Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_08-cv-02464/USCOURTS-caed-2_08-cv-02464-6/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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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

WILLIAM W. COPELAND, No. CIV S-08-2464-CMK

Plaintiff, 

vs. MEMORANDUM OPINION AND ORDER

COMMISSIONER OF SOCIAL 

SECURITY,

Defendant.

 /

Plaintiff, who is proceeding with retained counsel, brings this action for judicial

review of a final decision of the Commissioner of Social Security under 42 U.S.C. § 405(g). 

Pursuant to the written consent of all parties, this case is before the undersigned as the presiding

judge for all purposes, including entry of final judgment. See 28 U.S.C. § 636(c). Pending

before the court are plaintiff’s motion for summary judgment (Doc. 24) and defendant’s crossmotion for summary judgment (Doc. 28). 

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I. PROCEDURAL HISTORY

Plaintiff applied for social security benefits on November 22, 2005. In the

application, plaintiff claims that disability began on October 1, 2005. Plaintiff claims that

disability is caused by a combination of: “Bipolar I; Bipolar Mixed; Bipolar II, recurrent major,

with depressive and hypomania episodes; personality disorder; and borderline personality traits.” 

Plaintiff’s claim was initially denied. Following denial of reconsideration, plaintiff requested an

administrative hearing, which was held on December 14, 2007, before Administrative Law Judge

(“ALJ”) James A. Mitchell. In a April 23, 2008, decision, the ALJ concluded that plaintiff is not

disabled based on the following relevant findings:

1. The claimant has the following severe impairments: bipolar disorder,

alcohol abuse, and substance abuse disorder;

2. The claimant does not have an impairment or combination of impairments

that meets or medically equals an impairment listed in the regulations;

3. The claimant has the residual functional capacity to perform the full range

of work at all exertional levels but with the following non-exertional

limitations: his attention, concentration, understanding, and memory are

slightly limited; his ability to do simple routine repetitive tasks is slightly

limited; he requires occasional close supervision for more than two hours

on a work shift due to his non-compliance with his medication regime and

drug and alcohol abuse; he is able to lift up to fifty pounds occasionally

and twenty five pounds frequently;

4. Considering the claimant’s age, education, work experience, and residual

functional capacity, and based on vocational expert testimony, there are

jobs that exist in significant numbers in the national economy that the

claimant can perform.

After the Appeals Council declined review on August 19, 2008, this appeal followed.

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II. SUMMARY OF THE EVIDENCE

The certified administrative record (“CAR”) contains the following evidence,

summarized chronologically below:

October 3, 2005 – A contact sheet completed by staff at San Joaquin County

Mental Health reflects that plaintiff’s current GAF was 50. On mental status examination,

plaintiff’s mood was depressed, thought content was clear, and memory was intact. Plaintiff

reported having used methamphetamine three weeks prior and marijuana four days prior. 

October 11, 2005 – Notes from San Joaquin County Mental Health indicate that

plaintiff reported initially complaining of insomnia but then added he needs an antidepressant. 

He reported mood swings and intermittent suicidal ideation. Plaintiff said he had recently broken

up with a physically abusive boyfriend. 

October 25, 2005 – Chart notes from San Joaquin County Mental Health indicate

that plaintiff reported Depakote was making him dizzy and oversedated. However, he also stated

that he does not sleep well at night despite being tired all day. The diagnosis indicated on the

chart note is “Mood D/O NOS R/O Bipolar II.” Plaintiff was prescribed Zyprexa. 

November 23, 2005 – Records from San Joaquin County Mental Health indicate

that plaintiff failed to attend his appointment the day before with his treating physician, Dr.

Graff, and that he walked in because he ran out of medication. Plaintiff reported that he was

doing good and that medication was helping him sleep. Plaintiff said that he was experiencing

increased depression, but firmly denied any suicidal ideation. Plaintiff was cooperative and

denied any acute distress. Plaintiff was provided medication. 

January 2, 2006 – The CAR contains a “Function Report – Adult – Third Party”

submitted by plaintiff’s sister, Jamie Copeland. She stated that plaintiff spends most of his day

sleeping and, when not sleeping, he eats and watches television. Ms. Copeland stated that

plaintiff is “dependent on others to cook, due to tiredness and side effects [of medication].” She

added that he needs help remembering to take his medication because he “forgets track of time.” 

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Ms. Copeland also stated that plaintiff cannot cook for himself because of “drowsiness, muscle

aches, lack of motivation.” She stated that plaintiff does his own laundry once a month, but

doesn’t go out to do any kind of shopping. She also stated that he is moody with “highs & lows”

and that plaintiff is emotional and depressed. 

As to functional capabilities, Ms. Copeland stated that plaintiff’s impairments

make it difficult for him to lift, talk, complete tasks, concentrate, understand, and get along with

others. She stated that plaintiff could maybe walk a mile before needing rest. She added that he

is easily distracted and cannot pay attention for long, though she stated he had no problems

following written or spoken instructions. Ms. Copeland stated that plaintiff does not handle

stress well. 

January 4, 2006 – The CAR contains a “Contact Sheet” prepared by staff at San

Joaquin County Mental Health. The document indicates that, at that time, plaintiff’s GAF score

was 50 and had remained unchanged over the past year. On mental status examination, it was

noted that plaintiff was cooperative. His mood was reported as “tired.” Plaintiff had a nervous

affect. Thought content was appropriate. Memory and abstraction were both good. Plaintiff

denied drug and/or alcohol use. Plaintiff reported suicidal ideation, but no plan, and that he

wants to cut himself. 

January 6, 2006 – Plaintiff provided responses on a “Function Report – Adult”

submitted with his application for benefits. Plaintiff stated that he lives with his family. For

daily activities, plaintiff stated: “I wake up and watch T.V. and eat if some one cooks.” He added

that lately he hadn’t been “feeling good do to my meds.” He stated that he needs reminders to

take his medications. He also stated that he bathes once a week, does laundry once every other

week with assistance, doesn’t do anything with his hair, does not shave, and his mother cooks

meals for him. Plaintiff stated that, before the onset of disability, he was more energetic and able

to think more clearly. He states his impairments cause him to “get dizzy and drozie.” When

asked, however, to check boxes next to various activities his impairments prevent or limit (such

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It appears that plaintiff may have neglected to answer any of the questions on page 1

8 of 10 of the pre-printed form questionnaire. 

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as lifting, stooping, sitting, etc.), plaintiff did not check any boxes or otherwise indicate any

limitations. Plaintiff added that he does not handle stress well due to “anxieties and panic 1

attacks.” Plaintiff concluded his statement by adding: “I am trying to fix these problems.” 

January 11, 2006 – San Joaquin County Mental Health records reflect that

plaintiff failed to attend this scheduled appointment. 

February 22, 2006 – Chart notes from San Joaquin County Mental Health reflect

that plaintiff had missed at least four of his last appointments. The notes refer to “chronic missed

MD appts.” 

February 28, 2006 – Chart notes from San Joaquin County Mental Health reflect

that plaintiff had stopped taking his medications. The notes also state: “Pt. was drinking a couple

weeks ago.” 

April 27, 2006 – Agency examining doctor David C. Richwerger, Ed.D., reported

on a comprehensive psychiatric evaluation. The doctor reported the following history:

The claimant denies ever being admitted to a psychiatric hospital. The

claimant states he has gone to the Crisis Center at Mental Health when he

was sixteen to see a counselor. The claimant states he began some

outpatient psychiatric treatment in October 2005. He states his friends

referred him because he was “climbing the walls, crying, and getting

angry.” He states his last visit was with Dr. Graff in earlier April 2006. 

The claimant states he has difficulty concentrating and difficulty with his

memory. He states, “Not always. It just depends.” The claimant states in

the past he thought he heard voices. He states, “For a while I did, but I

don’t hear them now.” The claimant then stated he was not actually

hearing it. The claimant may have been referring to his own thoughts. 

The claimant states he has troubling thoughts. The claimant states he

often feels anxious and depressed. The claimant states he is not always

depressed but often has anxiety in public. The claimant denies suicidal

ideation but says he had suicidal thoughts about a month ago. He states at

the age of 17 or 18 he tried to get hit by a car. The claimant denied

homicidal ideation in the past but none at this time – just when he gets

very angry. The claimant states he had seen Dr. Graff once a month and

now his appointments with him are p.r.n. The claimant states he was

prescribed Depakote and Prozac. The claimant states the Depakote makes

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him more stable than before. 

Plaintiff told the doctor that “he used to drink a lot at the age of 16 but does not drink at all now.” 

He last used drugs when he was 16. As to current functioning, Dr. Richwerger reported:

The claimant lives in a house with his family. The claimant states he does

not sleep very well. He has often had problems sleeping and he does not

know why. He states his appetite varies a lot. The claimant states he does

household chores such as washing clothes and drying them on the line. He

takes care of his own personal needs. The claimant states he has no

outside activities or hobbies. The claimant states he handles his own

financial affairs. The claimant states he usually gets around by getting a

ride. The claimant is able to move about alone. The claimant’s mother

drove him to this evaluation. The claimant states he does not interact that

well with family and relatives. Things vary a lot. He avoids friends and

neighbors. The claimant states what he does just depends on the day. 

Nothing is consistent. The claimant states, “Lately, I have been cleaning a

lot. Sometimes, I am depressed. Sometimes, I have a lot of energy.” The

claimant states his last schooling was last year. 

Based on mental status examination results, Dr. Richwerger diagnosed bipolar II, mixed, and

assigned a GAF of 55. The doctor outlined the following functional assessment:

The claimant appears to have a moderate impairment in his ability to

perform detailed and complex tasks.

The claimant appears to have no impairment in his ability to perform

simple and repetitive tasks.

The claimant appears to have a slight impairment in his ability to perform

work activities on a consistent basis.

The claimant appears to have no impairment in his ability to perform work

activities without special supervision.

The claimant appears to have a moderate impairment in his ability to

complete a normal workday or workweek without interruption from a

psychiatric condition.

The claimant appears to have a slight impairment in his ability to

understand and accept instructions from supervisors. 

The claimant appears to have a slight impairment in his ability to interact

with co-workers and the public.

The claimant appears to have a slight impairment in his ability to maintain

regular attendance in the workplace.

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The claimant appears to have a slight impairment in his ability to deal with

the usual stresses encountered in competitive work. 

July 26, 2006 – Agency consultative doctor V.M. Meenakshi, M.D., submitted a

psychiatric review technique form. Plaintiff was assessed with mild difficulties in activities of

daily living and social functioning. The doctor opined that plaintiff is moderately limited in

ability to maintain concentration, persistence, and pace. There was insufficient evidence to

establish episodes of decompensation. The doctor also completed a mental residual functional

capacity assessment. Dr. Meenakshi opined that plaintiff was moderately limited in ability to

understand, remember, and carry out detailed instructions. In all other categories of functioning,

plaintiff was assessed as not significantly limited. 

September 12, 2006 – Records from San Joaquin County Mental Health indicate

that plaintiff reported using marijuana at age 15 and later methamphetamines. Plaintiff stated

that he last used methamphetamine in September 2005. 

November 27, 2006 – Chart notes from San Joaquin County Mental Health

indicate that, on mental status examination, plaintiff appeared to be very intelligent. His attitude

was angry, speech normal, mood depressed, and thought content clear. Plaintiff denied

hallucinations. He said he had not been sleeping and admitted to suicidal ideation. The notes

indicate that, at the time, plaintiff was taking Zoloft, Seroquel, and Hydraxine. 

December 21, 2006 – Plaintiff reported to a case worker from San Joaquin County

Mental Health that his medications were working well and he denied any depression at the time. 

January 12, 2007 – Progress noted from San Joaquin County Mental Health reveal

the following comment by plaintiff’s case manager: “He admits to struggling with

methamphetamine abuse, but has been clean for several months.” 

January 19, 2007 – Records from San Joaquin County Mental Health indicate that

plaintiff called in to cancel his therapy appointment because he had the flu. He denied any

psychiatric problems. 

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January 30, 2007 – Plaintiff reported to a case manager from San Joaquin County

Mental Health that he had been feeling depressed and that he reported to a crisis center the week

before because he started “cutting” himself. He denied feeling suicidal. 

February 9, 2007 – Plaintiff told a case manager from San Joaquin County Mental

Health that he felt his medications had been effective since being changed the week prior. 

Plaintiff denied experiencing any anxiety attacks or episodes of self-abuse. 

February 13, 2007 – Plaintiff reported to a case manager from San Joaquin County

Mental Health that he had not taken his medications for a few days and that he was “not good.” 

Plaintiff stated that he did not feel his medications were working. 

February 15, 2007 – Notes from San Joaquin County Mental Health indicate the

following:

Case manager met with client at HEART Office. He was appropriately

groomed, alert, and oriented x 3. He said he was feeling much better

today. He denied feeling depressed and denied any desire to harm himself. 

He said he went home Tuesday and slept after taking his meds. He is

continuing his med regime now. He also attended group today. . . .

February 22, 2007 – Chart notes from San Joaquin County Mental Health

indicate:

Case manager met with client at HEART Office. He was well groomed,

alert, and oriented x 3. He reported he is doing much better. He started

taking his meds as prescribed and denies adverse effects. He said he feels

much calmer and has slept much better since taking his meds. Case

manager engaged him in conversation about med education. He said he

wants to change his meds to better stabilize his meds. . . .

Plaintiff was encouraged to “continue working on recovery for his mental illness and drugs.” 

February 27, 2007 – Plaintiff reported to mental health staff at San Joaquin

County Mental Health that he finds himself “crying for hours on end about my flashbacks.” 

Plaintiff also reported feeling “insulted that his sister’s boyfriend, Brendan, wants to have sex

with him.” Chart notes indicate that plaintiff and his case manager discussed employment and

plaintiff said he wanted to try the “moving crew.” 

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February 28, 2007 – Progress notes from San Joaquin County Mental Health

reveal as follows:

Case manager met with client when we were done moving. He said he is

going well and his mood has been stable. Right now his meds are working

and he has no complaints. . . .

March 20, 2007 – Progress notes from San Joaquin County Mental Health reflect

that plaintiff had stopped attending the community skills building group class and that plaintiff

“gives many somatic complaints . . . as reasons not to work toward his goal at this time.” 

March 23, 2007 – Progress notes from San Joaquin County Mental Health reveal

that plaintiff was feeling good “because he just had a good session with his therapist.” Plaintiff’s

case manager helped him move his belongings to Sutter Manor. 

March 27, 2007 – Progress notes from San Joaquin County Mental Health

indicate that plaintiff attended a hockey game with staff from and other members of the HEART

Program. Plaintiff appeared to enjoy the game and was observed interacting with staff and peers

appropriately. 

April 2, 2007 – Notes from a group therapy session reflect the following:

Client was late to group and very disruptive. Client came into group

apologizing for being late and talked over the person who was speaking. 

After sitting down the client continued to respond to internal stimuli, and

then got up to get a drink and began talking louder. Client was asked to

leave group and was escorted to Crisis by Security. 

April 3, 2007 – Chart notes from San Joaquin County Mental Health reflect:

Case manager met with client at HEART Office. He appeared in better

spirits as he was smiling and laughing with his friends. He said he was

feeling much better today because he “prayed and did push ups” last night. 

He feels this helped center his mind. Case manager engaged him in

conversation about the importance of taking care of oneself physically. 

Case manager also encouraged him to attend the Spirituality Group on

Wednesdays with Allies. He stated he would try to make it and expressed

his desire to learn more spirituality. He appeared neutral in mood and

stable. 

April 6, 2007 – Chart notes from San Joaquin County Mental Health indicate that

plaintiff had been arrested several months ago for shoplifting. 

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26 “ETOH” is a medical abbreviation referring to alcohol. 2

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May 18, 2007 – Chart notes from San Joaquin County Mental Health reflect that

plaintiff admitted not taking his medications as prescribed. Plaintiff also reported that he felt

attending group sessions was helping, though he “feels stuck sometimes.” 

May 21, 2007 – Notes from San Joaquin County Mental Health indicate:

Case manager met with William at his room at Sutter Manor. He was

appropriately groomed, alert, and oriented x 3. He said he is feeling ok

today but continues to battle with his depression. He stated he is

committed to trying his Tegretol as prescribed for two weeks to see if it

helps his depression. He said he is in a new relationship and was having

some problems with him. Case manager listened and provided supportive

counseling emphasizing med education, and boundaries. He said he is

trying to focus on himself as much as possible. Case manager also

counseled him regarding med education. William said he realizes when he

gets depressed, he begins to isolate. Case manager encouraged him to

commit to attending a minimum of one group a week to help him break

the cycle of isolating. He said he would either come on Tuesday or Friday. 

We also discussed where he was in applying for his SSI. He said he is

waiting for a letter from SSI regarding a court date for appeal. William

appears depressed, but stable. Will continue to follow up as needed. 

June 21, 2007 – San Joaquin County Mental Health progress notes reveal the

following comment by the staff case manager: “Client has difficulty taking responsibility for

himself and uses his mental health issues as a means to get what he wants.” 

July 3, 2007 – Chart notes from San Joaquin County Mental Health indicate that

plaintiff was assaulted while attending a gay pride parade two weeks earlier. Plaintiff reported

that he thinks someone put something in his drink of “ETOH.” He said he woke up with no one 2

around and in severe pain. He reported rectal bleeding since the incident. Plaintiff was tearful

and stated he felt ashamed. Plaintiff’s mood was reported as “severely depressed.” Vegetative

symptoms of lack of appetite and excess sleep were also reported. Plaintiff was referred to the

hospital for a physical evaluation. 

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July 25, 2007 – The CAR contains chart notes from San Joaquin County Mental

Health reflecting that plaintiff’s speech was low and soft, his mood was calm, and plaintiff

denied hallucinations or suicidal ideation. Memory and abstraction were both good. 

August 7, 2007 – The CAR contains a psychiatric admission note prepared by

Muhammad Zia, M.D, a psychiatrist with San Joaquin County Mental Health. Dr. Zia reported

the following history:

The patient is currently under the care of Dr. Rizvi in the Outpatient

Clinic. It appears that there have been rapid med changes, initiated at

patient’s request with vague complaints of side effects and intolerability. 

He took an overdose on his medication and was medically cleared at St.

Joseph’s Medical Center. The patient says, “I’m tired of my life and don’t

want to live; don’t know what I will do after I go home.” The patient is

vague about any precipitating factors to his depression. There is no clear

indication of vegetative symptoms of depression recently. The patient

tends to be vague, somewhat confused, ambivalent, and paranoid. He does

not express his emotions well. He had difficulty in answering my

questions adequately. The patient said that he is living at Sutter Manor

and is on G.R. His SSI Disability is pending. The patient has been

declining in his functioning over the last few years. He has not been able

to graduate from high school and has no ability for gainful employment. 

The patient is vague about his past history of suicidal attempts. He denies

hearing voices. 

On mental status examination, the doctor reported the following:

On admission the patient is oriented and alert but rather sullen and

concrete with minimal verbalization. He is vague and evasive in his

presentation. His affect is restricted; his mood is depressed. He denied

any further suicidal impulses at this time. His cognitive and intellectual

functions are grossly intact. 

Plaintiff was diagnosed with Bipolar Disorder, Type I, recurrent severe as well as personality

disorder NOS. Plaintiff’s GAF was “Poor, 20/40.” 

August 20, 2007 – Notes from San Joaquin County Mental Health indicate that

plaintiff had been put on “weekly med-compliance” due to failure to take his medications as

prescribed. Despite plaintiff’s stated refusal to participate in drug rehabilitation, therapy, or

support groups, the notes reflect that plaintiff was making “some progress.” 

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August 27, 2007 – Chart notes from San Joaquin County Mental Health reflect as

follows:

Client was on time and neatly dressed and groomed for his appointment. 

Client reported that he had a good weekend. That one of his nephews

came and spent the night. Client sees being involved in his niece and

nephews lives as a positive and that he is able to set appropriate

boundaries and limits with them. Client also states that his mother, sister,

and aunt fought and that instead of trying to be the peace maker he did not

get involved and let them work things out and that this was much less

stressful for him. 

The notes indicate that plaintiff was making “some progress” towards his mental health goals.

August 28, 2007 – Notes following plaintiff’s attendance at a group therapy

session indicate: “Clt. was appropriate & an active participant in the group discussion. He

appeared to understand the concepts being presented.” 

September 7, 2007 – Notes from San Joaquin County Mental Health state:

. . . Client reported things had gone well this week and though the only

group he attended was the Spirituality Group which he really enjoyed. 

Client reports that he has been going to the gym for 6-8 hours a day to

work out, use the sauna and then work out again. Client stated that he

liked how it made him feel. . . .

Plaintiff stated that he felt he has made many changes. The notes reflect problems with

medication compliance. The notes also reflect that, generally, plaintiff was making “some

progress.” 

September 11, 2007 – Notes from San Joaquin County Mental health indicate:

. . . Client reported doing well. Client reported that he often goes to the

gym during the week and feels calmer each time. . . .

The chart notes indicate that plaintiff was making “clear progress.” 

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September 19, 2007 – Plaintiff walked in to San Joaquin County Mental Health

after missing his doctor’s appointment the day before. Plaintiff stated that he had run out of

medication. Plaintiff’s speech was flat, his mood was depressed and tired, and plaintiff denied

any hallucinations or suicidal ideation. Additional chart notes indicate as follows:

. . . Client expressed frustration with feeling pressured to attend several

groups each week and two individual therapy sessions per week as

suggested by his therapist. Client described himself as being bored,

impulsive, and having made decisions lately that he regrets. . . .

The chart notes indicate that plaintiff was making “some progress.” 

September 21, 2007 – Chart notes from San Joaquin County Mental Health

indicate that plaintiff did not show up for his appointment. 

October 1, 2007 – Chart notes from San Joaquin County Mental Health indicate

that plaintiff did not show up for his appointment. 

October 25, 2007 – Chart notes from San Joaquin County Mental Health state:

Client stopped by the office looking for conversation while waiting to pick

up his medication. Client reports that he has not been attending groups or

therapy but has been spending time learning about Borderline Personality

Disorder. Client shared that it has helped him to understand why he does

some of his behaviors that are impulsive and risky. Client states that

overall he has been feeling okay. He has had a few times that he has

thought about suicide but he talks about it to someone he trusts and does

not act on it. Client processed feelings about how the information is

helping him to view his mother in a different light. 

The notes indicate that plaintiff was having problems with medication compliance. The notes

also indicate that plaintiff was making “some progress” towards his mental health goals. 

November 21, 2007 – Records from San Joaquin County Mental Health reflect

that plaintiff reported “ongoing suicidal thoughts but has been unable to control them.” Plaintiff

requested placement in a facility that could provide a structured environment. 

/ / /

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III. STANDARD OF REVIEW

The court reviews the Commissioner’s final decision to determine whether it is: 

(1) based on proper legal standards; and (2) supported by substantial evidence in the record as a

whole. See Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999). “Substantial evidence” is

more than a mere scintilla, but less than a preponderance. See Saelee v. Chater, 94 F.3d 520, 521

(9th Cir. 1996). It is “. . . such evidence as a reasonable mind might accept as adequate to

support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971). The record as a whole,

including both the evidence that supports and detracts from the Commissioner’s conclusion, must

be considered and weighed. See Howard v. Heckler, 782 F.2d 1484, 1487 (9th Cir. 1986); Jones

v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). The court may not affirm the Commissioner’s

decision simply by isolating a specific quantum of supporting evidence. See Hammock v.

Bowen, 879 F.2d 498, 501 (9th Cir. 1989). If substantial evidence supports the administrative

findings, or if there is conflicting evidence supporting a particular finding, the finding of the

Commissioner is conclusive. See Sprague v. Bowen, 812 F.2d 1226, 1229-30 (9th Cir. 1987). 

Therefore, where the evidence is susceptible to more than one rational interpretation, one of

which supports the Commissioner’s decision, the decision must be affirmed, see Thomas v.

Barnhart, 278 F.3d 947, 954 (9th Cir. 2002), and may be set aside only if an improper legal

standard was applied in weighing the evidence, see Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th

Cir. 1988). 

IV. DISCUSSION

Plaintiff summarizes his arguments as follows:

The ALJ committed four principal errors in finding Mr. Copeland

“not disabled.” First, Mr. Copeland’s psychiatric impairment met or

equaled the requirements under 12.04 of the listing of impairments. 

Second, the ALJ failed to accurately characterize the medical evidence and

credit the opinions of the treating psychiatrists without a legitimate basis

for so doing. Third, the ALJ rejected Mr. Copeland’s and third party

statements regarding his functional limitations without providing clear and

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convincing reasons for so doing. Fourth, the ALJ failed to properly assess

Mr. Copeland’s residual functional capacity (RFC) and pose a legally

adequate hypothetical to the vocational expert. 

A. Evaluation of Medical Opinions

The weight given to medical opinions depends in part on whether they are

proffered by treating, examining, or non-examining professionals. See Lester v. Chater, 81 F.3d

821, 830-31 (9th Cir. 1995). Ordinarily, more weight is given to the opinion of a treating

professional, who has a greater opportunity to know and observe the patient as an individual,

than the opinion of a non-treating professional. See id.; Smolen v. Chater, 80 F.3d 1273, 1285

(9th Cir. 1996); Winans v. Bowen, 853 F.2d 643, 647 (9th Cir. 1987). The least weight is given

to the opinion of a non-examining professional. See Pitzer v. Sullivan, 908 F.2d 502, 506 & n.4

(9th Cir. 1990).

In addition to considering its source, to evaluate whether the Commissioner

properly rejected a medical opinion the court considers whether: (1) contradictory opinions are

in the record; and (2) clinical findings support the opinions. The Commissioner may reject an 

uncontradicted opinion of a treating or examining medical professional only for “clear and

convincing” reasons supported by substantial evidence in the record. See Lester, 81 F.3d at 831. 

While a treating professional’s opinion generally is accorded superior weight, if it is contradicted

by an examining professional’s opinion which is supported by different independent clinical

findings, the Commissioner may resolve the conflict. See Andrews v. Shalala, 53 F.3d 1035,

1041 (9th Cir. 1995). A contradicted opinion of a treating or examining professional may be

rejected only for “specific and legitimate” reasons supported by substantial evidence. See Lester,

81 F.3d at 830. This test is met if the Commissioner sets out a detailed and thorough summary of

the facts and conflicting clinical evidence, states her interpretation of the evidence, and makes a

finding. See Magallanes v. Bowen, 881 F.2d 747, 751-55 (9th Cir. 1989). Absent specific and

legitimate reasons, the Commissioner must defer to the opinion of a treating or examining

professional. See Lester, 81 F.3d at 830-31. The opinion of a non-examining professional,

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without other evidence, is insufficient to reject the opinion of a treating or examining

professional. See id. at 831. In any event, the Commissioner need not give weight to any

conclusory opinion supported by minimal clinical findings. See Meanel v. Apfel, 172 F.3d 1111,

1113 (9th Cir. 1999) (rejecting treating physician’s conclusory, minimally supported opinion);

see also Magallanes, 881 F.2d at 751. 

Regarding medical opinion evidence from treating, examining, and consulting

sources, the ALJ stated:

As for the opinion evidence, progress notes reported on January 27, 2006,

that the claimant had a GAF of 35 and on August 7, 2007, and November

21, 2007, a GAF of 40. (Exhibit 9F pages 3, 31, and 125). On August 7,

2007, Dr. Zia reported that the claimant had a GAF of 20/40 on admission

to the hospital. (Exhibit 9F page 30). Progress notes reported on August

23, 2006, January 24, 2007, July 2, 2007, that the claimant had a GAF of

45. (Exhibit 9F pages 47, 101, and 151). A San Joaquin County Mental

Health Services psychiatric intake assessment on September 12, 2006,

reported that the claimant had a GAF of 45. (Exhibit 9F page 132). 

Pursuant to 20 CFR § 404.1527 and Social Security Ruling 96-2p, the

undersigned assigns significant weight to these opinions, as they are wellsupported by the medical evidence finding that the claimant’s symptoms

are aggravated when he is non-compliant with his medication regime and

abuses alcohol and drugs. 

Progress notes reported on October 3, 2005, January 4, 2006, June 12,

2006, that the claimant had a GAF of 50. (Exhibit 1F pages 2 and 11, 9F

page 158). Dr. Richwerger reported on April 27 2006, that the claimant

had a GAF of 55. (Exhibit 2F page 5). Progress notes reported on March

31, 2006, that the claimant had a GAF of 55. (Exhibit 9F page 160). 

Pursuant to 20 CFR § 404.1527 and Social Security Ruling 96-2p, the

undersigned assigns significant weight to these opinions, as they are wellsupported by the medical evidence finding that the claimant had moderate

mental impairment symptoms when he is compliant with his medication

regime and abstains from alcohol and drugs. 

Scott Harrison, MHC-1, reported on September 9, 2007, September 11,

2007, September 19, 2007, September 24, 2007, September 28, 2007, that

the claimant’s symptoms limited his ability to maintain regular

employment and put him at a significant risk of being exploited and for

physical injury. (Exhibit 9F pages 10, 14, 17, 20, and 22). A treating

physician’s medical opinion, on the issue of the nature and severity of an

impairment, is entitled to special significance; and, when supported by

objective medical evidence and consistent with otherwise substantial

evidence of record, entitled to controlling weight. (citation omitted). 

However, statements that a claimant is ‘disabled’, ‘unable to work’ can or

cannot perform a past job, meets a listing, or the like are not medical

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opinions but are administrative findings dispositive of a case, requiring

familiarity with the Regulations and legal standards set forth therein and in

the Dictionary of Occupational Titles. Such issues are reserved to the

Commissioner. (citation omitted). Furthermore, Mr. Harrison is not a

physician or psychologist, apparently only the claimant’s therapist and the

record fails to support the therapist’s opinion that the claimant is incapable

of work. 

A Psychiatric Review Technique dated July 26, 2006, by V.M. Meenakshi,

M.D., a State psychiatric consultant, found that the objective medical

evidence supported a finding that the claimant had medically determinable

bipolar disorder. The claimant was found to be mildly limited in activities

of daily living and maintaining social functioning and have moderate

difficulties in maintaining concentration, persistence, or pace, and have no

episodes of decompensation. The claimant was not found to have a

history of chronic organic mental disorder. (Exhibit 5F). 

A Mental Residual Functional Capacity Assessment of the same date by

Dr. Meenakshi found that the objective medical evidence supported a

finding that the claimant was moderately limited in his ability to

understand, remember, and carry out detailed instructions. The claimant

was found not [to] be significantly limited in all other areas of mental

activity. The claimant was found to have the ability to carry out simple

tasks. (Exhibit 6F). 

The State psychiatric consultant opined that the claimant functions in a

generally independent fashion and can meet various personal needs from a

mental standpoint. The claimant is capable of completing daily living

functions with the constraints of their medical condition. The claimant

manages with a basic routine. The claimant can relate to others and is

capable of showing socially appropriate behaviors and negotiating in the

community. The claimant is capable of functioning in a competitive work

environment. The undersigned . . . has assigned significant weight to these

opinions because they were based upon a thorough review of the evidence

and familiarity with Social Security Rules and Regulations and legal

standards set forth therein. They are well-supported by the medical

evidence, including the claimant’s medical history and clinical and

objective signs and findings aswell as detailed treatment notes, which

provides a reasonable basis for claimant’s chronic symptoms and resulting

limitations. Moreover, the opinions are not inconsistent with other

substantial evidence of record. 

Plaintiff argues that the ALJ erred because: (1) no doctor ever concluded that plaintiff’s problems

were attributable to either non-compliance with medication or substance abuse; and (2) the

record documents plaintiff’s diagnosis of bipolar disorder and related symptoms. In sum,

plaintiff argues that the ALJ “played doctor” and substituted his medical opinions and

conclusions for those of the treating sources. 

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Plaintiff was treated for his mental health problems at San Joaquin County Mental

Health. Plaintiff worked primarily with a therapist who is not a medical doctor or licensed

psychologist. The record also reflects that plaintiff was treated by Dr. Zia. In particular, Dr. Zia

reported on an August 7, 2007, “5150" hospitalization. The ALJ references Dr. Zia’s discussion

only briefly in the hearing decision by noting that Dr. Zia assigned a GAF score of “Poor, 20/40"

upon admission. The ALJ does not specifically reject any of Dr. Zia’s conclusions. Of note, Dr.

Zia characterized his ongoing treatment of plaintiff as follows: “The patient has been declining in

his functioning over the last few years.” As the ALJ notes, this observation about plaintiff’s

mental condition is entitled to “special significance” and “controlling weight” when not

contradicted by other evidence in the record. However, the ALJ appears not to have assigned

controlling weight to this observation and the ALJ does not provide any specific or legitimate

reasons for ignoring or rejecting it. 

The record reflects that plaintiff’s case was reviewed by two agency doctors – Dr.

Richwerger, who examined plaintiff, and Dr. Meenakshi, who reviewed records. Given that Dr.

Meenakshi’s opinion is based entirely on Dr. Richwerger’s conclusion, essentially the only state

agency doctor to render an independent opinion is Dr. Richwerger, whose opinion the ALJ gave

significant weight. In doing so, however, the ALJ did not provide any specific analysis other

than to say that Dr. Richwerger’s assessment is consistent with evidence that plaintiff’s condition

is aggravated with non-compliance with medication and/or substance abuse. 

The court does not finds that these reasons are supported by substantial evidence

in the record. While there appears to be some history of non-compliance with medication, as

plaintiff notes no doctor ever stated that plaintiff’s problems are aggravated by non-compliance

or made better with compliance. A review of the entire record suggests instead that plaintiff’s

medications were often changed due to complaints of adverse side effects. The treatment records

tend to describe this process as “stabilization.” There are indications in the treatment records

that, at times, plaintiff’s condition was improved with medication and, at other times, his

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condition worsened while on medication. As to substance use, the court can find no indication in

the record of an instance where a doctor familiar with plaintiff’s case opined that plaintiff’s

mental impairments are the result of substance abuse. 

A remand is appropriate in order to allow the ALJ to further evaluate the medical

opinions. Specifically, it would be helpful to have more analysis as to Dr. Zia’s conclusions. It

may be necessary to obtain a medical source statement from Dr. Zia in which the doctor sets

forth a specific functional assessment and supporting objective findings. 

B. Lay Evidence

1. Plaintiff’s Statements

The Commissioner determines whether a disability applicant is credible, and the

court defers to the Commissioner’s discretion if the Commissioner used the proper process and

provided proper reasons. See Saelee v. Chater, 94 F.3d 520, 522 (9th Cir. 1996). An explicit

credibility finding must be supported by specific, cogent reasons. See Rashad v. Sullivan, 903

F.2d 1229, 1231 (9th Cir. 1990). General findings are insufficient. See Lester v. Chater, 81 F.3d

821, 834 (9th Cir. 1995). Rather, the Commissioner must identify what testimony is not credible

and what evidence undermines the testimony. See id. Moreover, unless there is affirmative

evidence in the record of malingering, the Commissioner’s reasons for rejecting testimony as not

credible must be “clear and convincing.” See id.; see also Carmickle v. Commissioner, 533 F.3d

1155, 1160 (9th Cir. 2008) (citing Lingenfelter v Astrue, 504 F.3d 1028, 1936 (9th Cir. 2007),

and Gregor v. Barnhart, 464 F.3d 968, 972 (9th Cir. 2006)). 

If there is objective medical evidence of an underlying impairment, the

Commissioner may not discredit a claimant’s testimony as to the severity of symptoms merely

because they are unsupported by objective medical evidence. See Bunnell v. Sullivan, 947 F.2d

341, 347-48 (9th Cir. 1991) (en banc). As the Ninth Circuit explained in Smolen v. Chater:

The claimant need not produce objective medical evidence of the

[symptom] itself, or the severity thereof. Nor must the claimant produce

objective medical evidence of the causal relationship between the

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medically determinable impairment and the symptom. By requiring that

the medical impairment “could reasonably be expected to produce” pain or

another symptom, the Cotton test requires only that the causal relationship

be a reasonable inference, not a medically proven phenomenon. 

80 F.3d 1273, 1282 (9th Cir. 1996) (referring to the test established in

Cotton v. Bowen, 799 F.2d 1403 (9th Cir. 1986)). 

The Commissioner may, however, consider the nature of the symptoms alleged,

including aggravating factors, medication, treatment, and functional restrictions. See Bunnell,

947 F.2d at 345-47. In weighing credibility, the Commissioner may also consider: (1) the

claimant’s reputation for truthfulness, prior inconsistent statements, or other inconsistent

testimony; (2) unexplained or inadequately explained failure to seek treatment or to follow a

prescribed course of treatment; (3) the claimant’s daily activities; (4) work records; and (5)

physician and third-party testimony about the nature, severity, and effect of symptoms. See

Smolen, 80 F.3d at 1284 (citations omitted). It is also appropriate to consider whether the

claimant cooperated during physical examinations or provided conflicting statements concerning

drug and/or alcohol use. See Thomas v. Barnhart, 278 F.3d 947, 958-59 (9th Cir. 2002). If the

claimant testifies as to symptoms greater than would normally be produced by a given

impairment, the ALJ may disbelieve that testimony provided specific findings are made. See

Carmickle, 533 F.3d at 1161 (citing Swenson v. Sullivan, 876 F.2d 683, 687 (9th Cir. 1989)). 

As to plaintiff’s testimony, the ALJ stated:

After considering the evidence of record, the undersigned finds that the

claimant’s medically determinable impairments could reasonably be

expected to produce the alleged symptoms; however, the claimant’s

statements concerning the intensity, persistence, and limiting effects of

these symptoms are not credible to the extent they are inconsistent with the

residual functional capacity assessment for the reasons explained below.

In terms of the claimant’s alleged disabling impairments, the record fails

to document any objective clinical findings establishing that the claimant

was not able to perform work in light of the reports of the treating and

examining practitioners and the findings made on examination. 

Dr. Richwerger reported on April 27, 2006, that the claimant’s thought

processes were clear, rational, and not disorganized or tangential. He was

oriented in all spheres and understanding of instructions was within

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normal limits. His reality contact was within normal limits and there was

no evidence of hallucinations, delusions, bizarre behavior, or response to

internal stimuli. (Exhibit 2F pages 3 and 5). Progress notes reported on

February 15, 2007, that the claimant denied feeling depressed and denied

any desire to harm himself. On February 22, 2007, it was reported that the

claimant was alert and oriented in all spheres and that he had been taking

his medications as prescribed with no adverse effects. He stated that he

felt calmer and slept much better since taking his medications. On March

23, 2007, the claimant was feeling good because he had a good session

with this therapist and he stated that he felt hopeful and more relaxed. On

March 27, 2007, it was reported that the claimant laughed and cheered at a

hockey game and socialized with peers and staff appropriately. On April

3, 2007, it was reported that the claimant was smiling and laughing with

his friends. The claimant was very social and enjoyed himself when he

participated at a monthly AA speaker meeting. It was reported that the

claimant was five months sober. On September 7, 2007, it was reported

that the claimant was going to the gym for 6-8 hours a day to use the sauna

and workout. (Exhibit 9F pages 21, 67, 69, 75, 55, and 90-91). It is

specifically noted that on June 21, 2007, it was reported that the claimant

had difficulty taking responsibility for himself and used his mental health

issues as a means to get what he wanted. (Exhibit 9F page 50). These

findings are indicative that the claimant’s complaints are not fully

substantiated by the objective medical conclusions and his symptoms may

not have been as limiting as the claimant has alleged in connection with

this application. 

Despite his testimony to the contrary, the record documents an extensive

history of drug and alcohol abuse. Progress notes reported on October 3,

2005, [indicate] that the claimant had used methamphetamine three weeks

previously and marijuana four days previously. (Exhibit 1F page 12). On

January 23, 2006, progress notes reported that the claimant had drank a

small amount of vodka a week previously. Progress notes reported on

February 26, 2006, [indicate] that the claimant took up to four Benadryl

and drank alcohol to sleep. On January 12, 2007, it was reported that the

claimant had been struggling with methamphetamine abuse, but had been

clean for several months. It was reported on July 2, 2007, that the

claimant drank alcohol and [was] found to have a GAF of 45. (Exhibit 9F

pages 47-38, 102, 106, and 162). 

The record also documents that the claimant has a repeated history of

failure to comply with or follow-up on recommendations made by his

treating physicians. Progress notes on November 23, 2005, January 14,

2006, February 26, 2006, March 31, 2006, February 9, 2007, September

19, 2007, September 21, 2007, and October 1, 2007, reported that the

claimant had missed numerous doctor’s appointments and counseling

appointments. On March 20, 2007, it was reported that the claimant had

stopped his community skills building class and gave many somatic

complaints as reasons not to work toward his goal at that time. It was

reported on May 18, 2007, that the claimant had not been taking his

medication as prescribed. On August 20, 2007, it was reported that the

claimant refused to do UDS and refused drug rehabilitation, therapy, and

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support group. (Exhibit 9F pages 9, 15-16, 27, 58, 79, 93, and 161-164). 

Progress notes reported on February 26, 2006, that the claimant had

missed four doctor’s appointments since November 22, 2005, and

cancelled other appointments and did not take his medications. On

February 13, 2007, it was reported that he had not taken his medications

for a few days. (Exhibit 9F pages 92 and 162). 

The record fails to document that the claimant has been hospitalized for

his impairments or show that the claimant has received significant active

care other than for conservative routine maintenance. After a close and

longitudinal examination of the record, including those documented

above, there emerges a clear pattern that when the claimant is compliant

with his medication regime and abstains from drug and alcohol abuse, he

improves considerably. When he fails to take his medications and abuses

drugs and alcohol, his symptoms are aggravated. (Exhibit 9F pages 58,

90, 92, and 162). A review of the claimant’s work history shows that the

claimant worked only sporadically prior to the alleged disability onset

date. This raises a question as to whether the claimant’s continuing

unemployment is actually due to medical impairments. There have been

no significant increase or changes in prescribed medication reflective of an

uncontrolled condition, nor did the claimant describe side effects from his

medication that would prevent him from substantial gainful activity. 

Furthermore, no treating or examining source determined that the

claimant’s impairments were totally debilitating or rendered the claimant

completely unemployable. 

The record includes evidence strongly suggesting that the claimant has

exaggerated symptoms and limitations. The record includes statements by

doctors suggesting the claimant was engaging in possible malingering or

misrepresentation. It is clear that the claimant is a manipulator and seeks

to avoid working and getting what he wants. (Exhibit 9f page 50). He has

no physical problems, per his testimony, and will try anything to avoid

working. Despite reporting that the claimant was in remission, they

continued to report that the claimant drank alcohol as late as July 2, 2007. 

(Exhibit 9F page 48). 

The claimant has admitted certain abilities which provide support for part

of the residual functional capacity conclusion in this decision. As noted

above, the claimant, his sister, and his examining physicians have

described daily activities which are not limited to the extent one would

expect, given the complaints of disabling symptoms and limitations. The

overall evidence suggests that the claimant has the ability to care for

himself and maintain his home. Furthermore, the performance of the

claimant’s daily activities as described is not inconsistent with the

performance of many basic work activities. 

* * *

. . . The claimant’s testimony is given no credibility. 

/ / /

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Plaintiff argues that the ALJ mischaracterized the evidence, picking and choosing only those

portions from the record which support the conclusion that plaintiff is not disabled. 

The court tends to agree. While the ALJ describes times when plaintiff was happy

and doing well, the record clearly demonstrates other times when plaintiff was not doing well. 

This type of swing from a manic state to a depressed state is the hallmark of bipolar disorder and

appears to have been ignored by the ALJ who focused only on plaintiff’s manic phases. The ALJ

also erred in at least one respect in his characterization of the record. Specifically, the ALJ states

in the hearing decision that there is no evidence that plaintiff has ever been hospitalized. To the

contrary, the CAR establishes that plaintiff was admitted for psychiatric hospitalization on

August 7, 2007, on a “5150" by Dr. Zia. 

The ALJ also cited plaintiff’s sporadic working history pre-application as

evidence that plaintiff’s mental impairment is not the cause of his alleged current inability to

work. This observation seems somewhat unfair given that plaintiff was a young adult when the

application for benefits was filed and, as such, one would expect a sporadic work history preapplication regardless of any mental impairment. Further, it is just as likely that plaintiff’s

mental impairments affected his ability to work prior to filing his application for benefits. 

The ALJ also cites alcohol use in July 2007 as a reason not to believe plaintiff’s

testimony. This, again, strikes the court as unfair given that the only references to alcohol use in

the record are a time in February 2006 when plaintiff stated he had a drink to help him sleep and

the incident in July 2007 when plaintiff claims someone at a parade spiked his drink and

thereafter assaulted him, possibly sexually. There is no other evidence of alcohol use during the

times covered by the record before the court. Two occasions of alcohol use cannot be fairly

characterized as “abuse.” 

/ / /

/ / /

/ / /

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The ALJ also states that plaintiff does not describe adverse side effects of

medication. Again, this is not consistent with the record. Specifically, plaintiff’s treatment

records from San Joaquin County Mental Health repeatedly refer to constant adjustments to

plaintiff’s medication due to complaints of adverse side effects such as drowsiness. Plaintiff also

described such adverse side effects in a function report submitted with his application. 

While, as discussed above, the court tends to agree with plaintiff that the ALJ may

have been somewhat unfair in his characterization of plaintiff’s testimony, the ALJ may properly

reject testimony as not credible where there are inconsistencies or apparent lies. Such is the case

here. The ALJ noted that plaintiff has stated several times that he stopped using

methamphetamine in September 2005. However, treatment notes from January 2007 reflect that

plaintiff had been struggling with methamphetamine abuse and had been clean for a few months. 

This suggests that, contrary to his statements that he stopped using methamphetamine in

September 2005, plaintiff was still using the drug as late as the end of 2006. The ALJ was

entitled to discredit all of plaintiff’s testimony based on this one inconsistency. 

2. Third-Party Statements

In determining whether a claimant is disabled, an ALJ generally must consider lay

witness testimony concerning a claimant's ability to work. See Dodrill v. Shalala, 12 F.3d 915,

919 (9th Cir. 1993); 20 C.F.R. §§ 404.1513(d)(4) & (e), 416.913(d)(4) & (e). Indeed, “lay

testimony as to a claimant's symptoms or how an impairment affects ability to work is competent

evidence . . . and therefore cannot be disregarded without comment.” See Nguyen v. Chater, 100

F.3d 1462, 1467 (9th Cir. 1996). Consequently, “[i]f the ALJ wishes to discount the testimony

of lay witnesses, he must give reasons that are germane to each witness.” Dodrill, 12 F.3d at

919. 

/ / /

/ / /

/ / /

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As to Ms. Copeland’s statement, the ALJ stated:

. . . Jamie Copeland, the claimant’s sister, reported in a third-party adult

function report that the claimant is able to watch television, take care of

his personal care, prepare meals, do laundry, pay bills, count change,

handle a savings account, use a checkbook and money orders, walk to the

corner store, listen to music, sing, and follow written and spoken

instructions. (Exhibit 3E). . . . [¶] The claimant’s sister reported that the

claimant visits and converses with family that he lives with. (Exhibit 3E).

* * *

. . . As noted above, the claimant, his sister, and his examining physicians

have described daily activities which are not limited to the extent one

would expect, given the complaints of disabling symptoms and limitations.

The court finds that this discussion falls short of setting forth reasons germane to Ms. Copeland

for rejecting her statements as to plaintiff’s functional abilities. A remand is appropriate to allow

the ALJ to consider Ms. Copeland’s statements in more detail. 

C. Listing 12.04

The Social Security Regulations “Listing of Impairments” is comprised of

impairments to fifteen categories of body systems that are severe enough to preclude a person

from performing gainful activity. Young v. Sullivan, 911 F.2d 180, 183-84 (9th Cir. 1990); 20

C.F.R. § 404.1520(d). Conditions described in the listings are considered so severe that they are

irrebuttably presumed disabling. 20 C.F.R. § 404.1520(d). In meeting or equaling a listing, all

the requirements of that listing must be met. Key v. Heckler, 754 F.2d 1545, 1550 (9th Cir.

1985).

Regarding applicability of the Listing of Impairments, the ALJ stated:

The record does not report the existence of any functional limitations

and/or diagnostic test results, which would suggest that the impairments

meet or equal the criteria of any specific listing. In addition, no treating or

examining physician has reported findings, which either meet or are

equivalent in severity to the criteria of any listed impairment, nor are such

findings indicated or suggested by the medical evidence of record. 

The claimant’s mental impairments, considered singly and in combination,

do not meet or medically equal the criteria of listings 12.04 or 12.09. In

making this finding, the undersigned has considered whether the

“paragraph B” criteria are satisfied. To satisfy the “paragraph B” criteria,

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the mental impairments must result in at least two of the following:

marked restriction of activities of daily living; marked difficulties in

maintaining social functioning; marked difficulties in maintaining

concentration, persistence, or pace; or repeated episodes of

decompensation, each of extended duration. A marked limitation means

more than moderate but less than extreme. Repeated episodes of

decompensation, each of extended duration, means three episodes within 1

year, or an average of once every 4 months, each lasting for at least 2

weeks. 

Regarding daily living, the ALJ stated:

In activities of daily living, the claimant has no restriction. The claimant

reported in his adult function report on January 6, 2006, that he is able to

watch television, take care of his personal care, do laundry, pay bills, count

change, handle a savings account, use a checkbook and money orders,

read, and listen to music. (Exhibit 4E). . . .

The ALJ then discussed Ms. Copeland’s third-party statement (outlined above) and continued as

follows:

. . .Dr. Richwerger reported on April 27, 2006, that the claimant stated that

he had been cleaning a lot. (Exhibit 2F page 3). The claimant testified at

the hearing that he lived at Heart House and is able to prepare meals 2

times a day, wash dishes once a week, vacuum/dust 3 times a week, do

laundry twice a month, go shopping with his sister once a month, change

sheets once a month, make the bed daily, use a cell phone making 9-20

calls a day, and use a computer 1-2 hours a week. 

As to social functioning, the ALJ stated:

In social functioning, the claimant has mild difficulties. The claimant

reported that he lived with his family. (Exhibit 4E). . . . Progress notes

reported on October 3, 2005, that the claimant lived with his mother and

sister. (Exhibit 1F page 12). Dr. Richwerger reported on April 27, 2006,

that the claimant lived with his family and had friends. (Exhibit 2F page

3). The claimant testified that he lived in Heart House, worked in daily

activites with his sister, and watches his nephew when his sister is out. 

The ALJ next addressed concentration, persistence, and pace:

With regard to concentration, persistence, or pace, the claimant has

moderate difficulties. His cognitive ability and memory are intact and the

medical reports indicate that he functions at a higher level that would

allow him to do basic work activity. The undersigned notes that the

claimant went into great detail answering his adult function report and

disability report. This is indicative of an ability to maintain an acceptable

level of concentration to perform at least simple tasks. 

/ / /

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Finally, the ALJ addressed episodes of decompensation:

As for episodes of decompensation, the claimant has experienced no

episodes of decompensation. Although there are reports of overdose in the

record, (exhibit 9F page [omitted in original]), there is no real indication

that this was a deliberate suicide attempt to permanently end his life. 

As to the “paragraph B” criteria, the ALJ concluded:

Because the claimant’s mental impairments do not cause at least two

“marked” limitations or one “marked” limitation and “repeated” episodes

of decompensation, the “paragraph B” criteria are not satisfied.

The ALJ also addressed whether the evidence established any of the “paragraph C” criteria:

The undersigned has also considered whether the “paragraph C” criteria

are satisfied. In this case, the evidence fails to establish the presence of

the “paragraph C” criteria. There are no extended episodes of

decompensation and the claimant is not expected to decompensate with an

increase in mental demands. Moreover, he does not need to live in a

highly structured living arrangement. 

For many of the reasons discussed above, the ALJ’s listing analysis is flawed. For

example, while the ALJ stated that plaintiff experienced no episodes of decompensation, the

record reflects at least one hospitalization in 2007. As to daily living, the court finds that a

remand is necessary to allow the ALJ to consider statements from plaintiff and third party

sources as to plaintiff’s daily activities. In this regard, the current hearing decision appears to

focus only on those times when plaintiff was in a manic phase and ignores those times when

plaintiff reported severe depression. As to concentration, persistence, and pace, the ALJ noted

that plaintiff’s ability to provide detailed answers on an adult function report is “indicative of an

ability to maintain an acceptable level of concentration to perform at least simple tasks.” This

strikes the court as pure speculation given that the ALJ does not also state how long it took

plaintiff to complete his application. For example, if it took plaintiff several days working only

minutes at a time to complete the paper work, such evidence could indicate an inability to

maintain concentration, persistence, or pace. As to the “paragraph C” criteria, the ALJ stated that

there is no evidence that plaintiff requires a structured living environment. However, the CAR

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indicates that plaintiff lived in various structured and assisted living facilities over the years. 

D. Hypothetical Questions

Hypothetical questions posed to a vocational expert must set out all the

substantial, supported limitations and restrictions of the particular claimant. See Magallanes v.

Bowen, 881 F.2d 747, 756 (9th Cir. 1989). If a hypothetical does not reflect all the claimant’s

limitations, the expert’s testimony as to jobs in the national economy the claimant can perform

has no evidentiary value. See DeLorme v. Sullivan, 924 F.2d 841, 850 (9th Cir. 1991). While

the ALJ may pose to the expert a range of hypothetical questions based on alternate

interpretations of the evidence, the hypothetical that ultimately serves as the basis for the ALJ’s

determination must be supported by substantial evidence in the record as a whole. See Embrey v.

Bowen, 849 F.2d 418, 422-23 (9th Cir. 1988). 

Because the ALJ concluded that plaintiff has non-exertional limitations, a

vocational expert was called to testify. The following exchange took place between the ALJ and

the vocational expert:

Q: For purpose of the following hypotheticals you should

assume your region is defined as the entire state of California. 

Hypothetical number one will be a medium FRC. Assume an individual

21 years of age, limited education, no work history and the following

restrictions. He can lift, push/pull 25 frequently, 50 occasionally; walk,

stand, stoop, bend frequently, sit occasionally; could one return of the

previously, are there jobs in the regional economy such a person could

perform? If so, what kind and how many?

A: Yes, jobs such as, if a person has just general medium

restrictions as you –

Q: Right.

A: – hypothetically say, Judge, then they could do jobs such as

auto detailer, 915.687-034, it’d be medium SVP 2, about 15,000 in the

State of California. They could do a job such as kitchen helper, 318.687-

010, medium SVP 2, 14,000; and hand packager, 920.587-018, it’d be

medium SVP 2, about 14,000 again, Judge.

Q: Assume for hypothetical number two these non-exertionals. 

He is, he is slightly limited in attention, concentration, understanding, and

memory. Vision, hearing, reaching, fine and gross manipulative abilities

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are all unlimited and intact. He is slightly limited in the ability to do a

simple, routine task. Environmentally no restrictions, unlimited contact

with public, occasional supervision, physical pain slight at most. Of the

previously mentioned what percent erosion?

A: No significant erosion, Judge.

Q: Assume for hypothetical number 2A that he is going to be

moderately limited in understanding and memory but only slightly limited

in attention and concentration. Of the previously mentioned other jobs

what percent erosion?

A: These are pretty basic jobs. I would say no significant

impact on these basic jobs, Judge.

Q: Assume for hypothetical number 2B that he is going to be

also moderately limited in attention, concentration as well as

understanding and memory but would remain only slightly limited in the

ability to do SRT. Of the previously mentioned what percent erosion?

A: Probably eliminate the kitchen helper. Hand packager

would be intact, very basic job. Auto detailer I’d probably eliminate about

half the jobs, Judge.

Q: Assume for hypothetical number 2C that he is going to be

moderately limited in the ability to do a simple, routine repetitive task and

would require close supervision, close being two hours or more per shift. 

Of the previously mentioned what percent?

A: I’d eliminate the work at that level, Judge.

Q: Assume for hypothetical number three a light RFC. 

Assume an individual 21 years of age, limited education, work history as

described and the following restrictions. He can lift, push, pull 20

occasionally, 10 frequently; walk/stand frequently; sit, stoop, or bend

occasionally. Are there jobs in the regional economy? If so, what kind

and how many?

A: If a person has just a general light restriction they would be

able to do jobs such as fast food worker, 311.472-010, light SVP 2, about

32,000. A job such as mail clerk would fit with a general light restriction,

Judge. Let’s see, that is DOT 209.687-026, light SVP 2, about 10,000;

and let’s say housekeeping job, 323.687-014, light SVP 2, about 75,000,

Judge.

Q: Assume for hypothetical number four these nonexertionals. He is slightly limited in attention, concentration,

understanding and memory. Vision, hearing, reaching, fine and gross

manipulative abilities are all intact and unlimited. He is slightly limited in

the ability to do SRT. Environmentally no restriction; unlimited contact

with public; occasional supervision; pain slight at most. Of the previously

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mentioned other jobs what percent erosion?

A: I would not see a significant erosion at the slight level,

Judge.

Q: Assume for hypothetical number 2A that he’s going to be

moderately limited in understanding and memory but remain only slightly

limited in attention and concentration and slightly limited in the ability to

do SRT. Of the previously mentioned what percent erosion?

A: [Under]standing and memory, I’d probably eliminate about

half the fast food work. I think mail clerk and housekeeping would still be

intact. 

Q: Assume for hypothetical number 2B that he is also

moderately limited in attention and concentration as well as understanding

and memory but again remains only slightly limited in the ability to do

SRT. Of the previously mentioned what percent?

A: I’d eliminate the fast food work I think. Mail clerk, let me

look at these. I’d eliminate all except the housekeeping. Probably

eliminate half of those. 

Q: Assume for hypothetical number 4C that he is going to

require close supervision, close being two hours or more per shift and

would be moderately limited in the ability to do SRT. Of the previously

mentioned what percent?

A: I’d eliminate the work at that level, Judge.

Plaintiff’s attorney did not ask the vocational expert any questions. 

For the reasons discussed above, the court finds that the hypothetical questions

posed to the vocational expert did not necessarily accurately describe plaintiff’s limitations. It is

possible that on remand the ALJ will reach different conclusions as to plaintiff’s daily activities

and/or ability to maintain persistence, concentration, and pace. 

/ / /

/ / /

/ / /

/ / /

/ / /

/ / /

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V. CONCLUSION

For the foregoing reasons, this matter will be remanded under sentence four of 42

U.S.C. § 405(g) for further development of the record and/or further findings addressing the

deficiencies noted above. 

Accordingly, IT IS HEREBY ORDERED that:

1. Plaintiff’s motion for summary judgment (Doc. 24) is granted;

2. Defendant’s cross-motion for summary judgment (Doc. 28) is denied; 

3. The matter is remanded for further administrative proceedings consistent

with this opinion; and

4. The Clerk of the Court is directed to enter judgment and close this file. 

DATED: April 7, 2010

______________________________________

CRAIG M. KELLISON

UNITED STATES MAGISTRATE JUDGE

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