Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_14-cv-00121/USCOURTS-caed-1_14-cv-00121-3/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Stephanie Lockhart
Plaintiff
Dorothy Jean Lockhart
Plaintiff

Document Text:

1

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

INTRODUCTION

Dorothy Jean Lockhart, mother of Stephanie Lockhart (“Plaintiff”)

1

, seeks judicial review of a 

final decision of the Commissioner of Social Security (“Commissioner”) denying Plaintiff’s 

application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) 

pursuant to Title II and Title XVI of the Social Security Act, respectively.

2

The matter is currently 

before the Court on the parties’ briefs, which were submitted, without oral argument, to U.S. 

 

1 On October 27, 2014, Dorothy Jean Lockhart filed a declaration stating that her daughter, Stephanie Lockhart, is 

deceased. (Doc. 17). Subsequently, Plaintiff’s mother, Dorothy Jean Lockhart, was substituted as Plaintiff by the Court on 

November 12, 2014. Doc. 20; See Stipulation, Doc. 19.

2 Carolyn W. Colvin became the Acting Commissioner of Social Security on February 14, 2013. Pursuant to Rule 25(d) of 

the Federal Rules of Civil Procedure, Carolyn W. Colvin should be substituted for Michael J. Astrue as the defendant in 

this suit.

DOROTHY JEAN LOCKHART,

 Plaintiff,

v.

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security,

Defendant.

)

)

)

)

)

)

)

)

)

)

Case No.: 1:14-cv-00121-BAM

ORDER REGARDING PLAINTIFF’S

SOCIAL SECURITY COMPLAINT

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 1 of 19
2

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Magistrate Judge Barbara A. McAuliffe.

3 After careful consideration of the entire record, including 

testimony and medical evidence and opinions, the Court will reverse the Commissioner’s decision and 

remand to the ALJ for the calculation of an award for benefits. 

FACTS AND PRIOR PROCEEDINGS

On December 7, 2009, Plaintiff filed applications for DIB and SSI alleging disability 

beginning October 15, 2009. AR 188–198. Plaintiff’s claim was denied both initially on February 22, 

2010, and upon reconsideration on October 28, 2010. Plaintiff requested and received a hearing before 

the Administrative Law Judge (“ALJ”), Sherrill A. Laprade Carvalho, who issued an order denying 

benefits on April 10, 2012. The Appeals Council denied Plaintiff’s request for review of the ALJ’s

decision on December 11, 2013, which made the Commissioner’s decision final. This appeal followed.

Plaintiff’s Testimony

On February 29, 2012, ALJ Carvalho presided over a hearing in Fresno, CA. AR 29–76. 

Plaintiff Stephanie Lockhart appeared and testified, and was represented by her attorney, Gina Fazio. 

Plaintiff’s mother, Dorothy Jean Lockhart, also appeared and testified.4

Plaintiff testified that she lived at home with her mother. Her primary complaints surround her 

mental health impairments. Plaintiff stated she was unable to work because she constantly hears voices 

that tell her what to do. Plaintiff also feels like she “causes earthquakes and car crashes.” AR 36.

Plaintiff last worked doing in-home care, but due to increased isolation she felt she could no longer 

appropriately fulfill her work obligations and she quit. AR 36–37. Plaintiff testified that she now stays 

in her room 95% of the day because she is agoraphobic. Id. Plaintiff has been hospitalized for acting 

on what the voices tell her to do—“a couple of times for trying to kill [herself] and maybe once for 

throwing a computer at [her] brother.” AR 37. 

When asked about her prior drug use, Plaintiff testified that she used marijuana and alcohol in 

high school, but denied using any other illegal drugs. AR 38. It had been at least eight years since she 

 

3 The parties consented to the jurisdiction of U.S. Magistrate Judge Barbara A. McAuliffe in accordance with the 

provisions of 28 U.S.C. § 636(c). See Docs. 8, 10.

4

Vocational Expert, Thomas C. Dachelet, also testified at the hearing; however, the VE testimony is unrelated to 

Plaintiff’s appeal. 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 2 of 19
3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

last used marijuana, and last drank alcohol in 1998 while she was working at the shipping company, 

UPS. AR 39.

When asked about her daily activities, Plaintiff testified that her medication has increased her 

weight significantly—approximately 100 pounds over two years. AR 44, which caused fatigue and 

affected her ability to get around, take a shower, and put on her socks. AR 36, 46. Plaintiff 

occasionally helps with dinner, vacuums about once a week, and does laundry about once every two 

weeks. AR 46, 49. She does not wash dishes, clean, take out the garbage, or do yard work. AR 40–41.

Plaintiff will occasionally take the bus, but she did not like to go outside due to a fear of 

confronting people. Plaintiff believes that “the voices in her head are people talking about her.” AR 

49. The voices come and go at random. AR 51. She previously enjoyed skateboarding, camping, and 

going to clubs, but no longer has hobbies. AR 42. Once she started doing in-home care, her depression 

and voices worsened, she became more agoraphobic, and her physical condition and hygiene declined. 

AR 42–43. Plaintiff showers once every two weeks and weighs 370 pounds. 

When asked about her treatment, Plaintiff testified that her medications caused her to twitch, 

and she does not have health insurance. AR 43. She attends Fresno County Behavioral Health and 

Community Medical for mental illness treatment. Id. She goes every three months, but does not 

believe they care; they “just take notes and send [her] off.” AR 43. She was told about Blue Skies, a 

counseling service for people with mental illness, but does not attend because she is afraid of acting on 

the voices in her head and possibly hurting someone. AR 52. 

The ALJ asked whether Plaintiff was aware that her medical records indicated that she used 

substances other than marijuana and alcohol in the past. AR 46–47. Plaintiff replied, “I don’t recall 

using any other drugs, besides marijuana and drinking. If there’s someone saying that I did, I mean, 

it’s not true. I mean, I haven’t used any other drugs.” AR 47. Plaintiff also testified that she was 

arrested for driving on a suspended license after her DUI conviction, but she did not remember getting 

arrested any other time. Id. Plaintiff’s attorney asked whether she remembered telling a doctor that she 

used marijuana daily. AR 50. Plaintiff did not remember, but admitted to having memory problems. 

Id.

///

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 3 of 19
4

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Medical Record

The entire medical record was reviewed by the Court. AR 314-436. The medical evidence will 

be referenced below as necessary to this Court’s decision.

The ALJ’s Decision

Plaintiff met the insured status requirements through December 31, 2013. AR 11. The ALJ 

found that Plaintiff had the following severe impairments: a schizoaffective disorder, cannabis 

dependence, polysubstance dependence in remission, degenerative joint disease, and obesity AR 13. 

With polysubstance abuse, Plaintiff does have an impairment or combination of impairments that 

meets or medically equals one of the listed impairments. AR 12. 

The ALJ also found that if Plaintiff stopped her substance use, her impairments would not meet 

or equal any impairment in the listings. AR 14. She would have the residual functional capacity to lift 

and/or carry 20 pounds occasionally and 10 pounds frequently, sit 6 hours in an 8-hour workday, stand 

and/or walk 2 hours each in an 8-hour workday, and occasionally stoop, balance, and kneel, but she 

could never climb. In addition, Plaintiff could sustain simple repetitive tasks. AR 15. The ALJ found 

that although Plaintiff would not be able to perform her past relevant work if Plaintiff stopped the 

substance use, there would be a significant number of jobs in the national economy that Plaintiff could 

perform. AR 21. The ALJ concluded that substance abuse was a contributing factor material to the 

determination of disability and therefore entered a finding that Plaintiff was not disabled. AR 23. 

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, this 

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 v. Perales, 402 U.S. 389, 401 (1971). The record as a 

whole must be considered, weighing both the evidence that supports and the evidence that detracts 

from the Commission’s conclusion. Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). In weighing 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 4 of 19
5

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

the evidence and making findings, the Commission must apply the proper legal standards. E.g., 

Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must uphold the Commissioner’s 

determination that the claimant is not disabled if the Secretary applied the proper legal standards, and 

if the Commission’s findings are supported by substantial evidence. Sanchez v. Sec’y of Health and 

Human Serv., 812 F.2d 509, 510 (9th Cir. 1987); see also Andrews v. Shalala, 53 F.3d 1035, 1039 (9th 

Cir. 2002).

REVIEW

In order to qualify for benefits, a claimant must establish that he or 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 show that he or she has a physical or mental impairment of such 

severity that he or she is not only unable to do his or her previous work, but cannot, considering his or 

her age, education, and work experience, engage in any other kind of substantial gainful work which 

exists in the national economy. Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th Cir. 1989). The 

burden is on the claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 

1990). 

DISCUSSION

Plaintiff contends that the ALJ erred in determining that her drug abuse is a contributing factor 

to her disability.

In this case, the ALJ conducted the DAA analysis, first finding that Plaintiff’s mental 

impairments met a Listing. Next, the ALJ considered whether Plaintiff would be disabled if she 

stopped the substance use. The ALJ determined that by removing the effects of the substance abuse 

Plaintiff would have a severe impairment or combination of impairments but they would not meet or 

medically equal any listed impairments. AR 14–15. Next, although Plaintiff’s residual functional 

capacity (“RFC”) would preclude past relevant work, there would be a significant number of other 

jobs in the national economy that Plaintiff could perform, absent her substance abuse. AR 22–23. 

Thus, the ALJ concluded that Plaintiff is not disabled because substance abuse is a contributing factor 

material to the determination of Plaintiff’s disability. AR 23.

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 5 of 19
6

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

A claimant is ineligible for benefits if alcoholism or drug addiction would “be a contributing 

factor material to the Commissioner’s determination that the individual is disabled.” 42 U.S.C. § 

423(d)(2)(C); Parra v. Astrue, 481 F.3d 742, 748 (9th Cir. 2007). In a case with evidence of drug or 

alcohol abuse, the claimant bears the burden of proving that her substance abuse “is not a contributing 

factor material to her disability.” Parra, 481 F.3d at 748. For purposes of determining whether a 

claimant’s substance abuse is a material contributing factor, the critical question is whether the 

claimant would still be disabled if she stopped using drugs or alcohol. 20 C.F.R. §§ 404.1535(b)(1), 

416.935(b)(1). In making this assessment, the ALJ is to evaluate which of the claimant’s physical and 

mental limitations “would remain if [the claimant] stopped using drugs or alcohol and then determine 

whether any or all of [the claimant’s] remaining limitations would be disabling.” 20 C.F.R. §§ 

404.1535(b)(2), 416.935(b)(2).

Plaintiff agrees that she is disabled, but contends her prior history of drug abuse does not 

materially contribute to her disability. Although Plaintiff does not dispute that she abused substances 

well before her disability onset date, she maintains there are no incidents of drug use during the 

relevant period and, therefore, her impairments were not affected by drug use. 

1. Substantial evidence does not support the ALJ’s determination that Plaintiff’s substance 

abuse was a material contributing factor to her disability 

Plaintiff’s primary argument is that the ALJ misread the medical records, which led to the 

ALJ’s erroneous finding that substance abuse was a factor material to Plaintiff’s disability. 

Specifically, there is no relevant medical evidence in the record that supports the ALJ’s finding that 

Plaintiff engaged in substance abuse during the relevant time period. The Commissioner disagrees and 

points to the same evidence the ALJ relied on—Plaintiff’s past history of drug use and a positive drug 

test from April 2010—as evidence of Plaintiff’s ongoing substance abuse. AR 562. The Court will 

address each of the ALJ’s relevant findings regarding substance use.

The ALJ relied on the following reasons to establish that Plaintiff suffered from drug 

addiction/alcoholism: (1) history of polysubstance dependence, AR 15; (2) Plaintiff’s arrest for 

possession and DUI, AR 21; (3) Plaintiff’s inconsistent statements of prior and current drug use, AR 

16–19, 20–22; (4) Dr. Chofla diagnosed “rule out polysubstance dependence” in June of 2011, AR 18,

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 6 of 19
7

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

and Dr. Collado diagnosed polysubstance dependence in October of 2011, id.; (5) the state agency 

doctor’s report shows ongoing drug use, AR 20; (6) Plaintiff was diagnosed with polysubstance 

dependence during 5150 in April 2010, AR 17; and (7) Plaintiff tested positive for marijuana during 

5150 hold in April of 2010, AR 17.

Having reviewed the evidence relied on by the ALJ to conclude that Plaintiff’s substance 

abuse was material to her disability, the Court finds that substantial evidence does not support the 

ALJ’s conclusion that Plaintiff’s prior, but not ongoing, drug use was a contributing factor to 

Plaintiff’s disability. 

First, the ALJ relied on Plaintiff’s history of drug use and DUI conviction, which, aside from

not being objective medical evidence, is prior to the disability onset date. See SSR 13-2p, at *10

(“[The ALJ will] not make a determination regarding materiality if a claimant has a history of DAA 

that is not relevant to the period under consideration.”). Plaintiff reported to her physician in 2007 that 

she was previously convicted of a DUI. Although the date of her DUI conviction is unknown, Plaintiff 

discussed her DUI conviction in December 2007—well before her December 2009 disability onset 

date. 

Second, Plaintiff’s inconsistent reporting of prior and current substance use to medical 

personnel and at the hearing is an acceptable reason to discredit Plaintiff’s subjective testimony, see

Smolen, 80 F.3d at 1294, but it is not medical evidence that can establish the existence of drug 

addiction or alcoholism, see id. (“Self-reported drug or alcohol use. . . . [is] not objective medical 

evidence provided by an acceptable medical source.”).

Third, the ALJ relied on Dr. Chofla’s “rule out polysubstance dependence” in June 2011 as a 

diagnosis of Plaintiff’s drug dependence. AR 18. However, this “rule out” reference means just the 

opposite, i.e., that no such diagnosis was warranted. A “rule-out” notation means that the patient meets 

some criteria of the disorder but the doctor is unwilling to diagnose it and more information is needed.

See Cha Yang v. Comm'r of SSA, 488 F. App’x 203, 207 (9th Cir. 2012)(“rule out” notation is not a 

clear, affirmative diagnosis); Langford v. Astrue, 2008 WL 2073951, at *3 (E.D. Cal. 2008); see also, 

http://medical-dictionary.thefreedictionary.com/rule-out (a rule out is “an exclusion” of possible 

diagnoses; to rule out means to “eliminate as a serious diagnostic consideration”). Dr. Chofla met with 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 7 of 19
8

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Plaintiff again in September 2011, and the same “rule-out” diagnosis appears on his progress notes. 

AR 618–19. The ALJ also mentioned that in October of 2011, Dr. Collado diagnosed Plaintiff with 

“polysubstance dependence.” AR 18. However, this diagnosis is also a “rule-out” notation. AR 616–

17. Dr. Collado’s notes read “polysubstance dependence (not medi-cal covered) (rule out).” AR 616. 

The progress reports by Dr. Collado and Dr. Chofla are nearly identical with respect to the subjective 

history sections (“Drugs: has claimed to deny. Denies any etoh or drugs. I quit at 25 so that’s how I 

lost my friends.”) as well as the notes sections (“++ HX of poly sub in subjective claimed remission.”).

AR 618–624. However, since both Dr. Chofla and Dr. Collado are simply restating Plaintiff’s self 

reported history of past drug use, this is not substantial evidence supporting the ALJ’s finding that 

Plaintiff currently suffers from DAA. 

Next, the ALJ stated: “I give greater weight to the opinions of state agency doctors because 

they are more consistent with the overall medical evidence of record discussed above, which shows 

minimal findings on mental status examinations, improvement with medications, and ongoing drug 

(marijuana) use.” AR 20.

Reviewing physician, Dr. Ginsburg performed a Physical Residual Capacity Assessment on 

February 16, 2010. AR 517–21. On February 22, 2010, reviewing physician, Dr. Murillo completed a 

Mental Residual Functional Capacity Assessment, AR 522–54, a Psychiatric Review Technique, AR 

525–35, and a Case Analysis detailing those findings. AR 536–40. Dr. Murillo made the following

note under Functional Information in the Case Analysis: “Note: clmt states to Kaiser 12/08, she has 

stopped daily marijuana use, does not appear, DA&A issue.” AR 536. Under the heading Significant 

Objective Findings, Dr. Murillo then summarized Plaintiff’s medical records from August 2007, to 

January 19, 2010. AR 537–39. Dr. Murillo noted that in November 2007, Plaintiff “[t]akes Vicodin 

and smokes marijuana for pain control.” AR 537. Next, Dr. Murillo observed that on November 5, 

2008, Plaintiff “states cannabis—daily for ‘medicinal’ purposes. Denies medical marijuana card.” AR 

538. 

The only time “Cannabis Dependence” appears in Plaintiff’s medical records after the 

disability onset date is in Dr. Murillo’s Psychiatric Review Technique. AR 531. Dr. Murillo’s findings 

are unremarkable, because as a reviewing physician, his findings merely restate what is in the record—

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 8 of 19
9

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

evidence of a history of substance abuse prior to the disability onset date of October 15, 2009. Further, 

the ALJ gave “greater weight to the opinion of the state agency doctors because they are more 

consistent with” either “the overall medical evidence of record” or “more consistent with . . . ongoing 

drug use.” AR 20. Reliance on these opinions to establish the existence of a current drug addiction 

was error as the reviewing physicians were relying on information prior to Plaintiff’s disability onset 

date. See Carmickle v. Comm’r Soc. Sec. Admin., 533 F.3d 1155, 1165 (9th Cir. 2008) (“Medical 

opinions that predate the alleged onset of disability are of limited relevance.”).

Finally, the ALJ noted that Plaintiff was diagnosed with polysubstance dependence during her 

5150 hold in April of 2010. AR 17. There are two handwritten notes that diagnose Plaintiff with 

“P.S.D.” (polysubstance dependence). AR 569, 571, 669, 671. However, those are not the only 

diagnoses from that hold: Dr. Ensom filed an Admission Physician’s Assessment and a Discharge 

Note for that same 5150 hold, and which both diagnose Plaintiff with “Polysubstance Abuse in full, 

sustained remission.” AR 573, 565. The fact that Dr. Ensom opined that Plaintiff was in full, sustained 

remission is further substantiated by Dr. Ensom’s notes, which show that he was aware of Plaintiff’s 

past drug use: “DRUGS: No drugs for 91⁄2 yrs; used MJ, hx of IVDA (cocaine, speed), acid, 

mushrooms, crack.” AR 572. It is not a rational interpretation of the evidence that Dr. Ensom would be 

aware of Plaintiff’s detailed history with narcotics, and, as discussed below, that she tested positive for 

one under his care, and yet diagnosed her in full, sustained remission.

The ALJ also relied heavily on an alleged positive marijuana test, noted by Dr. Ensom, from 

Plaintiff’s 5150 hold in April of 2010. AR 562–63. The ALJ interpreted a handwritten symbol—a 

circled plus sign—followed in handwriting with: “marijuana, past IVDA 10 years ago—acid, meth, 

cocaine,” id., as evidence that Plaintiff tested positive for marijuana. AR 17, 21 (citing Exhibits 11F, 

pp.4–25, and 20F, pp. 7–15.). This symbol appears next to the field titled Drugs under the SH section 

(social history) of the emergency room intake notes at St. Agnes. Id. Also in this section, Tobacco and 

ETOH are each marked with a slashed circle. Id. However, Dr. Habibe’s General Physician Orders 

from St. Agnes indicate no labs were done. AR 556. The date and time on the police report says April 

10, 2010, at 1825 hours. AR 553. Plaintiff arrived at St. Agnes at 1843, AR 561, and was registered 

and admitted at 1902. AR 557. Dr. Habibe’s emergency room notes were written at 1920. AR 562. 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 9 of 19
10

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Nowhere else in the records—referenced by the ALJ, the parties, or otherwise—is there any indication

that a drug test was administered. The timing of Plaintiff’s hospital admission and the related 

treatment notes detailing the time of her treatment corroborates a theory that Plaintiff was admitted 

and released without a drug test. Therefore, it is unclear whether Plaintiff relayed a history of 

marijuana use as she did on numerous times before, or whether she tested positive on this one occasion 

for marijuana. 

Nonetheless, the ALJ’s findings are largely dependent on the ambiguous handwritten symbol 

in the physician’s notes from Plaintiff’s 5150. Although the ALJ’s findings must be upheld if “the 

evidence is susceptible to more than one rational interpretation, one of which supports the ALJ’s 

decision,” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002), that a drug test was administered,

for which Plaintiff tested positive, is not a rational interpretation of this handwritten symbol. If a drug 

test was administered, Dr. Habibe’s order would have indicated as much, but his notes state the 

opposite—that no labs were ordered. Additionally, Dr. Ensom diagnosed Plaintiff in full remission.

Further, even if the handwritten symbol was in fact a positive drug test, it would not establish the 

existence of a Substance Use Disorder for purposes of materiality. See SSR 13-2p, *33 (“A single drug 

or alcohol test is not sufficient to establish DAA as a medically determinable impairment, nor does it 

provide pertinent information that can help us determine whether DAA is material to a finding of 

disability.”).

While neither party genuinely disputes that Plaintiff’s overall medical record reflects a prior

history of substance abuse, only prior to the disability onset date of October 15, 2009, however, do 

those records indicate Plaintiff used marijuana, and only a portion of those records diagnose cannabis 

dependence. AR 315, 357, 363, 378, 379, 383, 389, 401, 406. In fact, the records indicate that around 

November 2008 Plaintiff began to reduce her marijuana use and was determined to stop entirely. AR 

378, 383, 401, 406. Those records also indicate Plaintiff successfully stopped using marijuana as early 

as January 2009, AR 429, and she continued to report no marijuana use in May, August, October, and 

November 2009 as well. AR 450, 455, 470, 486, 493. The language changes around the disability 

onset date, at which point the records begin to reflect a “prior history of substance abuse.” AR 501, 

507.

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 10 of 19
11

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Prior to applying a drug addiction or alcoholism analysis, the ALJ must first have “medical 

evidence” of substance use disorder, which can only be provided by an acceptable medical source. The 

claimant bears the burden during the second analysis to prove substance use is not a contributing 

factor material to her disability. Parra, 481 F.3d at 748. This burden only shifts to Plaintiff in the 

event the medical records contain medical evidence of a substance use disorder. Here, Plaintiff 

provided significant objective medical evidence from acceptable medical sources that while she 

abstained from drugs after her onset date, her disability remained. See 20 CFR §§ 404.1513, 1535, and 

§§ 416.913, 416.935. For these reasons, the Court concludes that the ALJ’s finding that Plaintiff 

currently suffers from DAA is not supported by substantial evidence.

2. The ALJ Improperly Weighed the Medical Evidence

Plaintiff’s next argument is that the ALJ committed reversible error by failing to give legally 

adequate reasons for rejecting the opinions of every psychiatrist and psychologist who examined or 

treated her.

There are three types of medical opinions (treating, examining, and nonexamining) and each 

type is accorded different weight. See Valentine v. Comm’r of Soc. Sec. Admin., 574 F.3d 685, 692 

(9th Cir. 2009); Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1996). Generally, more weight is given 

to the opinion of a treating source than the opinion of a doctor who did not treat the claimant. See 

Turner v. Comm’r of Soc. Sec. Admin., 613 F.3d 1217, 1222 (9th Cir. 2010); Winans v. Bowen, 853 

F.2d 643, 647 (9th Cir. 1987). The Court “afford[s] greater weight to a treating physician’s opinion 

because ‘he is employed to cure and has a greater opportunity to know and observe the patient as an 

individual.’” Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989) (quoting Sprague v. Bowen, 812 

F.2d 1226, 1230 (9th Cir. 1987)). Likewise, more weight is given to the opinion of an examining 

source than to a nonexamining source. See Lester, 81 F.3d at 830-31; Pitzer v. Sullivan, 908 F.2d 502, 

506 & n.4 (9th Cir. 1990). “The ALJ must consider all medical opinion evidence.” Tommasetti v. 

Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008) (citing § 404.1527(b)).

If a treating doctor’s opinion is not contradicted by another doctor (i.e., there are no other 

opinions from examining or nonexamining sources), it may be rejected only for “clear and 

convincing” reasons supported by substantial evidence in the record. See Ryan v. Comm’r of Soc. Sec. 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 11 of 19
12

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Admin., 528 F.3d 1194, 1198 (9th Cir. 2008); Lester, 81 F.3d at 830. If the treating or examining 

physician’s opinion is contradicted, the ALJ must provide specific, legitimate reasons based on 

substantial evidence in the record for rejecting that opinion. See Valentine, 574 F.3d at 692; see also

§404.1527(d)(2). The law is clear in this circuit that the ALJ must defer to the treating doctor’s 

opinion, even if controverted by another doctor, unless the ALJ makes findings setting forth specific, 

legitimate reasons for rejecting it that are based on substantial evidence in the record. See Turner, 613 

F.3d at 1222. However, the “ALJ need not accept the opinion of any physician, including a treating 

physician, if that opinion is brief, conclusory, and inadequately supported by clinical findings.” Bray 

v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 1228 (9th Cir. 2009) (internal quotation marks and 

citation omitted). “The ALJ can meet this burden by setting out a detailed and thorough summary of 

the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings.” 

Magallanes, 881 F.2d at 751 (internal quotation marks and citation omitted).

The ALJ’s personal observations of the claimant at the hearing do not constitute a substantial 

reason for rejecting the opinions of a treating physician when the claimant professes psychological 

impairment. See Montijo v. Sec’y of Health & Human Servs., 729 F.2d 599, 602 (9th Cir. 1984) (per 

curiam). “Particularly in a case where the medical opinions of the physicians differ so markedly from 

the ALJ’s, it is incumbent on the ALJ to provide detailed, reasoned, and legitimate rationales for 

disregarding the physicians’ findings.” Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988).. “[A]n 

ALJ cannot avoid these requirements simply by not mentioning the treating physician’s opinion and 

making findings contrary to it.” Lingenfelter v. Astrue, 504 F.3d 1028, 1038 n.10 (9th Cir. 2007). 

“When an examining physician relies on the same clinical findings as a treating physician, but differs 

only in his or her conclusions, the conclusions of the examining physician are not ‘substantial 

evidence.’” Orn, 495 F.3d at 632. “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, 849 

F.2d at 421–22.

A. Robert L. Morgan, Ph.D.

Examining physician, Dr. Morgan met with Plaintiff on January 27, 2012 for a Comprehensive 

Psychological Evaluation. AR 637–44. He also filed a Psychiatric Review Technique, 645–47. Dr. 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 12 of 19
13

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Morgan reviewed Fresno County Mental Health records from 2011, and he reviewed a prescription 

record from Fresno County Mental Health for 2010 and 2011. Dr. Morgan determined that Plaintiff 

met listing 12.03 for Schizophrenic, Paranoid and Other Psychotic Disorders. He found marked 

limitations in activities of daily living; marked limitations in difficulties in maintaining social 

functioning; marked limitations in difficulties in maintaining concentration, persistence, or pace; and 

one or two episodes of decompensation, each of extended duration.

Dr. Morgan noted that Plaintiff denied the use of alcohol or illegal drugs, and found “no 

evidence of malingering or fictitious behavior, no bizarre or unusual behaviors.” He also found that 

Plaintiff was experiencing feelings of sadness, failure, hopelessness, and thoughts of suicide. AR 641. 

She has trouble making decisions, has feelings of worthlessness, and has lost interest in most of the 

things in her life that she used to derive pleasure from. Id. She remains irritable, fatigued, and has 

completely lost interest in sex. AR 641–42. Plaintiff was having “severe difficulty with feelings that 

someone else can control her thoughts . . . that she is watched or talked about by others,” as well as 

“fears of death or dying, . . . trouble concentrating, feeling tense, feelings of guilt, spells of terror or 

panic and the idea that something is wrong with her mind.” AR 624. Dr. Morgan noted that Plaintiff’s 

“profile is marked by significant elevations across several scales indicating a broad range of clinical 

features and increasing the possibility of multiple diagnoses.” Id. Dr. Morgan found profiles of this 

type “usually associated with marked distress and severe impairment in functioning,” which suggests 

“significant thinking and concentration problems accompanied by prominent distress and dysphoria.” 

Id. Plaintiff is likely to remain “withdrawn and isolated, feeling estranged from the people around her

. . . . and this hopelessness and pessimism combined with the likelihood of impaired judgment may 

place her at increased risk for self harm.” Id. Plaintiff’s “marked peculiarities in thinking and 

experience . . . . are often associated with an active psychotic episode with poor judgment and 

impairment in reality testing is a hallmark characteristic.” Id.

Dr. Morgan also found it likely that Plaintiff “experiences unusual perceptual events or fullblown hallucinations.” Id. She is also likely to be socially isolated, “[h]er thought processes are likely 

to be marked by confusion, distractibility, and difficulty concentrating, and she [may] experience her 

thoughts as blocked, withdrawn or somehow influenced by others.” Id.

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 13 of 19
14

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Dr. Morgan determined Plaintiff met criteria for Listing 12.03, and diagnosed schizoaffective 

disorder, PTSD, arthritis in the knees, lower back pain, and dizziness, with a GAF of 50. AR 642–43. 

He determined Plaintiff was presenting with “psychotic features and deterioration that is persistent as 

evidenced by both delusions and hallucinations.” AR 643.

The ALJ gave “little weight to the opinion of psychological consultative examiner Dr. Morgan 

[], as I do not believe that his ‘marked’ mental limitations are indicative of the claimant’s mental 

functioning when not using drugs.” AR 20. 

Although, Dr. Morgan’s report is the most recent, updated, and thorough consultative

examination in the record, the ALJ rejected Dr. Morgan’s opinion for drug-related reasons. This was 

error as the ALJ was acting on the erroneous interpretation of the evidence that a medically 

determinable substance use disorder existed. Thus, the reason for rejecting Dr. Morgan’s opinion is 

not supported by substantial evidence.

B. Josefina A. Collado, M.D. 

Dr. Collado met with Plaintiff for the first time in September 2010, at which point Dr. Collado 

diagnosed Plaintiff with Schizoaffective Disorder, Personality Disorder, Obesity, Poor Social Skills, 

with a GAF of 55. The next time Dr. Collado met with Plaintiff was October, 2011, where Dr. Collado 

diagnosed Plaintiff with Schizoaffective Disorder, Rule-Out Polysubstance Dependence, Rule-Out 

Dependent Personality Disorder, Obese, with a GAF of 56. On this October progress note, Dr. Collado 

acknowledged Plaintiff’s prior history by noting a desire to decrease Plaintiff’s Xanax and discontinue 

in the future, but noted “(++Hx of polysub in subjective remission) pt reports she rather follow with 

another provider that will cont life long benzo maint.” AR 617.

As mentioned above, Dr. Collado’s “rule-out” notations are not diagnoses. Dr. Collado 

submitted a Mental Disorder Questionnaire dated February 9, 2012, stating that Plaintiff’s condition 

was not likely to improve in the next 12 months. AR 648–49.

The ALJ accorded little weight to “the check-box” statement of Dr. Collado “because it does 

not consider the claimant’s mental status when engaging in drug use.” AR 20. The ALJ found Dr. 

Collado’s opinion “conclusionary [sic] and brief, and unsupported by clinical findings.” Id. On

Plaintiff’s last treatment with Dr. Collado, Plaintiff’s “stable” condition and GAF score of 56 are 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 14 of 19
15

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

“inconsistent with [Dr. Collado’s] opinion that the claimant has significant impairments that would 

impair her ability to work.” Id. Lastly, the ALJ found that “the records show improvement of the 

claimant’s mental symptoms when she is compliant with medications, and mental status examinations 

have yielded only minimal findings which do not support a finding of disability.” Id.

The Court finds that the ALJ considered Dr. Collado’s opinion in conflicting ways. First, the 

ALJ relied on Dr. Collado’s diagnosis of polysubstance abuse to reject Plaintiff’s credibility and to 

demonstrate an overall inconsistency in the record of substance use and diagnoses. Then, the ALJ 

rejected Dr. Collado’s opinion because “it does not consider [Plaintiff’s] mental status when engaging 

in drug use.” AR 20. Although the ALJ does not need to accept an opinion that is brief, conclusory, 

and unsupported by findings, see Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 1228 (9th Cir. 

2009), the ALJ was still required to provide a “detailed and thorough summary of the facts and 

conflicting clinical evidence, stating [her] interpretation thereof, and making findings.” Magallanes, 

881 F.2d at 751 (internal quotation marks and citation omitted).

The ALJ rejected Dr. Collado’s medical opinion because of a presumption that Plaintiff was 

engaging in substance abuse. As stated previously, there is no evidence to substantiate the ALJ’s 

premise. For this reason, the ALJ improperly assessed Dr. Collado’s medical opinion.

C. Treating Physicians Drs. Patel, Ensom, and Margot

Sugnaykumar P. Patel, M.D., treated Plaintiff at Kaiser for a year leading up to her disability 

onset date, at which point she transferred care to Fresno County. Dr. Patel diagnosed Plaintiff with 

schizoaffective disorder in October, 2009. AR 484–89. The ALJ did not provide a reason for rejecting 

Dr. Patel’s diagnosis.

Richard Margot, Ph.D., certified Plaintiff for temporary disability in October, 2011. Dr. 

Margot noted, “Client is suffering with schizoaffective disorder, which impairs her memory, 

concentration, leaving her home, reality testing and being around others.” AR 614-15. Dr. Margot 

noted that Plaintiff’s mental condition was not related to drug and/or alcohol abuse. AR 615. The ALJ 

gave little weight to Dr. Margot’s opinion because there were “no supporting treatment records.” AR 

18. 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 15 of 19
16

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

In December 2009, Dr. Ensom treated Plaintiff at Urgent Care through Fresno County 

Department of Behavioral Health. Dr. Ensom recognized Plaintiff’s long history with that department 

dating “back to 1995 (Cannabis abuse and –induced anxiety disorder),” as well as alcohol and meth 

abuse. AR 589. He noted that Plaintiff was hearing voices, experiencing anxiety and anger, and her 

appearance was “[w]ell-groomed, obese, tearful.” Id. Dr. Ensom diagnosed Plaintiff with Major 

Depressive Disorder, Recurrent, Severe, without psychotic features; Borderline Personality Disorder; 

and provided a GAF score of 45. AR 589, 593. He certified Plaintiff for disability benefits for one 

year. AR 503.

Dr. Ensom also treated Plaintiff during her 5150 hold in April of 2010, where he diagnosed 

Plaintiff with: Psychotic Disorder NOS (not otherwise specified); Dysthymic Disorder; Polysubstance 

Dependence in full, sustained remission; Personality Disorder NOS with borderline traits; Obesity; 

and a GAF of 40. AR 565, 570, 572–73. Dr. Ensom noted: “No drugs for 9 1⁄2 yrs; used MJ, hx of 

IVDA (cocaine, speed), acid, mushrooms, crack.” AR 572. 

Dr. Ensom treated Plaintiff again in May of 2010, where he diagnosed Schizoaffective 

Disorder, Personality Disorder NOS, Obesity, Social Isolation, and GAF 50. In Dr. Ensom’s notes 

from May, he noted: “Denies recent [drug] use. Used MJ in past.” AR 590.

The ALJ gave “this opinion little weight because it is inconsistent with the medical evidence of 

record discussed herein. . . . [and] Dr. Ensom did not address the claimant’s drug use.” AR 16. The 

ALJ also noted that since Plaintiff told Dr. Ensom in May of 2010 “that she had not used marijuana for 

6 months, [that] indicates she could have been using marijuana at the time of [his] opinion []. 

Furthermore, in January of 2010, mental status examination by Dr. Ensom was essentially within 

normal limits, although the claimant appeared depressed with constricted affect.” Id.

The Court finds that the ALJ provided an adequate reason for rejecting Dr. Margot’s opinion 

but failed to provide specific and legitimate reasons supported by substantial evidence in the record for 

not according controlling weight to Plaintiff’s treating physicians, Drs. Patel and Ensom. See Turner, 

613 F.3d at 1222. The ALJ did not provide a reason for rejecting Dr. Patel’s opinions and rejected Dr. 

Ensom’s opinion because he “did not address the claimant’s drug use.” On the contrary, the Court 

finds that Dr. Ensom did address Plaintiff’s history of drug use and determined that drug addiction or 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 16 of 19
17

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

alcoholism was no longer a factor in Plaintiff’s diagnoses. The ALJ’s reasons for rejecting Dr. 

Ensom’s medical source opinion is again predicated on the existence of a substance use disorder. 

Consequently, like Dr. Collado’s opinion, the ALJ improperly discredited Dr. Ensom’s opinion.

Here, the ALJ was required to set forth specific reasons for rejecting the opinions of the 

uncontradicted treating and consultative physicians. The ALJ recognized that there was consensus 

between the physicians that Plaintiff suffered from severe mental health impairments that affected her 

ability to perform work, but concluded her substance abuse contributed to her disability. The Court 

finds that the given justifications for rejecting the medical evidence does not rise to the requisite level 

of specificity and clarity to reject uncontradicted medical opinions. Nor do they rise to the level of 

specific and legitimate reasons required for the ALJ to reject conflicting opinions between examining 

physicians. These omissions constitute reversible legal error.5

As is discussed above, the Court finds reversible error in the ALJ’s findings based on the 

evaluation of the medical evidence. An ALJ’s finding that the substance use is material must be 

supported with evidence in the record that is fully developed and that establishes that the claimant’s 

co-occurring mental disorder would improve to the point of nondisability in the absence of DAA. See 

Sousa, 143 F.3d at 1245; SSR 13-2p, 2013 SSR LEXIS 2, 78 Fed. Reg. at 11943-44. Here, to 

conclude that Plaintiff’s substance use was material to her disability, the ALJ discounted medical 

opinions that indicated Plaintiff’s impairments because they did not establish that Plaintiff’s substance 

use contributed to Plaintiff’s symptoms. This was reversible error as the Court has already indicated 

that the ALJ failed to perform the proper analysis of Plaintiff’s substance abuse disorder. Accordingly, 

the court will reverse the ALJ’s opinion and decline to reach the merits of her other challenges.

///

 

5

Because the Court reverses this case, the Court dispenses with an exhaustive analysis of the ALJ’s assessment of 

the credibility of Plaintiff’s and Plaintiff’s mother. The Court need not consider Plaintiff's argument regarding credibility in 

light of the need for reversal on other grounds. See Marcia v. Sullivan, 900 F.2d 172, 177 n.6 (9th Cir. 1990) (“Because we 

reverse, we do not reach the other arguments raised.”); Pendley v. Heckler, 767 F.2d 1561, 1563 (11th Cir. 1985) (per 

curiam) (“Because the 'misuse of the expert’s testimony alone warrants reversal,’ we do not consider the appellant’s other 

claims.”)

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 17 of 19
18

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

REMAND

The only issue left is whether to remand for further administrative proceedings or for payment 

of benefits. Plaintiff argues that this case satisfies the Ninth Circuit’s credit-as-true doctrine. That is, 

the Court can remand to the ALJ with instructions to award benefits if each of the following three 

requirements are satisfied: (1) the record is fully developed and further administrative proceedings

would serve no useful purpose; (2) the ALJ failed to provide legally sufficient reasons for rejecting 

Plaintiff’s testimony or medical opinions; and (3) if that evidence were credited as true, the ALJ would 

be required to find the claimant disabled on remand. Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 

2014).

The Commissioner, however, contends that the proper remedy would be to remand for further 

administrative proceedings. Although the Ninth Circuit has developed this credit-as-true rule, 

Commissioner adds, the courts have the “flexibility to remand for further proceedings when the record 

as a whole creates serious doubt as to whether the claimant is, in fact, disabled within the meaning of 

the Social Security Act.” Id. at 1021.

The parties are in agreement that this Court may remand for payment of benefits where a fully 

developed record renders further administrative proceedings meaningless. See Smolen v. Chater, 80 

F.3d 1273, 1292 (9th Cir. 1996). When a court reverses the ALJ’s decision, “the proper course, except 

in rare circumstances, is to remand to the agency for additional investigation or explanation.” Moisa v. 

Barnhart, 367 F.3d 882, 886 (9th Cir. 2004) (citing INS v. Ventura, 537 U.S. 12, 16 (2002) (per 

curiam)). The Court finds this case to be one of those rare circumstances. The ALJ found Plaintiff 

disabled in the first five-step sequential evaluation, and removing the Substance Use Disorder from 

that first evaluation does nothing to the functional limitations that were found in the first evaluation; 

the disability determination in the first evaluation remains undisturbed. See 20 CFR §§ 404.1513, 

1535, and §§ 416.913, 416.935. There is one additional consideration not mentioned by the parties: 

Plaintiff is deceased, she died seven months after this appeal was filed. (Doc. 17). Accordingly, there 

can be little to no additional objective medical findings to supplement this record.

In closing, this record is fully developed and additional proceedings would not be helpful. 

When the evidence that the ALJ rejected is given its proper weight (e.g., Plaintiff’s testimony, Dr. 

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 18 of 19
19

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Ensom’s opinion, Dr. Collado’s opinion, Dr. Patel’s opinion, and Dr. Morgan’s opinion) it becomes 

clear that Plaintiff meets Listing 12.03. As a result, the Court will reverse the Commissioner’s decision 

and remand to the ALJ for payment of benefits. See Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1996) 

(stating that the court should remand for payment of benefits when evidence that was improperly 

rejected demonstrates that the claimant meets or equals a Listing); Smolen, 80 F.3d at 1292 (same); 

Ramirez v. Shalala, 8 F.3d 1449, 1455 (9th Cir. 1993) (same). Hammock v. Bowen, 879 F.2d 498, 502 

(9th Cir. 1989) (crediting as true those examining or treating physician opinions that the ALJ rejected 

without providing legally adequate reasons).

ORDER

Based on the foregoing, IT IS THEREFORE ORDERED THAT the Commissioner's decision 

is REVERSED and REMANDED pursuant to 42 U.S.C. § 405(g) for an immediate award of benefits.

IT IS SO ORDERED.

Dated: October 1, 2015 /s/ Barbara A. McAuliffe _

UNITED STATES MAGISTRATE JUDGE

Case 1:14-cv-00121-BAM Document 24 Filed 10/01/15 Page 19 of 19