, within five minutes and after thirty minutes. (Tr. 290.) Dr. Desmonde found that, given mental health support, Plaintiff was capable of understanding simple instructions, brief social interactions and tolerating the stress of competitive employment within his capabilities. (Tr. 290.)
2. Physical Exam
In May 2011, Plaintiff underwent a complete physical exam by Dr. Hind Tabit, a primary care physician. With Dr. Tabit, Plaintiff discussed his previous use of intravenous drugs, cocaine, heroin, methamphetamine, and prescription pills; he reported abstinence from them for the previous six months. (Tr. 294.) In his summary of the exam, Dr. Tabit referred to drug abuse and noted that Plaintiff was "in the process of quitting." (Tr. 296.) Dr. Tabit found that Plaintiff was alert and had a healthy appearance. (Tr. 295.)
3. Records Relating to Treating Relationship: Ali Rassa, Counselor
Following its assessment of Plaintiff's mental health, Accend Services drafted an ARMHS Services plan for Plaintiff, authorizing four hours of weekly services, coordinated by counselor Ali Rassa. (Tr. 276-87.) Accend Services intended to teach Plaintiff symptom management, socialization, and leisure skills. (Tr. 279.) Mr. Rassa provided Plaintiff with resources to learn these skills and they worked on incremental goals, such as "make and keep a 24-hour commitment to act calm." (Tr. 374.) By June 2011, Plaintiff was able to catch and check anger with his children and their mother and to engage in their activities. (Tr. 405.)
Plaintiff followed Mr. Rassa to his new employer, the Human Development Center, where the two completed a Functional Assessment in October 2011. (Tr. 385; 344-46.) Plaintiff's health had improved due to regular exercise, he was routinely caring for his children, and had little trouble with activities of daily living; though he remained socially limited, he was aware of his mental health symptoms and was engaged in treatment. (Tr. 344-45.) In weekly progress notes Mr. Rassa repeatedly noted Plaintiff's incorporation of positive coping skills and improved communication tactics. (Tr. 347-57.) By December 2011, Plaintiff had seen the positive effects of his coping behavior and the benefits to controlling his aggression; he was using the mechanisms he had learned to reduce his anxiety. (Tr. 425-30.) Plaintiff reported to Mr. Rassa that he fought inclinations to act defensively at his Rule 25 chemical dependency assessment by rethinking his behavior and concluded that it had gone well. (Tr. 434.) In his December 30, 2011 Functional Assessment, Mr. Rassa noted that Plaintiff had begun Rule 25 treatment for marijuana use. (Tr. 431.)
In January 2012, though he reported low self-esteem to Mr. Rassa, Plaintiff noted how different he was and how much he had improved in the previous year. (Tr. 440.) By February 2012, he reported to Mr. Rassa that his anger was "not really an issue" since learning and using coping skills. (Tr. 443.) At a children's birthday party, Plaintiff was able to recognize why crowds overwhelmed him and he used reasoning to suppress negative inclinations and concentrate on the party; though it was exhausting, he sustained control over his symptoms for four hours without a break. (Tr. 444-45.)
In March 2012, Plaintiff was reevaluated for ARMHS eligibility by psychotherapist Carol Johnson at The Human Development Center. (Tr. 450-54.) Ms. Johnson documented that Plaintiff was very personable, an excellent listener and had done an outstanding job of explaining his symptoms and his methods of managing them. (Tr. 452.) He continued to need ARMHS support in managing his symptoms, particularly sleep disturbance, but he had made large strides in understanding and coping with his mental health impairments. (Tr. 454.) At that point, Plaintiff had abstained from using marijuana for over six weeks. (Tr. 451.) Plaintiff told Mr. Rassa that he could not have endured the assessment three months earlier, but the skills he had gleaned from the ARMHS services had enabled him to do so. (Tr. 457.) He also told Mr. Rassa that he was much happier when he was able to use his coping skills. (Tr. 458-59.)
In April 2012, Plaintiff continued to report progress and the positive benefits of controlling his anger; though he was stressed by trying to quit smoking, he was able to control his anger and enjoy quality time with his children. (Tr. 460-64.) In May 2012, Mr. Rassa noted that Plaintiff considered discontinuing ARMHS services in light of his progress. (Tr. 465.) By early June 2012, Plaintiff and Mr. Rassa transitioned into meeting every two weeks to continue to discuss chemical dependency treatment and therapy progress. (Tr. 549.) In June 2012, Plaintiff worked with Mr. Rassa to draft a letter to vacate his apartment so he could move in with his partner and their children. (Tr. 550.) In July and August 2012, they discussed the process for expunging criminal records, which Plaintiff investigated independently. (Tr. 552-53.)
In September 2012, Plaintiff underwent another Functional Assessment with Mr. Rassa at the Human Development Center, which was differs selectively from the previous Assessment. (Tr. 554-56.) In September 2012, Plaintiff did not take medications for his mental-health impairments, but he was able to manage his impairments by using healthy coping skills. (Tr. 554) Mr. Rassa noted that Plaintiff's mental health symptoms barred him from acquiring and keeping employment but that Plaintiff was interested in being employed once his symptoms were under control. (Tr. 554.) Reviewing the Assessment with Plaintiff, Mr. Rassa noted that Plaintiff great input and was very open and engaging. (Tr. 558.) Plaintiff reported to Mr. Rassa that he became bored while his children were in school and was interested in seeking a part-time job. (Tr. 559.) By October 2012, he had begun taking classes at the Minnesota Work Center. (Tr. 560.)
4. Records Relating to Treating Relationship: Kimberly Lunde, Psychotherapist
In September 2011, Nystrom and Associates noted that Plaintiff's unmanaged depressive and anxiety symptoms had a significant negative impact on his ability to accomplish goals; he needed to develop improved symptom management skills. (Tr. 411-12.) That same month, Plaintiff began weekly therapy sessions with psychotherapist Kimberly Lunde. (Tr. 325-43; 501.) At their first Ms. Lunde found him stable, talkative, and engaged. (Tr. 501.) Following initial progress with positive-thinking strategies, in October 2011 Ms. Lunde twice noted that Plaintiff had suicidal ideation with no plan to act, for which they discussed a safety plan. (Tr. 502-11.) At that time, Ms. Lunde ...