Enfield v. Colvin, No. 1:2015cv03032 - Document 22 (E.D. Wash. 2016)

Court Description: ORDER GRANTING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT Re: 14 Motion for Summary Judgment; denying 19 Motion for Summary Judgment. Signed by Senior Judge Robert H. Whaley. (AY, Case Administrator)

Download PDF

Enfield v. Colvin Doc. 22 1 2 3 4 5 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WASHINGTON 6 7 BOYD ENFIELD, 8 Plaintiff, 9 v. 10 11 12 13 14 15 16 17 18 19 CAROLYN W. COLVIN, Acting Commissioner of Social Security, No. 1:15-CV-03032-RHW ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT Defendant. Before the Court are the parties’ cross-motions for summary judgment, ECF Nos. 14 & 19. Mr. Enfield brings this action seeking judicial review, pursuant to 42 U.S.C. § 405(g), of the Commissioner’s final decision, which denied his application for Disability Insurance Benefits and Supplemental Security Income under Titles II & XVI of the Social Security Act, 42 U.S.C §§ 401-434 & 13811383F. After reviewing the administrative record and briefs filed by the parties, the Court is now fully informed. For the reasons set forth below, the Court 20 ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 1 Dockets.Justia.com 1 GRANTS Plaintiff’s Motion for Summary Judgment and REMANDS for 2 additional proceedings consistent with this order. 3 4 I. Jurisdiction Mr. Enfield filed for Disability Insurance Benefits on December 15, 2011, 5 AR 182, and Supplemental Security Income on February 9, 2012. AR 185. His 6 amended alleged onset date is August 1, 2003. AR 182. Mr. Enfield’s application 7 was initially denied on June 12, 2012, AR 107-109, and on reconsideration on 8 October 23, 2012, AR 124-125. 9 A hearing with Administrative Law Judge (“ALJ”) Virginia M. Robinson 10 occurred on August 1, 2003. AR 25-54. On November 13, 2013, the ALJ issued a 11 decision finding Mr. Enfield ineligible for disability benefits. AR 10-20. The 12 Appeals Council denied Mr. Enfield’s request for review on January 8, 2015, AR 13 1-3, making the ALJ’s ruling the “final decision” of the Commissioner. 14 Mr. Enfield timely filed the present action challenging the denial of benefits, 15 on February 23, 2015. ECF No. 4. Accordingly, Mr. Enfield’s claims are properly 16 before this Court pursuant to 42 U.S.C. § 405(g). 17 18 II. Sequential Evaluation Process The Social Security Act defines disability as the “inability to engage in any 19 substantial gainful activity by reason of any medically determinable physical or 20 mental impairment which can be expected to result in death or which has lasted or ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 2 1 can be expected to last for a continuous period of not less than twelve months.” 42 2 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). A claimant shall be determined to be 3 under a disability only if the claimant’s impairments are of such severity that the 4 claimant is not only unable to do his previous work, but cannot, considering 5 claimant's age, education, and work experience, engage in any other substantial 6 gainful work that exists in the national economy. 42 U.S.C. §§ 423(d)(2)(A) & 7 1382c(a)(3)(B). 8 9 The Commissioner has established a five-step sequential evaluation process for determining whether a claimant is disabled within the meaning of the Social 10 Security Act. 20 C.F.R. §§ 404.1520(a)(4) & 416.920(a)(4); Lounsburry v. 11 Barnhart, 468 F.3d 1111, 1114 (9th Cir. 2006). 12 Step one inquires whether the claimant is presently engaged in “substantial 13 gainful activity.” 20 C.F.R. §§ 404.1520(b) & 416.920(b). Substantial gainful 14 activity is defined as significant physical or mental activities done or usually done 15 for profit. 20 C.F.R. §§ 404.1572 & 416.972. If the claimant is engaged in 16 substantial activity, he or she is not entitled to disability benefits. 20 C.F.R. §§ 17 404.1571 & 416.920(b). If not, the ALJ proceeds to step two. 18 Step two asks whether the claimant has a severe impairment, or combination 19 of impairments, that significantly limits the claimant’s physical or mental ability to 20 do basic work activities. 20 C.F.R. §§ 404.1520(c) & 416.920(c). A severe ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 3 1 impairment is one that has lasted or is expected to last for at least twelve months, 2 and must be proven by objective medical evidence. 20 C.F.R. §§ 404.1508-09 & 3 416.908-09. If the claimant does not have a severe impairment, or combination of 4 impairments, the disability claim is denied, and no further evaluative steps are 5 required. Otherwise, the evaluation proceeds to the third step. 6 Step three involves a determination of whether any of the claimant’s severe 7 impairments “meets or equals” one of the listed impairments acknowledged by the 8 Commissioner to be sufficiently severe as to preclude substantial gainful activity. 9 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526 & 416.920(d), 416.925, 416.926; 10 20 C.F.R. § 404 Subpt. P. App. 1 (“the Listings”). If the impairment meets or 11 equals one of the listed impairments, the claimant is per se disabled and qualifies 12 for benefits. Id. If the claimant is not per se disabled, the evaluation proceeds to 13 the fourth step. 14 Step four examines whether the claimant’s residual functional capacity 15 enables the claimant to perform past relevant work. 20 C.F.R. §§ 404.1520(e)-(f) 16 & 416.920(e)-(f). If the claimant can still perform past relevant work, the claimant 17 is not entitled to disability benefits and the inquiry ends. Id. 18 Step five shifts the burden to the Commissioner to prove that the claimant is 19 able to perform other work in the national economy, taking into account the 20 claimant’s age, education, and work experience. See 20 C.F.R. §§ 404.1512(f), ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 4 1 404.1520(g), 404.1560(c) & 416.912(f), 416.920(g), 416.960(c). To meet this 2 burden, the Commissioner must establish that (1) the claimant is capable of 3 performing other work; and (2) such work exists in “significant numbers in the 4 national economy.” 20 C.F.R. §§ 404.1560(c)(2); 416.960(c)(2); Beltran v. Astrue, 5 676 F.3d 1203, 1206 (9th Cir. 2012). 6 7 III. Standard of Review A district court's review of a final decision of the Commissioner is governed 8 by 42 U.S.C. § 405(g). The scope of review under § 405(g) is limited, and the 9 Commissioner's decision will be disturbed “only if it is not supported by 10 substantial evidence or is based on legal error.” Hill v. Astrue, 698 F.3d 1144, 11 1158-59 (9th Cir. 2012) (citing § 405(g)). Substantial evidence means “more than 12 a mere scintilla but less than a preponderance; it is such relevant evidence as a 13 reasonable mind might accept as adequate to support a conclusion.” Sandgathe v. 14 Chater, 108 F.3d 978, 980 (9th Cir.1997) (quoting Andrews v. Shalala, 53 F.3d 15 1035, 1039 (9th Cir. 1995)) (internal quotation marks omitted). In determining 16 whether the Commissioner’s findings are supported by substantial evidence, “a 17 reviewing court must consider the entire record as a whole and may not affirm 18 simply by isolating a specific quantum of supporting evidence.” Robbins v. Soc. 19 Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006) (quoting Hammock v. Bowen, 879 20 F.2d 498, 501 (9th Cir. 1989)). ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 5 1 In reviewing a denial of benefits, a district court may not substitute its 2 judgment for that of the ALJ. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 3 1992). If the evidence in the record “is susceptible to more than one rational 4 interpretation, [the court] must uphold the ALJ's findings if they are supported by 5 inferences reasonably drawn from the record.” Molina v. Astrue, 674 F.3d 1104, 6 1111 (9th Cir. 2012); see also Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 7 2002) (if the “evidence is susceptible to more than one rational interpretation, one 8 of which supports the ALJ’s decision, the conclusion must be upheld”). Moreover, 9 a district court “may not reverse an ALJ's decision on account of an error that is 10 harmless.” Molina, 674 F.3d at 1111. An error is harmless “where it is 11 inconsequential to the [ALJ's] ultimate nondisability determination.” Id. at 1115. 12 The burden of showing that an error is harmful generally falls upon the party 13 appealing the ALJ's decision. Shinseki v. Sanders, 556 U.S. 396, 409–10 (2009). 14 15 IV. Statement of Facts The facts of the case are set forth in detail in the transcript of proceedings, 16 and only briefly summarized here. Mr. Enfield was 32 years old at the alleged date 17 of onset. AR 167. He has earned his GED. AR 50-51. Mr. Enfield sustained 18 injuries in a car accident in 2003, and the ALJ found Mr. Enfield to suffer from 19 degenerative disc disease. AR 12. Mr. Enfield has also been diagnosed by a 20 consultative examiner to have impulse control anger issues, psychotic disorder, ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 6 1 antisocial personality disorder, and personality disorder not otherwise specified. 2 AR 30. He also has a history of methamphetamine use. AR 32-33. 3 Mr. Enfield previously worked as a telemarketer. AR 45-46. He also did 4 shop maintenance work, ground manager work, and packed apples prior to his car 5 accident. AR 19. He has some limited work experience from prison. AR 45. 6 7 8 9 V. The ALJ’s Findings The ALJ determined that Mr. Enfield was not under a disability within the meaning of the Act from August 1, 2003, his alleged date of onset. AR 20. At step one, the ALJ found that Mr. Enfield had not engaged in substantial 10 gainful activity since August 1, 2003 (citing 20 C.F.R. §§ 404.1571 et seq. & 11 416.971 et seq.). AR 12. 12 At step two, the ALJ found Mr. Enfield had the following severe 13 impairments: degenerative disc disease (citing 20 C.F.R. §§ 404.1520(c) & 14 416.920(c)). AR 12. 15 At step three, the ALJ found that Mr. Enfield did not have an impairment or 16 combination of impairments that meets or medically equals the severity of one of 17 the listed impairments in 20 C.F.R. §§ 404, Subpt. P, App. 1. AR 22-25. 18 At step four, the ALJ found Mr. Enfield had the residual functional capacity 19 to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) with these 20 exceptions: (1) he can lift up to twenty pounds occasionally and lift or carry ten ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 7 1 pounds frequently; (2) he can stand or walk approximately six hours in an eight- 2 hour workday; (3) he can sit approximately six hours in an eight-hour workday 3 with normal breaks; (4) he can occasionally climb ramps, stairs, ladders, ropes, and 4 scaffolds; and (5) he can occasionally balance, stoop, kneel, crouch, and crawl. AR 5 16. 6 The ALJ determined that Mr. Enfield is able to perform his past relevant 7 work as a telemarketer because it does not require activities precluded by his 8 residual functional capacity. AR 18-19. 9 At step five, the ALJ found that, in the alternative, in light of his age, 10 education, work experience, and residual functional capacity, in conjunction with 11 the Medical-Vocational Guidelines, there are also other jobs that exist in 12 significant numbers in the national economy that he can perform. AR 19. 13 14 VI. Issues for Review Mr. Enfield argues that the Commissioner’s decision is not free of legal error 15 and not supported by substantial evidence. Specifically, he argues the ALJ erred 16 by: (1) rejecting Mr. Enfield’s mental health impairments at step two; (2) 17 improperly rejecting the opinions of Mr. Enfield’s medical providers; (3) 18 improperly rejecting Mr. Enfield’s subjective complaints and lay testimony; (4) 19 failing to conduct a proper step four assessment; and (5) failing to meet the step 20 five burden. ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 8 1 2 VII. Discussion A. The ALJ Erred in Her Step Two Analysis. 3 At step two in the five-step sequential evaluation for Social Security cases, 4 the ALJ must determine whether a claimant has a medically severe impairment or 5 combination of impairments. An impairment is found to be not severe “when 6 medical evidence establishes only a slight abnormality or a combination of slight 7 abnormalities which would have no more than a minimal effect on an individual’s 8 ability to work.” Yuckert v. Bowen, 841 F.2d 303, 306 (9th Cir. 1988) (quoting 9 SSR 85-28). Step two is generally “a de minimis screening device [used] to 10 dispose of groundless claims,” and the ALJ is permitted to find a claimant lacks a 11 medically severe impairment only when the conclusion is clearly established by the 12 record. Webb v. Barnhart, 433 F. 683, 687 (9th Cir. 2005) (quoting Smolen v. 13 Chater, 80 F.3d 1273, 1290 (9th Cir.1996)). 14 The ALJ found Mr. Enfield’s mental impairments, impulse control anger 15 issues and antisocial personality disorders, as diagnosed by Dr. Manuel Gomes, 16 PhD, to be non-severe, and she found no evidence of psychotic disorder. AR 13- 17 15. Dr. Gomes found Mr. Enfield capable of performing simple, repetitive tasks 18 and some complex, detailed tasks, and generally Mr. Enfield was mildly impaired. 19 AR 431-32. However, Dr. Gomes found Mr. Enfield severely impaired in his 20 ability to deal with usual stress encountered in the workplace. AR 432. The ALJ ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 9 1 rejected this portion of the opinion because, the ALJ asserted, it was based on the 2 subjective information of Mr. Enfield that was not credible. AR 14. See infra pp. 3 16-20. 4 Under step 2, an impairment is not severe if it does not significantly limit a 5 claimant’s ability to perform basic work activities. Edlund v. Massanari, 253 F.3d 6 1152, 1159 (9th Cir. 2001) (citing 20 C.F.R. § 404.1521(a)(b)). These include the 7 ability to respond appropriately to supervision, co-workers, and usual work 8 situations. Id. (citing 20 C.F.R. § 404.1521(b)(5)). Therefore, the opinion that Mr. 9 Enfield could not adapt to normal workplace stress, particularly with regard to 10 11 interpersonal relations, should qualify as a severe impairment under step 2. Because Mr. Enfield was found to have at least one severe impairment, this 12 case was not resolved at step two. Mr. Enfield does not assign error to the ALJ’s 13 finding at step three. Thus, any error in the ALJ’s finding at step two is harmless, if 14 all impairments, severe and non-severe, were considered in the determination Mr. 15 Enfield’s residual functional capacity. See Lewis v. Astrue, 498 F.3d 909, 910 (9th 16 Cir. 2007) (holding that a failure to consider an impairment in step two is harmless 17 error where the ALJ includes the limitations of that impairment in the 18 determination of the residual functional capacity). Because the ALJ failed to 19 account for all of these impairments in step four, the Court finds this was not 20 harmless error. ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 10 1 2 3 B. The Rejection of Some of Mr. Enfield’s Doctors was in Error. 1. Legal Standard. The Ninth Circuit has distinguished between three classes of medical 4 providers in defining the weight to be given to their opinions: (1) treating 5 providers, those who actually treat the claimant; (2) examining providers, those 6 who examine but do not treat the claimant; and (3) non-examining providers, those 7 who neither treat nor examine the claimant. Lester v. Chater, 81 F.3d 821, 830 (9th 8 Cir. 1996) (as amended). 9 A treating provider’s opinion is given the most weight, followed by an 10 examining provider, and finally a non-examining provider. Id. at 830-31. In the 11 absence of a contrary opinion, a treating or examining provider’s opinion may not 12 be rejected unless “clear and convincing” reasons are provided. Id. at 830. If a 13 treating or examining provider’s opinion is contradicted, it may only be discounted 14 for “specific and legitimate reasons that are supported by substantial evidence in 15 the record.” Id. at 830-31. 16 The ALJ may meet the specific and legitimate standard by “setting out a 17 detailed and thorough summary of the facts and conflicting clinical evidence, 18 stating his interpretation thereof, and making findings.” Magallanes v. Bowen, 881 19 F.2d 747, 751 (9th Cir. 1989) (internal citation omitted). When rejecting a treating 20 provider’s opinion on a psychological impairment, the ALJ must offer more than ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 11 1 his or her own conclusions and explain why he or she, as opposed to the provider, 2 is correct. Embrey v. Bowen, 849 F.2d 418, 421-22 (9th Cir. 1988). 3 2. Dr. Gomes 4 Dr. Gomes was an examining doctor. The ALJ and the parties do not cite to 5 a contrary opinion, nor does the Court’s review of the record find one. Non- 6 examining doctor Dr. Diane Fligstein, PhD, corroborates the finding of Dr. Gomes 7 and recommends that Mr. Enfield to work away from the general public, as he is 8 only “capable of superficial coworker contact of a non-cooperative nature.” AR 66. 9 Another non-examining doctor, Dr. Steven Haney, MD, affirmed this opinion and 10 also limited work settings to those “that require minimal interpersonal contact.” 11 AR 87. Thus, in the absence of a contrary opinion, the ALJ was required to provide 12 clear and convincing reasons to reject Dr. Gomes’s opinion. Lester, 81 F.3d at 830. 13 The ALJ afforded some weight to Dr. Gomes’s opinion, but she rejected his 14 findings of psychotic disorder, AR 13, and his assessment that Mr. Enfield has 15 severe limitations in his ability to deal with usual stress encountered in a 16 workplace. AR 14. The ALJ reasoned that these findings were inconsistent with 17 the record and based on the unreliable reports of the claimant. AR 13-14. 18 An ALJ may rely on doubts about credibility to reject part of a doctor’s 19 opinion, but they must also sustain the clear and convincing burden to reject that 20 which is not based on subjective complaints. See Edlund, 253 F.3d at 1159 (finding ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 12 1 error with an ALJ’s reliance on credibility doubts to reject the entire report of a 2 physician, including portions that could be deemed otherwise reliable). 3 The ALJ asserted that Dr. Gomes diagnosed a psychotic disorder based on 4 hallucinations in prison. AR 13. At his appointment with Dr. Gomes, Mr. Enfield 5 stated that he had problems with hallucinations when he was in “the hole” for five 6 months at a time. AR 429. The available prison records do not reflect any 7 behavioral problems. AR 362-385. However, the record does indicate that he was 8 prescribed Celexa and Risperdal. AR 375. While the record does not demonstrate 9 psychotic behavior, it also does not explain why his prison physicians chose to put 10 Mr. Enfield on antipsychotic medication. Id. It is not unreasonable for Dr. Gomes 11 to diagnose a psychotic condition based on a previous prescription of antipsychotic 12 medication, even if the record does not specifically indicate instances of psychotic 13 behavior. 14 Further, Dr. Gomes performed objective testing, in addition to reviewing 15 Mr. Enfield’s history. AR 427-432. An impairment may be determined by 16 medically-acceptable clinical diagnoses, as well as objective medical findings. Day 17 v. Weinberger, 522 F.2d 1154, 1156 (9th Cir. 1975). In this case, Dr. Gomes 18 provides both. Upon review of the opinion, the Court notes no evidence of concern 19 by Dr. Gomes that the testing performed was unreliable or that the doctor 20 suspected malingering. AR 427-432. It is unclear how much the objective testing ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 13 1 versus subjective history influenced Dr. Gomes. Even the ALJ asserted that it 2 appeared Dr. Gomes “relied in part on the claimant’s self-report about his prison 3 and past behavioral problems,” AR 14 (emphasis added), which implies that the 4 ALJ recognized some of the opinion was based on objective, clinical opinions. 5 The ALJ points to inconsistencies with Mr. Enfield’s activities of daily 6 living. The Court does not agree that having a family and romantic relationship are 7 evidence that Mr. Enfield is not limited in his dealing with typical workplace 8 stressors. Even the most extreme anxiety cases do not require complete isolation at 9 all times, and the Court does not find that having family is preclusive from having 10 11 disabling social conditions. Further, the statement from Krista Lortie, Mr. Enfield’s girlfriend, 12 corroborates his personality impairments. The ALJ ignored this testimony entirely. 13 See infra pp. 20-22. Ms. Lortie stated that Mr. Enfield has problems getting along 14 with family, friends, neighbors, and others. AR 242. Specifically, she stated that he 15 “gets irritable and upset at others, sometimes for no real reason.” Id. She also 16 offered that Mr. Enfield “no longer goes and hangs out with old friends doing 17 things they used to do.” Id. Simply because Ms. Lortie has continued her 18 relationship with Mr. Enfield despite his personality impairments, does not rise to a 19 legally sufficient reason to reject the opinion of an examining doctor. 20 ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 14 1 There is no evidence that Mr. Enfield regularly spends time in crowds, 1 and 2 the limited occasions that are spent in public are not inconsistent with the specific 3 limitations found by Dr. Gomes. For example, the ability to grocery shop (AR 261) 4 is not inconsistent with Dr. Gomes’s assessment. Dr. Gomes offered a very specific 5 limitation that was tailored to “the usual stress encountered in a competitive 6 workplace.” AR 432. Dr. Gomes opined that because Mr. Enfield has not learned 7 to properly manage his stress, in light of personality disorder, he would walk away 8 from a particularly stressful situation. Id. Whereas this would be unacceptable 9 behavior in a workplace, it would not be significant in a grocery store. 10 Finally, the Commissioner is unavailable with the argument that Dr. 11 Gomes’s opinion is inconsistent because Mr. Enfield had never been let go from a 12 job because he was unable to get along with others. ECF No. 19 at 8. As Dr. 13 Gomes correctly points out, Mr. Enfield “has not had a significant work history.” 14 AR 431. It is not unreasonable that he has not been dismissed, particularly if he has 15 spent a large portion of his adult life in prison. 16 The ALJ failed to provide clear and convincing reasons for rejecting the 17 opinion of Dr. Gomes. The ALJ did not account for any mental impairments in her 18 calculation of the residual functional capacity. Thus, this error is not harmless 19 20 1 The Court does not find the record supports the ALJ’s conclusion that Mr. Enfield attends church regularly.There is a single mention of church in reference to Mr. Enfield’s rejection of medication for his bipolar disorder. AR 406. ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 15 1 because it cannot be considered inconsequential to the determination of disability. 2 Molina, 674 F.3d at 1115. 3 3. Dr. Fligstein 4 ALJ Robinson gave little weight to Dr. Fligstein’s opinion. Dr. Fligstein 5 opined that Mr. Enfield was capable only of superficial contact and should work 6 away from the general public. Her opinion was consistent with that of Dr. Gomes. 7 The ALJ did not adopt the opinion because it “appear[ed] to rely heavily on 8 Dr. Gome’s [sic] evaluation and his diagnoses of antisocial personality disorder 9 and anger impulse control issues.” AR 14. As discussed previously, the ALJ did 10 not properly consider all of Dr. Gomes’s opinion, so this alone cannot constitute a 11 legally sufficient reason to disregard Dr. Fligstein’s opinion. See supra pp. 12-16. 12 Additionally, Dr. Fligstein references additional sources of information to form her 13 opinion than just Dr. Gomes’s diagnoses. AR 63. 14 The ALJ failed to properly consider Dr. Fligstein’s opinion. Again, because 15 none of Mr. Enfield’s mental impairments were accounted for in his residual 16 functional capacity, this error is not harmless. 17 18 C. The ALJ properly discounted Mr. Enfield’s credibility. An ALJ engages in a two-step analysis to determine whether a claimant’s 19 testimony regarding subjective symptoms is credible. Tommasetti v. Astrue, 533 20 F.3d 1035, 1039 (9th Cir. 2008). First, the claimant must produce objective ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 16 1 medical evidence of an underlying impairment or impairments that could 2 reasonably be expected to produce some degree of the symptoms alleged. Id. 3 Second, if the claimant meets this threshold, and there is no affirmative evidence 4 suggesting malingering, “the ALJ can reject the claimant’s testimony about the 5 severity of [his] symptoms only by offering specific, clear, and convincing reasons 6 for doing so.” Id. 7 In weighing a claimant's credibility, the ALJ may consider many factors, 8 including, “(1) ordinary techniques of credibility evaluation, such as the claimant's 9 reputation for lying, prior inconsistent statements concerning the symptoms, and 10 other testimony by the claimant that appears less than candid; (2) unexplained or 11 inadequately explained failure to seek treatment or to follow a prescribed course of 12 treatment; and (3) the claimant's daily activities.” Smolen, 80 F.3d at 1284. When 13 evidence reasonably supports either confirming or reversing the ALJ's decision, the 14 Court may not substitute its judgment for that of the ALJ. Tackett v. Apfel, 180 15 F.3d 1094, 1098 (9th Cir.1999). “General findings are insufficient: rather the ALJ 16 must identify what testimony is not credible and what evidence undermines the 17 claimant’s complaints.” Lester, 81 F.3d at 834. 18 a. Mr. Enfield’s daily activities 19 20 The Court already addressed the ALJ’s alleged inconsistencies between Mr. Enfield’s mental impairments and his daily activities in the analysis regarding Dr. ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 17 1 Gomes’s opinion. See supra pp. 12-16. Thus what remains here are the 2 inconsistencies between Mr. Enfield’s physical impairments (his back problems) 3 and his daily activities. 4 The ALJ noted several activities of daily living that are inconsistent with Mr. 5 Enfield’s allegations of the level of impairment related to his back. In particular, 6 the ALJ noted: personal care, meal preparation, light household chores, laundry, 7 shopping, walking around an orchard, fishing, and mowing the lawn in stages. AR 8 18. These activities are inconsistent with someone that alleges disabling back pain. 9 In addition, the record shows other activities that are inconsistent with 10 disabling back pain. For example, in September 2011, after his alleged onset date, 11 Mr. Enfield injured his back while splitting wood. AR 416-420. Mr. Enfield told 12 emergency room staff that he believed he picked up too heavy a piece of wood. AR 13 419. Again, in December 2012, Mr. Enfield sought treatment for injuring his upper 14 back after lifting a heavy box at Costco. AR 451. 15 The Court does not find the ALJ erred when assessing Mr. Enfield’s 16 credibility because his activities of daily living are inconsistent with his alleged 17 physical impairments. 18 b. Inconsistency with the record 19 The ALJ asserted that Mr. Enfield’s statements regarding his time in prison 20 are inconsistent with the record. For example, Mr. Enfield told Dr. Gomes that he ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 18 1 suffered hallucinations while in “the hole” in prison. AR 429. There is nothing in 2 the record to corroborate this. AR 362-385. Complicating the review, there are no 3 disciplinary records at all on file. 4 Although the prison records lack specificity, they do demonstrate that Mr. 5 Enfield was being treated with antipsychotic medication. This may or may not be 6 due to hallucinations, but it does demonstrate the diagnosis of some form of 7 psychotic disorder. Thus, the ALJ’s conclusion that the claimant has no established 8 psychotic disorder is not supported by the record. The Court does not need to rule 9 on whether the overall lack of evidence relating to Mr. Enfield’s allegations of his 10 experiences in prison, however, because the ALJ did not err in the finding of 11 credibility with regard to his daily activities. 12 c. Failure to treat 13 Also in consideration of Mr. Enfield’s credibility, the ALJ noted that he 14 failed to continue treatment for both mental and physical impairments. A 15 claimant’s statements may be less credible when treatment is inconsistent with the 16 level of complaints or a claimant is not following treatment prescribed without 17 good reason. Molina v. Astrue, 674 F.3d 1104, 1114 (9th Cir. 2012). When 18 refusing prescribed treatment, the reasons presented for not following the treatment 19 must be related to the mental impairment and not a matter of personal preference. 20 Id. ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 19 1 Mr. Enfield did seek treatment for his back issues as they arose, but he did 2 not continue with recommended physical therapy. AR 355. The record indicates 3 that he only attended one visit and never followed up for the second. Id. The ALJ 4 opined that this is not consistent with disabling pain, and the Court accepts this 5 opinion. 6 As previously discussed, Mr. Enfield was prescribed Celexa and Riperdal 7 during his time in prison. AR 375. Despite his own admission that he did better 8 while on the medication, Mr. Enfield chose not to continue the medications. AR 9 406. He opted rather to manage his condition “spiritually.” Id. The record, 10 however, does not demonstrate that he sought regular consultation with a religious 11 figure, and both he and Ms. Lortie stated that he did not attend church. AR 241, 12 262. Mr. Enfield also stated to Dr. Gomes that he has not sought any outpatient 13 mental health services. AR 428. 14 There is nothing that indicates Mr. Enfield’s treatment is not a matter of 15 personal preference, and thus the ALJ was permitted to use this lack of treatment in 16 an adverse credibility determination. Molina, 674 F.3d at 1114. 17 18 D. The ALJ erred in part with regard to lay witness testimony. Mr. Enfield’s long-term girlfriend Ms. Lortie provided a third-party function 19 report in March 2012. AR 237-244. “Other sources” for opinions include nurse 20 practitioners, physicians' assistants, therapists, teachers, social workers, spouses, ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 20 1 and other non-medical sources. 20 C.F.R. §§ 404.1513(d), 416.913(d). An ALJ is 2 required to “consider observations by non-medical sources as to how an 3 impairment affects a claimant's ability to work.” Sprague v. Bowen, 812 F.2d 1226, 4 1232 (9th Cir.1987). Non-medical testimony can never establish a diagnosis or 5 disability absent corroborating competent medical evidence. Nguyen v. Chater, 100 6 F.3d 1462, 1467 (9th Cir.1996). 7 An ALJ is obligated to give reasons germane to “other source” testimony 8 before discounting it. Dodrill v. Shalala, 12 F.3d 915 (9th Cir.1993). The ALJ 9 provides no reasons, much less germane ones, to discount Ms. Lortie’s testimony. 10 11 Rather, the ALJ does not address it at all. This in error. An ALJ’s failure to consider competent lay witness testimony is harmless 12 only when “it can confidently conclude that no reasonable ALJ, when fully 13 crediting the testimony, could have reached a different disability determination.” 14 Stout v. Comm’r of Soc. Sec., 454 F.3d 1050, 1056 (9th Cir. 2006). When applying 15 this rule, the Court must determine that failure to consider could not be 16 “inconsequential to the ultimate nondisability determination.” Id. at 1055. The 17 error must be non-prejudicial to the claimant. Id. However, “[w]here lay witness 18 testimony does not describe any limitations not already described by the claimant, 19 and the ALJ's well-supported reasons for rejecting the claimant's testimony apply 20 equally well to the lay witness testimony, it would be inconsistent with our prior ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 21 1 harmless error precedent to deem the ALJ's failure to discuss the lay witness 2 testimony to be prejudicial per se.” Molina, 674 F.3d at 1117. 3 The ALJ rejected Mr. Enfield’s credibility. See supra pp. 16-20. So far as 4 the information provided by Ms. Lortie that is based on subjective information by 5 Mr. Enfield, the ALJ’s failure to address this lay witness testimony would be 6 harmless error. See Molina, 674 F.3d at 1117. 7 However, the ALJ entirely rejected Mr. Enfield’s mental impairments. In 8 turn, she rejected any objective observations of those. There were no “well- 9 supported reasons for rejecting” Ms. Lortie’s testimony because it was not based 10 on credibility evaluations of Mr. Enfield. Id. With regard to objective statements 11 by Ms. Lortie, the ALJ needed to provide germane reasons for discounting. Thus, 12 the Court finds the ALJ erred in part with regard to Ms. Lortie’s testimony. 13 E. The ALJ Failed to Account for All of Mr. Enfield’s Limitations in 14 the Residual Functional Capacity and Erred in Steps Four and Five. 15 An ALJ may accept or reject restrictions that are not supported by 16 substantial evidence. Osenbrock v. Apfel, 240 F.3d 1157, 1164 (9th Cir. 17 2001)(citing Magallanes, 881 F.2d at 756-57)). The ALJ was not required to 18 accept the testimony of Mr. Enfield because he found him to be less than credible; 19 however, he erred in other areas, particularly with regard to Mr. Enfield’s mental 20 impairments. Because the ALJ did not properly account for all of Mr. Enfield’s ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 22 1 impairments, the Court finds that the residual functional capacity is incomplete. As 2 it flows from the incomplete residual functional capacity, the hypothetical 3 presented to the vocational expert and resulting determination that Mr. Enfield can 4 perform past relevant work, or alternatively, other work available in the national 5 economy, is flawed. See DeLorme v. Sullivan, 924 F.2d 841, 850 (9th Cir. 1991) 6 (holding that if a hypothetical fails to include all of limitations, the expert’s 7 testimony has no evidentiary value). 8 9 F. Remedy. The Court has the discretion to remand the case for additional evidence and 10 findings or to award benefits. Smolen, 80 F.3d at 1292. The Court may award 11 benefits if the record is fully developed and further administrative proceedings 12 would serve no useful purpose. Id. Remand is appropriate when additional 13 administrative proceedings could remedy defects. Rodriguez v. Bowen, 876 F.2d 14 759, 763 (9th Cir. 1989). In this case, the Court finds that further proceedings are 15 necessary for a proper determination to be made. 16 On remand, the ALJ shall credit the opinions of Drs. Gomes and Fligstein. 17 The ALJ will also consider the objective testimony related to Mr. Enfield’s mental 18 impairments that Ms. Lortie provided. Once accepting these opinions, the ALJ 19 shall recalculate the residual functional capacity, considering all impairments, and 20 then evaluate, based on this updated residual functional capacity, Mr. Enfield’s ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 23 1 ability to perform past relevant work, as well as work available in the national 2 economy. 3 VIII. Conclusion 4 Having reviewed the record and the ALJ’s findings, the Court finds the 5 ALJ’s decision is not supported by substantial evidence and contains legal error. 6 Accordingly, IT IS ORDERED: 7 8 9 10 11 1. Plaintiff’s Motion for Summary Judgment, ECF No. 14, is GRANTED, in part. 2. Defendant’s Motion for Summary Judgment, ECF No. 19, is DENIED. 3. The District Court Executive is directed to enter judgment in favor of Plaintiff and against Defendant. 4. This matter is REMANDED to the Commissioner for further proceedings 12 13 consistent with this Order. IT IS SO ORDERED. The District Court Executive is directed to enter this 14 Order, forward copies to counsel and close the file. 15 DATED this 11th day of March, 2016. 16 17 s/Robert H. Whaley ROBERT H. WHALEY Senior United States District Judge 18 19 20 ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT ~ 24

Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You should read the full case before relying on it for legal research purposes.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.