Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_06-cv-00301/USCOURTS-caed-1_06-cv-00301-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:416 Denial of Social Security Benefits

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Michael J. Astrue is substituted for his predecessor as Commissioner of 1

the Social Security Administration. 42 U.S.C. § 405(g); Fed. R. Civ. P.

25(d)(1).

The Honorable Oliver W. Wanger ordered the case assigned to the 2

undersigned Magistrate Judge on August 1, 2006. 

1

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

TIA LEE, )

)

Plaintiff, )

v. )

)

MICHAEL J. ASTRUE, )

Commissioner of Social )

Security, )

)

Defendant. )

)

 )

1:06-cv-00301-SMS

DECISION AND ORDER DENYING

PLAINTIFF’S SOCIAL SECURITY

COMPLAINT (DOC. 1)

ORDER DIRECTING THE ENTRY OF

JUDGMENT FOR DEFENDANT MICHAEL J.

ASTRUE, COMMISSIONER OF SOCIAL

SECURITY, AND AGAINST PLAINTIFF

TIA LEE

Plaintiff is proceeding in forma pauperis and with counsel

against the Commissioner of Social Security. Plaintiff seeks 1

judicial review of a final decision of the Commissioner denying

an application for Supplemental Security Income (SSI) benefits

under Title XVI of the Social Security Act (the Act). Pursuant to

28 U.S.C. § 636(c)(1), the parties have consented to the

jurisdiction of the Magistrate Judge to conduct all proceedings

in this matter, including ordering the entry of final judgment.2

Case 1:06-cv-00301-SMS Document 24 Filed 12/19/07 Page 1 of 26
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2

The matter is currently before the Court on the parties’ briefs,

which have been submitted without oral argument to the Honorable

Sandra M. Snyder, United States Magistrate Judge.

I. Procedural History

On October 10, 2002, Plaintiff protectively filed an

application for Supplemental Security Income (SSI), alleging

disability since October 1, 2002, because of high blood pressure,

arthritis, pain in the back and shoulder, and a mental condition

associated with depression, anxiety, insomnia, delusions,

hallucinations, suicidal ideation, and difficulty working with

others. Although Plaintiff had previously filed an application

for SSI regarding a disability allegedly beginning on March 19,

2001, it was denied after hearing by decision dated September 6,

2002. However, the administrative law judge (ALJ) in the instant

proceeding did not apply a continuing presumption of disability

from this previous, unfavorable decision. (A.R. 16-23, 56-61, 87,

107, 114.) After Plaintiff’s claim was denied initially and on

reconsideration, Plaintiff requested, and appeared at, a hearing

before the Honorable Patricia Leary Flierl, ALJ of the Social

Security Administration (SSA), on April 27, 2005. (71-74, 77-80,

16, 23.) Plaintiff appeared with an attorney and testified with

the assistance of a Hmong interpreter. On May 23, 2005, the ALJ

denied Plaintiff’s application for benefits. (Id. at 16-23.)

Plaintiff appealed the ALJ's decision to the Appeals Council.

After the Appeals Council denied Plaintiff’s request for

review on February 16, 2006, Plaintiff filed the complaint in

this action on March 16, 2006. (Id. at 4-7.) Briefing commenced

in December 2006, with Defendant’s brief being filed on January

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24, 2007, and Plaintiff’s reply on January 30, 2007. 

II. Standard and Scope of Review

Congress has provided a limited scope of judicial review of

the Commissioner's decision to deny benefits under the Act. In

reviewing findings of fact with respect to such determinations,

the Court must determine whether the decision of the Commissioner

is supported by substantial evidence. 42 U.S.C. § 405(g).

Substantial evidence means "more than a mere scintilla,"

Richardson v. Perales, 402 U.S. 389, 402 (1971), but less than a

preponderance, Sorenson v. Weinberger, 514 F.2d 1112, 1119, n. 10

(9th Cir. 1975). It is "such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion."

Richardson, 402 U.S. at 401. The Court must consider the record

as a whole, weighing both the evidence that supports and the

evidence that detracts from the Commissioner's conclusion; it may

not simply isolate a portion of evidence that supports the

decision. Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9 Cir. th

2006); Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). It

is immaterial that the evidence would support a finding contrary

to that reached by the Commissioner; the determination of the

Commissioner as to a factual matter will stand if supported by

substantial evidence because it is the Commissioner’s job, and

not the Court’s, to resolve conflicts in the evidence. Sorenson

v. Weinberger, 514 F.2d 1112, 1119 (9 Cir. 1975). th

In weighing the evidence and making findings, the

Commissioner must apply the proper legal standards. Burkhart v.

Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must

review the whole record and uphold the Commissioner's

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determination that the claimant is not disabled if the

Commissioner applied the proper legal standards, and if the

Commissioner's findings are supported by substantial evidence.

See, Sanchez v. Secretary of Health and Human Services, 812 F.2d

509, 510 (9th Cir. 1987); Jones v. Heckler, 760 F.2d at 995. If

the Court concludes that the ALJ did not use the proper legal

standard, the matter will be remanded to permit application of

the appropriate standard. Cooper v. Bowen, 885 F.2d 557, 561 (9th

Cir. 1987).

III. Disability

In order to qualify for benefits, a claimant must establish

that she is unable to engage in substantial gainful activity due

to a medically determinable physical or mental impairment which

has lasted or can be expected to last for a continuous period of

not less than twelve months. 42 U.S.C. § 1382c(a)(3)(A). A

claimant must demonstrate a physical or mental impairment of such

severity that the claimant is not only unable to do the

claimant’s previous work, but cannot, considering age, education,

and work experience, engage in any other kind of substantial

gainful work which exists in the national economy. 42 U.S.C.

1382c(a)(3)(B); Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th

Cir. 1989). The burden of establishing a disability is initially

on the claimant, who must prove that the claimant is unable to

return to his or her former type of work; the burden then shifts

to the Commissioner to identify other jobs that the claimant is

capable of performing considering the claimant's residual

functional capacity, as well as her age, education and last

fifteen years of work experience. Terry v. Sullivan, 903 F.2d

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28 All references to the Code of Federal Regulations are to the 2005 version unless otherwise stated. 3

5

1273, 1275 (9 Cir. 1990). th

The regulations provide that the ALJ must make specific

sequential determinations in the process of evaluating a

disability: 1) whether the applicant engaged in substantial

gainful activity since the alleged date of the onset of the

impairment, 2) whether solely on the basis of the medical

evidence the claimed impairment is severe, that is, of a

magnitude sufficient to limit significantly the individual’s

physical or mental ability to do basic work activities; 3)

whether solely on the basis of medical evidence the impairment

equals or exceeds in severity certain impairments described in

Appendix I of the regulations; 4) whether the applicant has

sufficient residual functional capacity, defined as what an

individual can still do despite limitations, to perform the

applicant’s past work; and 5) whether on the basis of the

applicant’s age, education, work experience, and residual

functional capacity, the applicant can perform any other gainful

and substantial work within the economy. See 20 C.F.R. § 416.920.3

Here, the ALJ concluded that Plaintiff, a forty-five-yearold woman who lacked a formal education, was illiterate and

unable to communicate in English, and who had no relevant past

work history in this country, suffered from severe depressive

disorder, not otherwise specified, arthritis, and post-traumatic

stress disorder that did not meet or medically equal a listed

impairment; Plaintiff retained the residual functional capacity

to perform light exertion and simple, one-step and two-step tasks

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with moderate difficulties in maintaining concentration,

persistence and pace, and mild limitations in her activities of

daily living and social functioning associated with her

depressive disorder and post traumatic stress disorder (A.R. 16-

17, 21.) The ALJ concluded that Plaintiff could perform almost

all of the requirements of light work, and using the MedicalVocational Guidelines (the Grids) as a framework for decision,

the ALJ further concluded that Plaintiff was capable of

performing numerous unskilled jobs that existed in significant

numbers in the national economy. (A.R. 21-22.)

IV. Plaintiff’s Residual Functional Capacity

Plaintiff argues that the ALJ’s finding regarding

Plaintiff’s residual functional capacity (RFC) was not supported

by a statement of adequate reasons or by substantial evidence

because the ALJ failed to give the appropriate weight to the

opinion of treating source Dr. Kaleka and to consultative

examiner Dr. Forward, who opined that Plaintiff suffered greater

limitations from her mental impairment than did the experts

relied upon by the ALJ.

The pertinent law has been recently summarized:

The opinions of treating doctors should be given

more weight than the opinions of doctors who do not

treat the claimant. Lester [v. Chater, 81 F.3d 821, 830

(9th Cir.1995) (as amended).] Where the treating

doctor's opinion is not contradicted by another doctor,

it may be rejected only for “clear and convincing”

reasons supported by substantial evidence in the

record. Id. (internal quotation marks omitted). Even if

the treating doctor's opinion is contradicted by

another doctor, the ALJ may not reject this opinion

without providing “specific and legitimate reasons”

supported by substantial evidence in the record. Id. at

830, quoting Murray v. Heckler, 722 F.2d 499, 502 (9th

Cir.1983). This can be done by setting out a detailed

and thorough summary of the facts and conflicting

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clinical evidence, stating his interpretation thereof,

and making findings. Magallanes [v. Bowen, 881 F.2d 747,

751 (9th Cir.1989).] The ALJ must do more than offer his

conclusions. He must set forth his own interpretations and

explain why they, rather than the doctors', are correct.

Embrey v. Bowen, 849 F.2d 418, 421-22 (9th Cir.1988).

Reddick v. Chater, 157 F.3d 715, 725 (9th Cir.1998);

accord Thomas, 278 F.3d at 957; Lester, 81 F.3d at

830-31.

Orn v. Astrue, 495 F.3d 625, 632 (9 Cir. 2007). th

A. Dr. Kaleka

Plaintiff testified with some equivocation that no one had

ever told her to see, and that she had not seen, any

psychiatrist, counselor, or therapist. (A.R. 296.) She reported

to Dr. Ramon Q. Raypon, a psychiatrist, in April 2003 that she

had no psychiatric hospitalization or treatment other than drugs

prescribed by her primary care physician, Dr. Kaleka. (A.R. 159.)

The Court considers the ALJ’s decision in its entirety.

The ALJ noted the opinion of Dr. Raypon after his

consultative examination of Plaintiff in April 2003 in which he

diagnosed Plaintiff with depressive disorder, not otherwise

specified. Dr. Raypon concluded that Plaintiff had no apparent

significant difficulties in maintaining appropriate social

functioning; had the capacity to maintain concentration and

attention to an activity for a short period; could understand,

remember, and carry out simple verbal directions; was capable of

handling funds; and would likely be impaired in her ability to

engage in and sustain work activities but would benefit from

continuing current psychotropic medications. (A.R. 17-18, 159-

61.) 

The ALJ further noted the opinion of state agency medical

consultant Glenn Ikawa, M.D., of July 2003 that Plaintiff could

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sustain simple, repetitive tasks for eight hours (A.R. 164) and

of psychiatrist Archimedes Garcia in January 2004 affirming Dr.

Ikawa’s assessment (A.R. 18, 164). 

The ALJ noted Plaintiff’s treatment by Dr. Kaleka for

depression and physical ailments as well as Dr. Kaleka’s

assessment of April 2002 that suggested mental limitations (not

recited by the ALJ) and stated that Plaintiff had fair ability to

perform simple tasks. (A.R. 18, 216-19.) With respect to Dr.

Kaleka’s medical source statement dated July 2002, the ALJ noted

the contrast between the assessment and contemporaneous, routine

treatment notes. Dr. Kaleka reported that Plaintiff’s ability to

relate and interact with others and withstand the stress of work

was poor; her ability to understand, remember, and carry out

simple instructions, deal with the public, and maintain

concentration for two-hour increments was impaired and was

expected to last about one year. (A.R. 18, 211-12, 229-30.) 

The ALJ further noted a physician’s assistant’s welfare

assessment dated July 29, 2002, that Plaintiff’s several

medications for depression might cause drowsiness and sleepiness.

(A.R. 18, 209, 207-10.)

The ALJ further referred to records that reflected that Dr.

Kaleka continued to treat Plaintiff conservatively for depression

and anxiety in October 2003. (A.R. 18, 269.) The ALJ referred to

a physician’s assistant’s mental capacities form dated January

2004 that indicated that Plaintiff could not work or follow

instructions, and which reflected other limitations that the ALJ

did not mention. (A.R. 18, 266.) The ALJ reasoned that the

statement was not supported by treatment records and thus was not

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given controlling weight. (A.R. 18.) The ALJ also noted that the

most recent progress notes from Dr. Kaleka reflected continued

conservative treatment in the form of medications for depression,

anxiety, and Plaintiff’s physical ailments. (A.R. 19, 280-82.)

The ALJ reviewed consulting psychiatric examiner Dr. E.

Michiel’s findings and opinions after his examination of

Plaintiff in November 2003, and he specifically noted that Dr.

Michiel had opined that Plaintiff could maintain attention and

concentration to carry out simple one-step or two-step job

instructions. (A.R. 18, 249-51.) After reviewing Plaintiff’s

subjective complaints, the ALJ concluded that Plaintiff’s alleged

inability to work was not credible to the degree alleged. (A.R.

19-20, 22.) 

The ALJ then stated reasons pertinent to Dr. Kaleka’s

opinions, including 1) Plaintiff had only received treatment in

the form of medication from her treating source; 2) Dr. Kaleka’s

assessment of April 2002 appeared to be an attempt to help

Plaintiff obtain benefits because the limitations reported

appeared out of proportion to actual clinical findings; 3) Dr.

Kaleka’s report of April 2002 that Plaintiff had significant loss

of memory resulting in a fair ability to understand, remember,

and carry out simple instructions was contradicted by the

findings during the later evaluation of November 2003 (A.R. 250),

during which Plaintiff could recall three out of five objects

after five minutes and could make correct change from $1.00; 4)

Plaintiff’s treating source did not refer her to mental health

for counseling or group therapy, and she had not sought further

treatment for her mental complaints; and 5) while Dr. Raypon, the

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first consulting psychiatrist, opined that continuing symptoms of

depression would likely impair Plaintiff’s ability to engage in

and sustain work activities. Dr. Michiel, the consulting

psychiatrist who had most recently examined Plaintiff, had found

her capable of maintaining attention and concentration sufficient

to perform one-step and two-step simple job instructions based on

her presentation and reported activities of daily living, which

was most consistent with the overall evidence. (A.R. 20.)

Here, the ALJ reviewed the entire medical record and

determined that Dr. Kaleka’s opinion was not supported by it. The

ALJ also expressly stated several reasons pertinent to his giving

limited weight to the opinion of Dr. Kaleka. The ALJ reviewed the

overall, longitudinal record of treatment with respect to

Plaintiff’s medical condition. He stated that Dr. Kaleka’s

treatment notes were routine in nature, in contrast to his

assessments of April and July 2002, which were relatively

restricted. (A.R. 18.) The record supports this finding because

it reveals that in April 2002, based on Plaintiff’s reports

and/or clinical findings of insomnia, depression, anxiety, guilt

feelings, mood changes, fear and nightmares, and easily lost

temper, Dr. Kaleka diagnosed depression with psychotic features

and anxiety treated with limited response by medications

(Seroquel, Restril, and Buspar) with a fair to guarded prognosis;

Plaintiff had poor ability to follow work rules, relate to coworkers, deal with the public, use judgment, interact with

supervisors, deal with work stress, function independently, and

maintain attention and concentration, understand, remember and

carry out detailed or complex job instructions, behave in an

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emotionally stable manner, relate predictably in social

situations, and demonstrate reliability, but fair ability to

understand, remember and carry out simple instructions and to

maintain personal appearance; she had limited ability to

concentrate to do anything because of loss of memory, and she

lost her temper easily and could not withstand the stress and

pressures; and she could not manage her benefits in her own best

interest. (A.R. 216-19.) 

Again, the two-page assessment of July 1, 2002, of Dr.

Kaleka indicated that Plaintiff had poor ability to relate and

interact with supervisors and coworkers, very poor ability to

understand, remember and carry out an extensive variety of

technical and/or complex job instructions, impaired ability to

understand, remember and carry out simple one-step or two-step

job instructions, deal with the public, or maintain concentration

and attention for at least two-hour increments; Plaintiff had

poor ability to withstand the stress and pressures associated

with an eight-hour work day and day-to-day work activity;

impaired and limited ability to handle funds; limited response to

treatment; her medications might cause drowsiness or headaches;

the prognosis was fair to guarded for one year; and the medical

provider expressly stated that Plaintiff needed to be evaluated.

(A.R. 211-12, 229-30.) 

No treatment notes or clinical findings accompanied this

evaluation. However, reference to the treatment notes of Dr.

Kaleka over the long period of approximately monthly treatment

from February 2001 through March 2005 reveals that they are

routine to the point of being nearly identical. (A.R. 213, 239-

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42, 235-37, 223-28, 221, 215, 213, 210, 206, 200, 198, 193-98,

186-89, 183-84, 267-69, 261-64, 256-57, 280-82.) Plaintiff

routinely reported substantially subjective symptoms, including

insomnia, depression, anxiety, crying, guilt feelings, mood

changes, fearfulness, nightmares; sometimes loss of memory,

anger, loss of sleep, and lost temper were also noted. Dr. Kaleka

diagnosed depression and anxiety at first, then depression with

psychotic features, and then depression with anxiety; Dr. Kaleka

treated Plaintiff with medications beginning in early 2001 and

continuing through 2005. (A.R. 213, 280-81.) 

The record supports the ALJ’s conclusion that the treatment

notes are routine and the treatment conservative in the face of

an assessment of total disability. It is established that a

conclusional opinion that is unsubstantiated by relevant medical

documentation and/or not supported by clinical findings may be

given less weight. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th

Cir. 1992); Magallanes v. Bowen, 881 F.2d 747, 751; Johnson v.

Shalala, 60 F.3d 1428, 1432-33 (9 Cir. 1995). It is appropriate th

for an ALJ to consider the absence of supporting findings, and

the inconsistency of conclusions with the physician’s own

findings, in rejecting a physician’s opinion. Johnson v. Shalala,

60 F.3d 1428, 1432-33 (9 Cir. 1995); Matney v. Sullivan, 981 th

F.2d 1016, 1019 (9th Cir. 1992); Magallanes v. Bowen, 881 F.2d

747, 751 (9 Cir. 1989). Greater weight will be given to opinions th

based on or supported by relevant evidence, such as medical signs

and laboratory findings. 20 C.F.R. § 404.1527(d)(3); 20 C.F.R. §

416.927(d)(3). Likewise, the better an explanation a source

provides for an opinion, the more weight will be given to the

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opinion. Id. The more consistent an opinion is with the record as

a whole, the more weight will be given to the opinion. 20 C.F.R.

§ 404.1527(d)(4); 20 C.F.R. § 416.927(d)(4). Further, it is

established that even where an expert’s report identifies

characteristics that might limit a claimant’s ability to perform

work on a sustained basis, if the report fails to explain how

such characteristics preclude work activity in the claimant’s

case, it is appropriate and adequate for an ALJ to 1) determine

that the level of impairment stated is unreasonable in light of

the symptoms and other evidence in the record, and 2) set forth

that analysis. See Morgan v. Commissioner of Social Security 169

F.3d 595, 601 (9 Cir. 1999). th

The ALJ here stated his reasons and relied on the lack of

treatment notes that substantiated the nature and extent of the

limitations claimed by Plaintiff and her treating physician. The

evidence relied upon was such as a reasonable mind might accept

as adequate to support the conclusions. Substantial evidence

supported the ALJ’s conclusion.

Because the actual clinical findings made by Dr. Kaleka were

out of proportion to the severe limitations imposed by Dr.

Kaleka, the ALJ could properly conclude that Dr. Kaleka’s

assessment of April 2002 appeared to be an attempt to help

Plaintiff obtain benefits. The purpose for which an opinion is

provided is not a legitimate basis for evaluating the reliability

of the report; however, evidence of the circumstances under which

a report was obtained and its consistency with other records,

reports, or findings could form a legitimate basis for evaluating

the reliability of the report. The correct standard with respect

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to an opinion’s purpose is that in the absence of other evidence

to undermine the credibility of a medical report, the purpose for

which the report was obtained does not provide a legitimate basis

for rejecting it. Reddick v. Chater, 157 F.3d 715, 726 (9 Cir. th

1998).

Here, the ALJ referred to legitimate and specific reasons

other than the purpose of the report that tended to undermine Dr.

Kaleka’s opinion. After concluding that the ALJ’s April 2002

assessment (significant memory loss resulting in only a fair

ability to understand, remember, and carry out simple

instructions) appeared to be an attempt to help Plaintiff obtain

benefits because of the disparity between actual clinical

findings and the limitations imposed, the ALJ then further noted

that the opinion was contradicted by findings during Dr.

Michiel’s exam in November 2003, when Dr. Michiel found that

Plaintiff could recall three objects after five minutes and could

make correct change from $1.00. (A.R. 250.) The ALJ’s reliance on

more up-to-date and specific findings by the consulting examiner

was legitimate and specific and was supported by substantial

evidence.

The ALJ then addressed another limiting opinion, that of Dr.

Raypon, and expressly relied instead on the later opinion of Dr.

Michiel, who found that Plaintiff could maintain attention and

concentration sufficient to perform one-step and two-step simple

job instructions. The ALJ stated several reasons for adopting the

opinion of Dr. Michiel, including 1) the opinion of Dr. Michiel

was more recent; 2) the opinion was consistent with Plaintiff’s

presentation and her reported activities of daily living; and 3)

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it was the opinion most consistent with the overall evidence.

(A.R. 20.)

As previously discussed, the ALJ’s characterization of the 

medical record was supported by substantial evidence; both

examining specialists Dr. Raypon and Dr. Michiel found that

Plaintiff could remember and perform simple instructions. Dr.

Michiel’s report was more recent. The opinion that Plaintiff

could perform simple instructions was consistent with Plaintiff’s

reported activities of daily living, including the ability to

care for her personal needs, drive her car, do the shopping,

visit with relatives (but not clean house or cook) (A.R. 250 [as

reported to Dr. Michiel]), talk to neighbors (A.R. 296), and cook

and warm food (A.R. 298). Plaintiff’s activities of daily living

involved simple activities on a regular basis. Further, the

overall medical evidence and the most recent medical evidence

supported the ALJ’s evaluation of the evidence.

Thus, the ALJ gave specific and legitimate reasons,

supported by substantial evidence in the record, for crediting

the report of Dr. Michiel over the reports of Dr. Raypon and Dr.

Kaleka. 

Further, the ALJ gave reasons in addition to the purpose of

the opinion that supported his assessment of Plaintiff’s mental

RFC. The ALJ also expressly noted that additional records

submitted from Dr. Kaleka reflected only conservative treatment

for depression/anxiety as well as Plaintiff’s physical

impairments; further, the January 2004 mental capacities form

completed by a physician’s assistant indicated that the Plaintiff

could not work or follow instructions, but it was not given

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controlling weight because it was not supported by treatment

records. (A.R. 18.)

Reference to the record of treatment in January 2004 (A.R.

265-67) shows that Dr. Kaleka circled many of the same symptoms

regarding Plaintiff’s psychological condition (insomnia,

depression, anxiety, guilt feeling, changes in mood, nightmares),

noted she was anxious or depressed, and diagnosed

depression/anxiety. (A.R. 267.) Medication continued to be the

only treatment for Plaintiff’s mental impairment; thus, the

record supports the ALJ’s reasoning that Plaintiff’s treating

doctor continued to recommend only conservative treatment.

Further, the treatment records going back to October 2003

reflected only the circling of the same symptoms, which by virtue

of their nature were based substantially on Plaintiff’s reports,

and which did not appear to demonstrate the claimed total loss of

function attributed to Plaintiff by the physician’s assistant.

(A.R. 268-69.) Yet with respect to Plaintiff’s mental impairment,

the physician’s assistant opined that Plaintiff could not attend

class, work, or follow instructions; she did not adapt to stress,

and she had depression and anxiety. (A.R. 266.) 

The treatment records are not supportive of total disability

because they do not reflect clinical findings that would justify

the extensive disability claimed. It is further unclear whether

any dysfunction is related to specific settings or contexts, and

whether or not it is affected by the medication which the

physician continued to use for treatment. In the main, the

opinion is stated in ultimate terms to the effect that Plaintiff

could not work or attend class. It is established, however, that

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a determination of whether or not a claimant meets the statutory

definition of disability is a legal conclusion reserved to the

Commissioner; the opinion of a medical source on the ultimate

issue of disability is not conclusive. Magallanes v. Bowen, 881

F.2d 747, 751 (9 Cir. 1989). th

The Court concludes that substantial evidence in the record

supports the ALJ’s reasoning that the treatment records did not

support the physician’s assistant’s opinion of Plaintiff’s

disability. This reasoning is specific and legitimate. It was not

disputed that Plaintiff suffered a mental impairment. The

critical inquiry was the extent to which Plaintiff’s mental

impairment actually affected Plaintiff’s functional capacity. The

ALJ’s finding that the record from the treating sources was

inadequate to support the extent of limitation claimed by

Plaintiff and her physicians was directly pertinent to the

required analysis.

In summary, the Court rejects Plaintiff’s contention that

the ALJ failed to give legally adequate or specific and

legitimate reasons for weighing the opinions of the various

psychiatric experts discussed above. Further, the Court finds

that substantial evidence supported the findings.

B. Dr. Forward and Trainee’s Assessment

Plaintiff challenges the correctness of the ALJ’s reasons

for rejecting a psychological evaluation completed by a trainee

and reviewed and signed by a licensed clinical psychologist, Dr.

Valerie Forward. Plaintiff argues that the ALJ erred in

concluding that the evaluation was done by a trainee. Further,

because the ALJ failed to note or decide that the assessment was

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explanatory and consistent with Dr. Kaleka’s opinion, the ALJ

failed properly to evaluate the opinion. 

The ALJ stated the following:

At the request of claimant’s attorney, the claimant

received a psychological evaluation from Alycia Barlow, 

psychological trainee, with Psychological Service Center,

in January 2005. On mental status examination, the claimant

was described as withdrawn and her affect appeared 

restricted and depressed. The claimant admitted to past

and current thoughts of suicide, but she denied having

receiving (sic) any mental health services. The claimant

reported feeling anxious. The claimant reported having 

eleven children, with the tragic death of her youngest

in 1991. The examiner opined that the claimant appeared

to exhibit symptoms of unresolved grief when discussing

her loss. She also reported auditory hallucinations that 

were likely the result of depression. At this time, the 

examiner considered the claimant’s recent and remote

memory to be moderately impaired. However, on testing, the

claimant was able to correctly identify time on

the clock and all denominations of money, and knew the

purposes of money. She claimed that she does not use

the telephone if no one is home, though she was able

to demonstrate how to use it. The diagnosis was major

depressive disorder, recurrent and severe, and post

traumatic stress disorder, chronic. The examiner 

reported in summary that the claimant demonstrated mild

deficits in her ability to interact, which were more

likely due to cultural and psychological factors rather

than a cognitive impairment. The examiner reported in 

closing that the claimant’s lack of formal education, 

extreme psychological distress and limited acculturation 

reduce her ability to function at her full intellectual

capacity and limit her ability to perform adaptive

functions. Although the trainee recommended individual

psychotherapy relative to the unresolved grief issue and

also group therapy and psychiatric evaluation to evaluate

the medications currently prescribed (Exhibit 8F, pages

1-7), there is no evidence that these treatment avenues

have been pursued by the claimant.

(A.R. 19.) Later, the ALJ returned to the assessment:

While evidence also suggests that the claimant suffers 

from post traumatic stress disorder, associated with a 

prior traumatic loss of child, neither of the psychiatrists

who evaluated the claimant for the Administration found

evidence that this impairment resulted in any limitations

in functioning and actually did not even diagnose it. The

recent psychological assessment, obtained by the claimant’s

attorney, suggests that the claimant’s limitations result 

from a combination of psychological distress, as well 

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a (sic) lack of formal education and limited 

acculturation. However, I note that education and 

acculturation are already factored into the Medical

Vocational Guidelines and are not a medical impairment.

Further, this examiner was trainee and under Social 

Security Regulations is not considered an acceptable

medical source. Thus, her opinion, while considered,

is not given controlling weight.

(A.R. 20-21.)

The report of the evaluation reveals that it was requested

by Plaintiff’s attorney’s office; involved a structured clinical

interview, mental status examination, and psychological as well

as adaptive and social functioning tests; and was conducted with

one evaluator, Alycia Barlow, a psychological trainee, on January

19, 2005. (A.R. 270-79, 270-71.) No information is given

concerning the educational background of the trainee. The report

indicates that all assessment results were reviewed with a

licensed clinical psychologist, Dr. Valerie Forward, Ph.D. (A.R.

271.) Both trainee Barlow and Dr. Forward signed the assessment

on February 3, 2005 (two weeks after the examination). (A.R. 276,

279.) 

The ALJ properly concluded that the trainee was not an

acceptable medical source under Social Security Regulations.

(A.R. 20-21.) Symptoms of the claimant alone cannot establish a

physical or mental impairment; rather, there must be evidence

from an acceptable medical source. 20 C.F.R. §§ 416.902, 416.908,

416.913(a). Acceptable medical sources for the purposes of this

case include licensed physicians and licensed or certified

psychologists. 20 C.F.R. § 416.913(a). 

The ALJ appropriately concluded that the trainee was not an

acceptable medical source. Although an acceptable medical source

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reviewed the assessment of the trainee, it does not appear that

the acceptable medical source herself conducted the interview or

tests or otherwise actually engaged in the face-to-face

evaluation of the claimant. Instead, it appears that an

unlicensed trainee was the actual sole examiner, and then at some

unspecified time after the trainee’s evaluation, the acceptable

medical source reviewed the work of the trainee. The trainee does

not appear to have had any certification of any type; further,

there are no data regarding the trainee’s education, the extent

of the relationship between the licensed clinical psychologist

and the trainee, or the former’s supervision of the latter. Thus,

this case may be distinguished from Gomez v. Chater, 74 F.3d 967,

970-71 (9 Cir. 1996).

th

Further, the Court notes that the ALJ also properly relied

on the fact that the trainee’s assessment was based not only upon

medical factors, but also upon Plaintiff’s education and

acculturation. (A.R. 20.) The record shows that the trainee

relied on Plaintiff’s lack of formal education and cultural

factors, concluding that Plaintiff’s mild deficits in interacting

with her environment were most likely attributable to cultural

factors as well as psychological ones; the trainee also concluded

that Plaintiff’s unconventional reasoning and perceptual

abilities might result from a lack of formal education and

cultural factors. (A.R. 273, 275.) The trainee concluded:

In summary, her lack of formal education, extreme 

psychological distress and limited acculturation reduce

her ability to function at her full intellectual capacity

and limit her ability to perform adaptive functions

she may otherwise be capable of.

(A.R. 275.) Reliance on strictly cultural and educational factors

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would run afoul of the regulations, which provide that an

impairment must result from anatomical, physiological, or

psychological abnormalities which can be shown by medically

acceptable clinical and laboratory diagnostic techniques. 20

C.F.R. § 416.908. An impairment must be established by medical

evidence consisting of signs, symptoms, and laboratory findings.

Id. As Defendant notes, the Medical-Vocational Guidelines, or

“Grids,” already include education and some cultural factors,

such as work experience, skills, and literacy. See, e.g., 20

C.F.R. Part 404, Subpart P, Appendix 2, §§ 200.00(a), (d); 201.00

(d), (e), (g).

V. Lack of Testimony of a Vocational Expert at Step Five

Plaintiff argues that because Plaintiff had two severe

mental impairments and had no past relevant work, vocational

testimony was required at step five of the disability analysis.

Plaintiff argues that the “Grids,” or Medical Vocational

Guidelines, speak only to exertional factors; because Plaintiff

had a mental non-exertional impairment that limited him to simple

one-step and two-step tasks, the evidence was insufficient to

sustain the determination that Plaintiff could perform other

work.

The ALJ concluded that Plaintiff was not disabled by

application of Rule 202.16 because Plaintiff had the

nonexertional capacity to perform almost all the requirements of

light work. The ALJ concluded that the limitation to tasks of a

simple, repetitive nature did not significantly erode the

occupational base of work at the various levels of exertion

because the Commissioner had identified numerous unskilled jobs

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All references to the DOT are to the Dictionary of 4

Occupational Titles, fourth edition revised in 1991.

22

which did not involve more than simple, one-step and two-step

tasks. (A.R. 22.) The ALJ concluded that Plaintiff’s mental

limitations did not significantly erode the unskilled

occupational base of jobs. (Id.)

Plaintiff argues that the fact that jobs were unskilled was

not sufficient to accommodate Plaintiff’s limitation to simple,

one-step and two-step tasks because many unskilled jobs have a

reasoning level that require more than the ability to understand,

remember, and carry out simple instructions. Plaintiff contends

that Plaintiff’s limitation most reasonably equates to reasoning

level one of the DOT standards; in the DOT many unskilled jobs 4

have a reasoning level beyond level one. Therefore, reference to

the grids is inappropriate.

Once a claimant proves he cannot return to his former work,

the Secretary must show that there are jobs in the national

economy that the claimant can perform. Jones v. Heckler, 760 F.2d

993, 998 (9th Cir.1985). The guidelines may only be applied when

they accurately reflect a claimant’s limitations. Desrosiers v.

Secretary of Health & Human Services, 846 F.2d 573, 576-77 (9th

Cir. 1988). If a nonexertional limitation significantly limits

the range of work one can perform, mechanical application of the

grids is inappropriate, and a VE is required. Tackett v. Apfel,

180 F.3d 1194, 1102 (9 Cir. 1999). Absent other reliable th

evidence of an applicant’s ability to perform specific jobs, the

Secretary must use a vocational expert. Perminter v. Heckler, 765

F.2d 870, 872 (9th Cir.1985). However, where nonexertional

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limitations are found not to significantly limit a claimant’s

exertional capacity, then use of the grids is appropriate. Razey

v. Heckler, 785 F.2d 1426, 1430 (9 Cir. 1986), as amended, 794 th

F.2d 1348 (where substantial evidence supported the agency’s

conclusion that the claimant’s generalized anxiety disorder did

not prevent him from engaging in the work that he was physically

able to do, use of the grids was appropriate); Odle v. Heckler,

707 F.2d 439, 440 (9th Cir.1983) (where substantial evidence

supported the finding that the claimant’s non-exertional

impairments of deafness, dizziness, and drug dependence did not

significantly limit his exertional capacities, use of the grids

was appropriate, and no finding as to specific jobs was

required).

The functional capacity to perform a full range of light

work includes approximately 1600 separate sedentary and light

unskilled occupations constituting jobs that can be performed

after a short demonstration or within thirty days, and do not

require special skills or experience. 20 C.F.R. Part 404, Subpart

P, Appendix 2, § 202.00(a). Each occupation represents numerous

jobs in the national economy. Soc. Sec. Ruling 85-15. 

The capacity to perform a full range of light work

represents a substantial work capability compatible with making a

work adjustment to substantial numbers of unskilled jobs and thus

generally provides sufficient occupational mobility even for

severely impaired individuals who are not of advanced age and

have sufficient educational competence for unskilled work. 20

C.F.R. Part 404, Subpart P, Appendix 2, § 202.00(b).

With respect to unskilled work, the basic 

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mental demands of competitive, remunerative, unskilled work

include the abilities on a sustained basis to understand, carry

out, and remember simple instructions; to respond appropriately

to supervision, coworkers, and usual work situations; and to deal

with changes in a routine work setting. Soc. Sec. Ruling 85-15 p.

4. A substantial loss of ability to meet any of these basic workrelated activities would severely limit the potential

occupational base. Id. Further, unskilled jobs ordinarily involve

dealing primarily with objects rather than data or people, and

they generally provide substantial vocational opportunity to a

person with a solely mental impairment who retains the capacity

to meet the intellectual and emotional demands of unskilled jobs

on a sustained basis. Id. 

The ALJ’s conclusion that Plaintiff’s limitation to simple,

repetitive tasks did not significantly reduce Plaintiff’s

capacity for a broad range of light work was supported by the

relevant expert opinions of Dr. Michiel and the state agency

physicians, which indicated that Plaintiff was not significantly

limited in any respect other than the limitation to simple,

repetitive tasks, which he could perform to the extent required

for employment. (Tr. 260-62.)

Further, with respect to the DOT alone, the DOT’s inclusion

of some jobs that require reasoning up to level 2 in unskilled

work, as Defendant notes, is accompanied by a statement that

although a worker at reasoning level 2 must be able to follow

“detailed” instructions, it further states that the instructions

would be uninvolved, that is, not a high level of reasoning. DOT,

Appendix C, § III. There is no exact correspondence between the

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regulations’ categories, which with respect to the capacity to

understand, remember, and concentrate include only “short and

simple instructions,” on the one hand, and “detailed” or

“complex” instructions on the other. 20 C.F.R. §

416.969a(c)(l)(iii); see, Meissl v.Barnhart, 403 F.Supp.2d 981,

985 (C.D.CA 2005) (noting the lack of exact correspondence

between the two systems of categorization, and further reviewing

authorities that reflected a view that an RFC for simple and

routine or repetitive work was more in line with reasoning level

2 than with level 1 in the DOT, which required only the slightest

bit of rote reasoning); Hackett v. Barnhart, 395 F.3d 1168, 1176

(10 Cir. 2005) (finding that a RFC of simple and routine work th

tasks was more consistent with reasoning at level 2, requiring

application of commonsense understanding to carry out detailed

but uninvolved written or oral instructions and dealing with

problems involving a few concrete variables in or from

standardized situations); but see Lucy v. Chater, 113 F.3d 905,

909 (8 Cir. 1997) (rejecting the contention that a claimant th

limited to following only simple instructions could engage in the

full range of sedentary work because many unskilled jobs in that

category require reasoning levels of two or higher).

Accordingly, in light of the provisions of the grid itself,

the Court concludes that the ALJ’s reliance on the grids was

appropriate. There was no need to obtain testimony from a

vocational expert. 

VI. Disposition

In conformity with the foregoing analysis, the Court

concludes that the ALJ’s decision was supported by substantial

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evidence in the record as a whole and was based on proper legal

standards. 

Accordingly, the Court AFFIRMS the administrative decision

of the Defendant Commissioner of Social Security and DENIES

Plaintiff’s Social Security complaint.

The Clerk of the Court IS DIRECTED to enter judgment for

Defendant Michael J. Astrue, Commissioner of Social Security, 

and against Plaintiff Tia Lee.

IT IS SO ORDERED.

Dated: December 18, 2007 /s/ Sandra M. Snyder 

icido3 UNITED STATES MAGISTRATE JUDGE

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