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Griffin v. Berryhill

United States District Court, W.D. New York

June 2, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          CHARLES J. SIRAGUSA United States District Judge.

         For the Plaintiff: Kenneth R. Hiller Timothy Hiller Law Offices of Kenneth Hiller 60000 North Bailey Avenue, Suite 1A Amherst, New York 14226 For the Defendant: Susan J. Reiss Social Security Administration Office of General Counsel 26 Federal Plaza, Room 3904 New York, New York 10278 Kathryn L. Smith, A.U.S.A.

         Office of the United States Attorney for the Western District of New York 100 State Street Rochester, New York 14614


         This is an action brought pursuant to 42 U.S.C. § 405(g) to review the final determination of the Commissioner of Social Security (“Commissioner” or “Defendant”), which denied the application of Shannon Nicole Griffin (“Plaintiff”) for Supplemental Security Income Benefits. Now before the Court is Plaintiff's motion (Docket No. [#7]) for judgment on the pleadings and Defendant's cross-motion [#13] for judgment on the pleadings. Plaintiff's application is denied, and Defendant's application is granted.


         The reader is presumed to be familiar with the parties' submissions, which contain detailed recitations of the pertinent facts. The Court has reviewed the administrative record [#5] and will reference it only as necessary to explain this Decision and Order.

         Plaintiff claims to be disabled due to both physical and mental impairments, but it is clear that the physical impairments are not disabling in and of themselves, and merely limit the exertional level at which Plaintiff can work.[1] The main thrust of Plaintiff's lawsuit is her contention that the ALJ failed to properly evaluate the medical evidence concerning her non-exertional impairments. See, Pl. Memo of Law [#7-1] at pp. 23-29.

         Exhibits 3F and 11F of the Administrative Record detail Plaintiff's treatment, between January 2010 and September 2014, at the Grace Family Medicine office in Rochester, New York, by her primary care physicians, Matthew Mack, M.D. (“Mack”) and William Morehouse, M.D. (“Morehouse”). Exhibit 3F covers the period of January 15, 2010 to November 1, 2012. (201-274). The office notes relating to this period of approximately three years contain ten references to Plaintiff's mental health, but are concerned primarily with other routine medical issues unrelated to Plaintiff's disability claim. Notably, every mental status examination performed as part of office visits during this period was normal. Specifically, the notes concerning such exams routinely stated, “Mental Status: No morbid ideation or overt thought disorder, ” with some entries adding, “capable of self management.” (271). On January 15, 2010, Mack reported that Plaintiff's depression was “improved.” (204). On May 26, 2010, Mack noted that Plaintiff was receiving mental health therapy and medication through a different office. (214). On February 23, 2011, Mack reported that Plaintiff's depression was “much stabler” on medication, with less depression and fewer panic attacks. (225). During that same visit, Mack reported that he had filled out disability-related paperwork for Plaintiff, based upon what he had been told by Plaintiff's therapist. (225) (“She brings me DHS papers; her counselor says she isn't yet ready to work . . . I put her down for being able to work [part time].”). Mack's report indicated, in pertinent part, that during the ensuing six months Plaintiff would be able to participate in “work, education or training” for only “5-10 hours per week, with reasonable accommodation.” (227). In that regard, when asked to list the factors limiting Plaintiff's ability to work, Mack wrote:

Avoid work environments of moderate or high [illegible] stress including complex work tasks, or crowded work environments. . . .
Anxiety/depression - P[atient] experiences panic attacks occasionally due to stressful situations. Occasionally her depression will cause lack of motivation isolation about once/month. No suicidal ideation.

(228). On November 15, 2011, Mack reported that Plaintiff had been discharged from mental health therapy after failing to attend appointments, and that she had stopped taking her medication, and had reported “some melt-downs, feeling useless.” (231). Mack also noted, though, that Plaintiff expressed interest in resuming both therapy and medication, and that she was “try[ing] to gain employment.” (231).

         On March 16, 2012, Mack reported that Plaintiff had brought disability forms for him to fill out. (249). However, Mack indicated that he would only fill out the form relating to Plaintiff's physical problems, and that he deferred to Plaintiff's mental health therapist to fill out any form relating to Plaintiff's mental impairments. (249) (“She brings in DHS work determination form. Her only physical limitation is due to L hip pains she has been having; larger limits are 2/2 [secondary to] mental health. She has a MH therapist, and will likely get a MH related DHS form for him to fill out.”).

         Exhibit 11F consists of Mack's and Morehouse's office notes for the period November 2012 through September 2014. During this period, the office notes contain fewer references to Plaintiff's depression than during the prior three years, and again mainly concern routine medical issues unrelated to Plaintiff's disability claim. Additionally, all of the mental status examinations remained normal. See, e.g., (548) (“Alert. Oriented to person, time, and place. No morbid ideation or overt though disorder and capable of self-management.”). Moreover, many of the references to Plaintiff's mental health indicate that her symptoms had improved with medication.

         On November 8, 2012, Morehouse reported that Plaintiff had resumed mental health therapy for “explosive disorder, ” which was “adequately compensated” with medication; Morehouse did not mention any depression symptoms. (543-544). On October 29, 2013, Morehouse reported that Plaintiff was taking Ambien and Trazodone for depression, and seeing a psychiatrist at a different office. (565). Morehouse noted, apparently based on Plaintiff's self-reporting, that she “still ha[d] episodes where her chest becomes tight and she feels [short of breath] with heart palpitations, ” which “has been associated with depressed mood, anxiety, irritability, panic attacks, insomnia, lack of motivation and poor concentration.” (565). On November 14, 2013, Morehouse reported both that Plaintiff's chest pains had ceased after taking medication, and that her depression had “improved.” (569). On May 23, 2014, Morehouse again reported that Plaintiff was complaining of chest pain, which she attributed to increased “stress recently” (570), though Morehouse apparently attributed her discomfort to a gastrointestinal problem. (571).

         Apparently because of such chest pain, Plaintiff was seen in the Emergency Room (“ER”) on August 12, 2014, at which time she noted that she had a history of depression and anxiety. (588). However, the attending doctor reported: “Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content are normal.” (589).

         Significantly, on September 22, 2014, Mack conducted a physical examination, and in the course of reviewing Plaintiff's “systems, ” he stated: “Psych: She denies anxiety, depression, panic attacks, insomnia, memory loss, concentration difficulty, suicidal ideation, increased stress, or hallucinations.” (599) (emphasis added). Mack further noted that Plaintiff had an “appropriate affect.” (600). Plaintiff reportedly told Mack that she was engaged and “trying to get pregnant.” (599).

         However, despite the fact that Plaintiff had, during her previous appointment, denied any mental health symptoms, and even though he had previously deferred to Plaintiff's therapist to complete any disability paperwork relating to mental health, on October 1, 2014, Mack filled out a disability report that not only addressed Plaintiff's alleged mental impairments, but also indicated that they rendered her incapable of working. (602-605). In that regard, Mack stated that Plaintiff had problems with “remember[ing] work-like procedures, ” “carry[ing] out detailed instructions, ” “work[ing] in coordination with or proximity to others without being unduly distracted, ” “mak[ing] simple work-related decision” and “complet[ing] a normal workday and workweek without interruptions from psychologically based symptoms, ” all of which would “preclude performance from 11% to 20% of an 8-hour workday.” (603). Further, Mack stated that Plaintiff had a problem with “maintain[ing] attention for two hour segments, ” that would “preclude performance for more than 20% of an 8-hour workday.” (603). Mack continued, opining that Plaintiff had problems dealing with supervisors, problems responding to changes in the workplace, problems dealing with “normal work stress, ” and problems planning and setting realistic goals, all of which would “preclude performance from 11% to 20% of an 8-hour workday.” (604). Mack further stated: “[Patient's] depression hinders focus causes some irritability/rigidity of her personality, impacting [the] above mentioned factors . . . full-time competitive employment could exacerbate . . . depression [secondary to] work stress.” (604-605).

         Exhibits 4F, 5F and 10F consist of treatment notes from Plaintiff's mental health therapy sessions at Unity Health System, where Plaintiff was seen by a series of therapists. (275-458, 482-541). Exhibits 4F and 5F cover the period of April 2010 through December 2012, though Plaintiff stopped attending appointments for one year within that period, between May 2011 (381) and May 2012 (388). Initially the focus of Plaintiff's treatment at Unity was her cannabis dependence, though her depression and anxiety were also addressed. As Plaintiff had success in abstaining from marijuana, the focus of the sessions turned more to her mental health symptoms. Moreover, Plaintiff initially sought treatment for anger management at the direction of the court (302), but eventually, after being terminated as a patient for failing to attend appointments, reinitiated treatment on her own.

         Between April 2010 and June 2010, Plaintiff was seen by Andrea Fedoruk, LCSW (“Fedoruk”). On April 12, 2010, at the start of treatment, Fedoruk noted that Plaintiff claimed to be very depressed, and exhibited a depressed mood and depressed/blunted affect. (310). Plaintiff also claimed to have poor concentration. (310). On May 18, 2010, Fedoruk reported that Plaintiff had completed necessary paperwork to allow her to fill prescriptions for Celexa and Trazodone. (316). Fedoruk noted that Plaintiff had a “more positive attitude, ” but still seemed depressed and irritable. (317).

         On July 29, 2010, Plaintiff began treating with a new therapist at Unity, Penny McClure (“McClure”). That same day McClure conducted a mental status exam that was unremarkable except that Plaintiff had a “depressed” mood and affect. (323). On September 20, 2010, McClure reported that Plaintiff was having “stressors relating to remaining sober, ” as well as preoccupations, depressed mood and depressed affect. (328).

         On October 14, 2010, McClure reported that Plaintiff had a “lifted mood compared to prior sessions” (333), with a “euthymic” mood and “normal” affect. (334). On October 27, 2010, McClure reported that Plaintiff was in a “good mood, ” with “euthymic” mood and “normal” affect. (339-340). On November 10, 2010, McClure noted that Plaintiff still had a “euthymic” mood and “normal” affect, despite having stopped taking medications because she was pregnant. (346). On December 20, 2010, Plaintiff told McClure that she as experiencing more anxiety since stopping the medications, and McClure noted that she had an anxious mood and normal affect. (351-352). On January 11, 2011, Plaintiff reported being stressed and worn out from “running around and trying to keep busy to keep her mind off using” marijuana (357), and McClure reported that she had a depressed mood and affect. (358).

         On March 18, 2011, Plaintiff began treating with a new Unity therapist, Wanda Ewer, LMSW (“Ewer”). (369). Plaintiff told Ewer that she “ha[d] stable living” and was “compliant with her medication.” (369). Plaintiff further stated that she was taking classes to earn her GED and to obtain vocational training as a security guard. (369). Ewer reported that Plaintiff had a euthymic mood and normal affect, and noted that Plaintiff “was attentive and ready to work on her goals and objectives.” (370).

         On April 15, 2011, Unity therapist Jamie Lee Watt, MS (“Watt”) reported that Plaintiff had a “euthymic mood and congruent affect, ” but was complaining of increased panic attacks, for which Watt suggested that she try breathing to calm herself. (377). On July 25, 2011, Watt reported that Unity was closing Plaintiff's file, because she had stopped attending appointments in May 2011. (380-381). Watt further noted that Plaintiff had expressed the need to smoke marijuana to calm down, and that her medications made her feel “a little agitated.” (385).

         A year later, Plaintiff returned to Unity for treatment and was seen by therapist Stephanie Catlin-Rakoski (“Catlin-Rakoski”). (388). On May 8, 2012, Plaintiff reportedly told Catlin-Rakoski that she was interested in obtaining her GED and studying to become a medical assistant. (396). That same day, Catlin-Rakoski conducted a mental status exam, and reported that Plaintiff had euthymic mood, normal affect, “helpless” thought process, and “tangential” thought form. (399). Plaintiff reportedly denied having any impairments with regard to activities of daily living. (399). On May 21, 2012, Plaintiff reported having decreased attention, mild anxiety and decreased concentration. (389).

         On or about June 8, 2012, Plaintiff began treating with Unity therapist Stephanie Dobbin, M.S. (“Dobbin”), at which time she told Dobbin that her depression symptoms consisted of low mood, lack of motivation, anhedonia, and suicidal thoughts. (402). Plaintiff further stated that she experienced anxiety in crowds and in enclosed spaces. (402). However, Plaintiff stated that she had abstained from marijuana for a year, and that she was motivated to receive mental health treatment. (402). Plaintiff also reiterated that she had no impairments in her activities of daily living. (404). On June 25, 2012, Plaintiff stated that her past choices had negatively affected her feelings of self worth, and that making “better, healthier choices” was having a positive impact on her mood and self-esteem. (406). On July 20, 2012, and August 3, 2012, Dobbin reported that Plaintiff had a normal mental status exam, including euthymic mood, normal affect, good insight and good ...

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