Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-1_18-cv-06516/USCOURTS-cand-1_18-cv-06516-1/pdf.json

Parties Involved:
Adeeba Sabr
Plaintiff
Andrew Saul
Defendant

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

EUREKA DIVISION

ADEEBA SABR,

Plaintiff,

v.

ANDREW SAUL,

Defendant.

Case No. 18-cv-06516-RMI 

ORDER ON CROSS MOTIONS FOR 

SUMMARY JUDGMENT

Re: Dkt. Nos. 24, 30

Plaintiff, Adeeba Mary Sabr, seeks judicial review of an administrative law judge (“ALJ”) 

decision denying her application for disability insurance benefits and supplemental security 

income under Titles II and XVI of the Social Security Act. Plaintiff’s request for review of the 

ALJ’s unfavorable decision was denied by the Appeals Council, thus, the ALJ’s decision is the 

“final decision” of the Commissioner of Social Security which this court may review. See 42 

U.S.C. §§ 405(g), 1383(c)(3). Both parties have consented to the jurisdiction of a magistrate judge 

(dkts. 9 & 13), and both parties have moved for summary judgment (dkts. 24 & 30). For the 

reasons stated below, the court will grant Plaintiff’s motion for summary judgment, and will deny 

Defendant’s motion for summary judgment.

LEGAL STANDARDS

The Commissioner’s findings “as to any fact, if supported by substantial evidence, shall be 

conclusive.” 42 U.S.C. § 405(g). A district court has a limited scope of review and can only set 

aside a denial of benefits if it is not supported by substantial evidence or if it is based on legal

error. Flaten v. Sec’y of Health & Human Servs., 44 F.3d 1453, 1457 (9th Cir. 1995). The phrase 

“substantial evidence” appears throughout administrative law and direct courts in their review of 

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factual findings at the agency level. See Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). 

Substantial evidence is defined as “such relevant evidence as a reasonable mind might accept as 

adequate to support a conclusion.” Biestek, 139 S. Ct. at 1154 (quoting Consol. Edison Co. v. 

NLRB, 305 U.S. 197, 229 (1938)). “In determining whether the Commissioner’s findings are 

supported by substantial evidence,” a district court must review the administrative record as a 

whole, considering “both the evidence that supports and the evidence that detracts from the 

Commissioner’s conclusion.” Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). The 

Commissioner’s conclusion is upheld where evidence is susceptible to more than one rational 

interpretation. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005).

PROCEDURAL HISTORY

On March 4, 2015, Plaintiff filed applications for disability insurance benefits under Title 

II, and supplemental security income under Title XVI, alleging an onset date of September 8, 2014

as to both applications. See Administrative Record (“AR”) at 15.

1 The ALJ denied the application 

on December 26, 2017. Id. at 29. The Appeals Council denied Plaintiff’s request for review on 

August 29, 2018. Id. at 1-4.

SUMMARY OF THE RELEVANT EVIDENCE

The youngest of six children, Plaintiff is 48 years old and resides in Alameda County, 

California. See Pl.’s Mot. (dkt. 24) at 6; and, AR at 763, 1212. Following a series of traumatic 

events and tragedies, coupled with a history of childhood abuse, Plaintiff was diagnosed by 

various treating and examining providers as being afflicted with a host of mental impairments 

including severe anxiety, panic attacks, depression, adjustment disorder, panic disorder, persistent 

depressive disorder (Dysthemia), chronic posttraumatic stress disorder (“PTSD”), major 

depressive disorder with recurrent episodes and psychotic features, generalized anxiety disorder, 

personality disorder with avoidant traits and paranoid and schizoid features, as well as an 

unspecified neurocognitive disorder. AR at 763, 765, 874, 890-91, 1213, 1406.

// 

 

1 The AR, which is independently paginated, has been filed in several parts as a number of 

attachments to Docket Entry #18. See (dkts. 18-1 through 18-26).

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The Medical Evidence

In August of 2015, Plaintiff was referred to Aparna Dixit, Psy.D., for a disability 

evaluation, from a psychological standpoint, by the California Department of Social Services. Id. 

at 763-65. After briefly noting, in a cursory and generalized fashion, that Plaintiff had a history of 

trauma and childhood abuse, Dr. Dixit reported that Plaintiff’s chief complaints were depression, 

severe anxiety, and PTSD. Id. at 763. Plaintiff told Dr. Dixit that she had not worked since 2013, 

that she was homeless at the time, and that she was unable to socialize with her friends or family. 

Id. at 764. In the course of this evaluation, Plaintiff was diagnosed with anxiety disorder, not 

otherwise specified (“NOS”), and depressive disorder NOS. Id. at 765. Dr. Dixit opined that 

because Plaintiff “presented with symptoms of anxiety [] [she] will benefit from counseling and 

psychiatric treatment for her psychiatric issues.” Id. Relating to Plaintiff’s cognitive functioning –

after finding that Plaintiff could remember 3 out of 3 objects immediately and after 3 minutes –

Dr. Dixit opined that Plaintiff may have some mild difficulties with remembering and carrying out 

complex or detailed instructions. Id. Likewise, based on their interaction during the examination, 

Dr. Dixit opined that Plaintiff may have some mild difficulties in dealing with the public. Id. 

In February of 2016, Plaintiff was referred to Lisa Kalich, Psy.D., for a psychological 

evaluation geared towards assessing Plaintiff’s abilities related to the activities of daily living, 

social functioning, episodes of decompensation, as well as concentration, persistence, and pace. Id. 

at 870. Dr. Kalich’s evaluation consisted of a clinical interview, as well as the administration of 

two diagnostic tools for the evaluation of depression and trauma symptoms. Id. In her report, Dr. 

Kalich began Plaintiff’s social history by noting that she lived with her parents until their divorce 

when Plaintiff was three years old; thereafter, “her childhood was marked by trauma and 

disruption.” Id. When Plaintiff was five years old, her mother, who had struggled with heroin 

dependence, was incarcerated for five years. Id. During those years, between the ages of four and 

ten, Plaintiff resided in various homes, including with the mother of her father’s girlfriend. Id. In 

this home, “she experienced frequent physical abuse . . . [and] was also the victim of sexual abuse 

by multiple perpetrators, including two of her brothers and her cousin.” Id. Plaintiff also grew up 

witnessing frequent bouts of domestic violence between her father and his girlfriends. Id. In her 

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teenage years, Plaintiff experienced anxiety to such a degree that it affected her school 

performance and caused her to be placed in special education, which eventually caused her to drop

out of school in the tenth grade. Id. at 871. Plaintiff eventually earned her G.E.D., and then 

attended a junior college for less than two years. Id.

Dr. Kalich noted that Plaintiff had been employed for the majority of her adult life, 

including a number of temporary clerical and receptionist positions, as well as working as an inhome health care worker for many years. Id. During this period, anxiety occasionally interfered 

with her work, particularly when Plaintiff would experience panic attacks at work. Id. In 2014, 

Plaintiff was diagnosed with breast cancer, and “shortly after her diagnosis, her anxiety symptoms 

intensified.” Id. She underwent surgery and radiation treatments, which caused the cancer to go 

into remission. Id. However, the anxiety continued to worsen to the point where “she experienced 

multiple panic attacks on a daily basis.” Id. at 872. The attacks could last as long as two hours, and 

they were interspersed generally with “constant worry about having another attack.” Id. 

Additionally, “a few times per week, she experiences flashbacks of the sexual abuse,” leading to 

Plaintiff’s “current symptoms of depression including low mood, feelings of worthlessness, 

anhedonia, and sleep an appetite disturbance.” Id. Dr. Kalich also noted that since 2015, Plaintiff 

has experienced homelessness, requiring her to sometimes sleep at shelters or in her car, “if a 

friend’s house is unavailable.” Id. at 871.

As to behavioral observations and Plaintiff’s mental status, Dr. Kalich observed that eye 

contact was varied and that Plaintiff most often either closed her eyes or looked away. Id. 

Plaintiff’s mood was observed as depressed and anxious, attended with evidence of psychomotor 

agitation such as rapidly moving her leg up and down. Id. While Plaintiff denied entertaining any 

such thoughts at the time of the evaluation, she acknowledged having contemplated suicide in the 

past. Id. at 872-73. Upon administering the Trauma Symptom Inventory (2nd ed.) (“TSI-2”), Dr. 

Kalich noted that Plaintiff’s score on the TSI-2 scale was so elevated that “her clinical profile 

could not be interpreted.” Id. at 873. Also, following the administering of the Beck Depression 

Inventory (2nd ed.) (“BDI-II”), Plaintiff’s responses indicated symptoms that were consistent with 

severe depression. Id. Dr. Kalich ultimately rendered an assessment of panic disorder, persistent 

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depressive disorder (Dysthemia), and chronic PTSD, while noting that due to her depression,

Plaintiff “likely experiences moderate to intermittently severe impairment with regard to activities 

of daily living.” Id. at 874. Regarding her panic disorder and PTSD, Dr. Kalich found that Plaintiff 

“likely struggles with intermittently severe deficits in concentration and attention.” Id. at 875. 

Because of the repetitive nature and frequency of the panic attacks, Dr. Kalich opined that Plaintiff 

is “unlikely to be able to complete a normal workday without the interference of her symptoms.” 

Id.

A few months later, in November of 2016, Plaintiff was referred to Pamela Paradowski, 

Ph.D., for what was a very limited psychological evaluation geared towards determining her 

suitability as a candidate for weight-loss surgery. See id. at 1212-13. Dr. Paradowski prepared a 

two-page report that cleared Plaintiff for the surgical procedure and largely focused on detailing 

Plaintiff’s various prior attempts at weight loss including “Weight Watchers, Atkins, fasting, diet 

pills, the paleo diet, a naturopath, laxatives, low carbohydrate and the cabbage soup diet.” Id. at 

1213. From a psychological standpoint, Dr. Paradowski only noted that “[g]iven the above 

discussion[,] it is felt that Ms. Sabr’s condition most closely approximates . . . Adjustment 

Disorder NOS.” Id.

In April of 2017, Plaintiff was referred by her attorney to Katherine Weibe, Ph.D., for a 

psychological evaluation geared towards determining Plaintiff’s state of cognitive and emotional 

functioning. Id. at 878. Initially, Dr. Weibe reviewed the above-described reports prepared by Drs. 

Kalich and Dixit, and then evaluated Plaintiff through a clinical interview and by administering a 

battery of diagnostic tests. Id. at 881. Delving deeply into Plaintiff’s background, Dr. Weibe began 

by noting that only recently had Plaintiff secured a place to live with assistance from Berkeley 

Food and Housing, and that she had spent the previous 18-month period suffering from 

homelessness. Id. at 878. 

By the time she was four years old, Plaintiff was already accustomed to being “physically 

abused by her mother who beat her with extension cords, phone records (sic), and lamp cords[,] all 

with knots in them.” Id. Due to her mother’s heroin dependency, coupled with her father’s refusal 

to take custody, Plaintiff was thereafter raised in various other homes as a foster child. Id. Dr. 

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Weibe then recounted the extent to which Plaintiff’s childhood was marked with abuse and trauma 

in these various homes. Id. at 878-79. When she was a young child, Plaintiff first became the 

victim of sexual abuse by an adult male cousin. Id. When she was 10 years old, and had once 

again become the victim of sexual abuse by one of her brothers, Plaintiff asked her eldest brother 

for help; but instead of helping, “[h]er oldest brother then started sexually abusing her most 

severely.” Id. at 878. Another of Plaintiff’s brothers, one who did not subject her to victimization, 

died after a man poured gasoline on him and set him on fire. Id. at 879. Plaintiff was the one to 

discover his body. Id. After her sister and mother both died of cancer, and after her own battle 

with cancer involving two surgeries and radiation treatment, when Plaintiff found herself 

unemployed and homeless, she reported that her father ignored her, except to occasionally attempt 

to recruit her to do “crooked stuff.” Id.

Based on Plaintiff’s clinical interview, as well as her performance on the various 

diagnostic tests administered, Dr. Weibe made a series of findings as to Plaintiff’s abilities

regarding language, attention and concentration, executive and memory functioning, and 

emotional functioning. Id. at 881-89. Dr. Weibe found Plaintiff to be mildly impaired in the areas 

of language, attention and concentration, visual and spatial abilities, as well as sensory and motor 

abilities. Id. at 881-83. Regarding the ability to plan, sequence, abstract, and organize – or, 

executive functioning – Plaintiff was found to be moderately impaired. Id. at 882. Plaintiff’s 

memory functioning, however, was found to be severely impaired given that her immediate and 

delayed memory were both in the extremely low range (i.e., in the bottom 1st and 2nd percentile

of the population). Id. at 882. In the domains of emotional functioning, Plaintiff was found to be 

severely impaired due to severe depression, severe anxiety, and chronic posttraumatic stress 

“beginning with experiences of sexual, physical, and emotional abuse during her childhood.” Id. at 

883. Dr. Weibe then cataloged Plaintiff’s recent symptoms as including “intrusive memories; 

nightmares; flashbacks; being triggered by reminders; strong physical reactions from reminders; 

avoiding memories, thoughts, or feelings; avoiding people, places, conversations, activities, 

objects, or situations; trouble remembering parts of the experience; strong negative beliefs about 

herself; blaming herself or someone else concerning the experience; strong negative feelings such 

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as fear, horror, anger, guilt, or shame; loss of interest in activities that she used to enjoy; feeling 

distant or cut off from other people; trouble experiencing positive feelings; irritable behavior; 

being hyper-vigilant; feeling jumpy or easily startled; having difficulty concentrating; and having 

trouble falling and staying asleep.” Id. at 883-84. Plaintiff’s symptoms would often cause fullblown panic attacks several times a week, each of which would last for an hour or longer. Id. at 

884. 

Given Plaintiff’s performance on the MCMI-IV, which is “an objective test of psychiatric 

functioning,” Dr. Weibe found that “[o]n the basis of the test data, it may be assumed that she has 

a severe psychological disorder.” Id. at 886. Specifically, Dr. Weibe diagnosed Plaintiff as 

suffering from a major depressive disorder with recurrent episodes and psychotic features; chronic 

PTSD; generalized anxiety disorder; a personality disorder with avoidant traits and paranoid and 

schizoid features; as well as with an unspecified neurocognitive disorder that needed to be 

diagnosed by a medical doctor. Id. at 890-91. Dr. Weibe then rendered three conclusions. First, 

that Plaintiff “evinces cognitive functioning deficits as well as psychiatric disorder problems that 

make it difficult for her to attend to, remember[,] and follow through with directions and tasks.” 

Id. at 890. Second, that Plaintiff’s psychiatric problems affect her cognitive abilities causing 

difficulties in relating effectively with others on a consistent basis. Id. Finally, Dr. Weibe 

concluded that the combination of Plaintiff’s psychiatric, cognitive, and personality functioning 

impairments “would make it difficult for her to function effectively and reliably in a full-time job 

for likely two years.” Id.

The following month, in May of 2017, Plaintiff began psychiatric treatment with Summer 

Savon, M.D., Ph.D.; and, following an initial evaluation and a number of therapy sessions, Dr. 

Savon submitted a letter summarizing her diagnostic impressions and opinions. Id. at 1406. Dr. 

Savon diagnosed Plaintiff with major depressive disorder, anxiety disorder, history of panic 

disorder, and PTSD. Id. After reviewing the reports of evaluations done by Dr. Kalich and Dr. 

Weibe, Dr. Savon noted that in addition to impairments in memory, executive and emotional 

functioning, Plaintiff also “struggles with psychotic symptoms which are incompatible with 

successful employment.” Id. Lastly, Dr. Savon opined that Plaintiff “requires a period of removal 

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from the work force in order to address her psychological issues through psychotherapy as well as 

to optimize her psychotropic medications . . . [and that] [o]nly in this way will she be able to 

develop the equanimity, psychological health and freedom from disturbances in her inner life that 

will make it possible for her to be successful in the workplace.” Id.

Lastly, during this same period, Plaintiff underwent weekly therapy sessions for the better 

part of a year with Kristen Crowley, LMFT, at the Mind to Mindful Psychotherapy Clinic. Id. at 

1401-04. Following more than forty 1-hour weekly therapy sessions between 2016 and 2017, 

Therapist Crowley opined that Plaintiff had marked limitations in dealing with normal work stress, 

and that Plaintiff had extreme limitations (“no useful ability to perform”) in the following areas: 

maintaining attention for two hour periods; maintaining regular attendance at work; completing a 

normal workday without interruptions from psychologically based symptoms; and, performing at a 

consistent pace without an unreasonable number or duration of rest periods. Id. at 1403. Further, 

Ms. Crowley opined that Plaintiff’s impairments would interfere with her workplace concentration 

or pace 40% of the time, and that Plaintiff’s symptoms could be expected to cause her to be absent 

from work more than four days per month. Id. at 1404.

THE FIVE STEP SEQUENTIAL ANALYSIS FOR DETERMINING DISABILITY

A person filing a claim for social security disability benefits (“the claimant”) must show 

that she has the “inability to do any substantial gainful activity by reason of any medically 

determinable physical or mental impairment” which has lasted or is expected to last for twelve or 

more months. See 20 C.F.R. §§ 416.920(a)(4)(ii), 416.909.2 The ALJ must consider all evidence in 

the claimant’s case record to determine disability (see id. § 416.920(a)(3)), and must use a fivestep sequential evaluation process to determine whether the claimant is disabled (see id. § 

416.920). “[T]he ALJ has a special duty to fully and fairly develop the record and to assure that 

the claimant’s interests are considered.” Brown v. Heckler, 713 F.2d 441, 443 (9th Cir. 1983).

Here, the ALJ evaluated Plaintiff’s application for benefits under the required five-step 

 

2 The regulations for supplemental security income (Title XVI) and disability insurance benefits 

(Title II) are virtually identical though found in different sections of the CFR. For the sake of 

convenience, the court will generally cite to the SSI regulations herein unless noted otherwise. 

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sequential evaluation. AR at 16-17. At Step One, the claimant bears the burden of showing she has 

not been engaged in “substantial gainful activity” since the alleged date the claimant became 

disabled. See 20 C.F.R. § 416.920(b). If the claimant has worked and the work is found to be 

substantial gainful activity, the claimant will be found not disabled. See id. The ALJ found that 

Plaintiff had not engaged in substantial gainful activity since the alleged onset date. AR at 18. At 

Step Two, the claimant bears the burden of showing that she has a medically severe impairment or 

combination of impairments. See 20 C.F.R. § 416.920(a)(4)(ii), (c). “An impairment is not severe 

if it is merely ‘a slight abnormality (or combination of slight abnormalities) that has no more than 

a minimal effect on the ability to do basic work activities.’” Webb v. Barnhart, 433 F.3d 683, 686 

(9th Cir. 2005) (quoting S.S.R. No. 96–3(p) (1996)). The ALJ found that Plaintiff suffered from 

the following severe impairments: PTSD, major depressive disorder, anxiety, obesity, breast 

cancer in remission. AR at 18. Additionally, the ALJ found that Plaintiff’s back disorder, atrial 

fibrillation, knee pain, and dyslexia were not severe impairments, while finding that Plaintiff’s 

bilateral carpel tunnel syndrome was not medically determined. Id. at 18-19. 

At Step Three, the ALJ compares the claimant’s impairments to the impairments listed in 

appendix 1 to subpart P of part 404. See 20 C.F.R. § 416.920(a)(4)(iii), (d). The claimant bears the 

burden of showing her impairments meet or equal an impairment in the listing. Id. If the claimant 

is successful, a disability is presumed and benefits are awarded. Id. If the claimant is unsuccessful, 

the ALJ assesses the claimant’s residual functional capacity (“RFC”) and proceeds to Step Four. 

See id. § 416.920(a)(4)(iv), (e). Here, the ALJ found that Plaintiff did not have an impairment or 

combination of impairments that met or medically equaled the severity of any of the listed 

impairments. AR at 19-20. Next, the ALJ determined that Plaintiff retained the RFC to perform 

work at the medium exertional level, but limited to simple, routine, and repetitive tasks, and with 

only occasional decision-making, changes in the work setting, and interacting with co-workers and 

the public. Id. at 20-27.

At Step Four, the ALJ determined that Plaintiff is not capable of performing her past 

relevant work as a home attendant or as an office assistant. Id. at 27. Lastly, at Step Five, the ALJ 

concluded that based on the RFC, Plaintiff’s age, education, and work experience, that there are 

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jobs that exist in significant numbers in which Plaintiff can still perform, such as hand packer, 

assembler, and machine feeder. Id. at 27-28. Accordingly, the ALJ concluded that Plaintiff had not 

been under a disability, as defined in the Social Security Act, from September 8, 2014 through the

date of the issuance of the ALJ’s decision, December 26, 2017. Id. at 28-29.

ISSUESS PRESENTED

Plaintiff presents several related issues for review. See Pl.’s Mot. (dkt. 24) at 5. First, 

Plaintiff contends that the ALJ erred by incorrectly evaluating and weighing the medical opinion 

evidence. Id. at 8-12. Plaintiff then argues that as a result of the ALJ’s errors in evaluating the 

medical opinion evidence, the ALJ erred in several regards at Step-2, including the ALJ’s failure 

to consider one of Plaintiff’s mental impairments at all. Id. at 12-13. Plaintiff also argues that the 

ALJ erred at Step-3 by failing to discuss the effects of Plaintiff’s five severe impairments, 

singularly or in combination, when evaluating their severity for equivalency with a listed 

impairment. Id. at 13-14. Next, Plaintiff contends that the ALJ erred in evaluating her credibility 

because the ALJ failed to identify which testimony was accepted and which testimony was 

rejected. Id. at 14-15. Based on the argument that the ALJ erred in evaluating the medical opinion 

evidence, Plaintiff also contends that the RFC finding was not based on substantial evidence, and 

that the ALJ failed to provide specific reasoning for every aspect of the RFC. Id. at 15-16. Lastly, 

Plaintiff contends that because the hypothetical questions posed to the vocational expert (“VE”) 

were based on an unsupported RFC, rendering much of the VE testimony unreliable, the

dependent finding of non-disability was flawed and that this court should remand for payment of 

benefits or for further proceedings as appropriate. Id. at 16-17. 

DISCUSSION

The ALJ formulated a RFC for medium work that would be limited to simple, routine, and 

repetitive tasks, and involving occasional decision-making, changes in the work setting, and 

interacting with co-workers and the public. Working backwards from that point, the ALJ then 

ventured to justify the RFC by giving “substantial weight to the August 2015 opinion of 

consultative psychological examiner Dr. Aparna Dixit, which is generally consistent with the 

claimant’s residual functioning capacity.” Id. at 25. Likewise, “substantial weight” was given to 

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Dr. Paradowski’s 2016 opinion that cleared Plaintiff for weight loss surgery because “it suggests a 

significant capacity for long-term decision making that is at odds with the claimant’s allegations.” 

Id. The ALJ gave limited weight to Dr. Kalich’s opinions because of the notion that it relied too 

heavily on Plaintiff’s reported symptoms and her responses to psychological testing instruments. 

Id. Likewise, the ALJ gave little weight to Dr. Wiebe’s 2017 assessment because “her conclusions 

rely heavily on the claimant’s reported symptoms . . . [and because] [s]uch complaints are not 

reflected elsewhere in the record.” Id. at 26. Little weight was also given to Dr. Savon’s opinion 

because, “[i]nsofar as Dr. Savon concedes that she is reliant upon [Drs. Wiebe and Kalich] in her 

assessment, I similarly accord her opinion little weight.” Id. Lastly, the ALJ gave little weight to 

Therapist Crowley’s assessment because “the record does not include accompanying treatment 

notes in support of her assessment,” and because the assessment is “at odds with” other isolated 

notations elsewhere in the record that indicate things such as, “improving mood,” “apartment 

hunting,” and “depression better.” Id. at 26. Accordingly, the ALJ concluded that Plaintiff was 

able to seek work as an assembler, a machine feeder, or hand packer. Id. at 28. 

Medical opinions are “distinguished by three types of physicians: (1) those who treat the 

claimant (treating physicians); (2) those who examine but do not treat the claimant (examining 

physicians); and (3) those who neither examine nor treat the claimant (nonexamining physicians).” 

Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). The medical opinion of a claimant’s treating 

provider is given “controlling weight” so long as it “is well-supported by medically acceptable 

clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial 

evidence in [the claimant’s] case record.” 20 C.F.R. § 404.1527(c)(2); see also Revels v. Berryhill, 

874 F.3d 648, 654 (9th Cir. 2017). In cases where a treating doctor’s opinion is not controlling, the 

opinion is weighted according to factors such as the nature and extent of the treatment 

relationship, as well as the consistency of the opinion with the record. 20 C.F.R. § 404.1527(c)(2)-

(6); Revels, 874 F.3d at 654. 

“To reject [the] uncontradicted opinion of a treating or examining doctor, an ALJ must 

state clear and convincing reasons that are supported by substantial evidence.” Ryan v. Comm’r of 

Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008) (alteration in original) (quoting Bayliss v. Barnhart, 

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427 F.3d 1211, 1216 (9th Cir. 2005)). “If a treating or examining doctor’s opinion is contradicted 

by another doctor’s opinion, an ALJ may only reject it by providing specific and legitimate 

reasons that are supported by substantial evidence.” Id. (quoting Bayliss, 427 F.3d at 1216); see 

also Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998) (“[The] reasons for rejecting a treating 

doctor’s credible opinion on disability are comparable to those required for rejecting a treating 

doctor’s medical opinion.”). “The ALJ can meet this burden by setting out a detailed and thorough 

summary of the facts and conflicting clinical evidence, stating his [or her] interpretation thereof, 

and making findings.” Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989) (quoting Cotton v. 

Bowen, 799 F.2d 1403, 1408 (9th Cir. 1986)). Further, “[t]he opinion of a nonexamining physician 

cannot by itself constitute substantial evidence that justifies the rejection of the opinion of either 

an examining physician or a treating physician.” Lester, 81 F.3d at 831 (9th Cir. 1995); see also 

Revels, 874 F.3d at 654-55. It should also be noted that greater weight is due to the “opinion of a 

specialist about medical issues related to his or her area of specialty.” 20 C.F.R. § 404.1527(c)(5);

see also Revels, 874 F.3d at 654. Lastly, where a Plaintiff’s condition progressively deteriorates, 

the most recent medical report is the most probative. See Young v. Heckler, 803 F.2d 963, 968 (9th 

Cir. 1986).

In addition to the medical opinions of doctors, an ALJ must also consider the opinions of 

medical providers who do not fall within the Social Security Administration’s definition of 

“acceptable medical sources.” See 20 C.F.R. § 404.1527(b), (f); see also Revels, 874 F.3d at 655. 

While those opinions are not automatically entitled to the same degree of deference, an ALJ may 

give less deference to such “other sources” only if the ALJ gives reasons germane to that witness. 

Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012); Revels, 874 F.3d at 654. The same factors 

used to evaluate the opinions of medical providers who are acceptable medical sources (e.g., the 

nature, length, and extent of the treatment relationship, consistency with the record, and the 

specialization involved) are used to evaluate the opinions of those who fall outside that category.

See 20 C.F.R. §§ 404.1527(f), 404.1527(c)(2)-(6); Revels, 874 F.3d at 654. Indeed, under some 

circumstances, the opinion of a treating provider who is not an acceptable medical source may be 

given greater weight than even the opinion of an “acceptable medical source” when that provider 

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“has seen the individual more often than the treating source, has provided better supporting 

evidence and a better explanation for the opinion, and the opinion is more consistent with the 

evidence as a whole.” 20 C.F.R. § 404.1527(f)(1); see also Revels, 874 F.3d at 655. 

Here, Defendant’s arguments largely echo the ALJ’s stated justifications for why the 

above-described medical evidence was rejected. See Def.’s Mot. (dkt. 30) at 16-22. For example, 

Defendant notes that in August of 2015, a consultative examiner, Dr. Aparna Dixit, observed that 

Plaintiff’s mood was only mildly anxious during the evaluation; that she could read; that she had 

fair grooming; was able to follow a 3-step command; was able to perform simple tasks; that she 

might have mild difficulty in dealing with the public, but not so with co-workers and supervisors; 

and ultimately, that Plaintiff “could cooperate effectively with the public and co-workers on 

simple, routine tasks.” Id. at 16-17. Defendant then notes that shortly thereafter, in October of 

2015 and February of 2016, two non-examining state agency consultants reviewed Dr. Dixit’s 

report and rendered largely concurring opinions. Id. at 12. Defendant also points to Dr. 

Paradowski’s 2016 decision to clear Plaintiff for weight loss surgery, relying on it to argue the 

point that “Plaintiff was able to make an informed choice regarding surgery and was sufficiently 

disciplined to follow post-operative procedures.” Id. at 17.

Defendant then argues that the ALJ properly rejected the opinions of Dr. Kalich and Dr. 

Wiebe because they “appeared to be based on Plaintiff’s own self-reports,” and because their 

opinions were “inconsistent” with notations made elsewhere in the record, generally by treatment 

providers for physical impairments, and of questionable relevance, such as Plaintiff’s ability to 

attend medical appointments, groom herself, or to obtain simple meals. Id. at 19-20; see also AR at 

25-26. As to Dr. Savon’s opinion, Defendant justifies the rejection of the opinion of Plaintiff’s 

treating psychiatrist by rephrasing a particular statement from Dr. Savon’s letter to the ALJ. 

Defendant contends that Dr. Savon’s opinion was due to be given no weight because Dr. Savon 

“admittedly relied on the opinions of Drs. Wiebe and Kalich,” which the ALJ had already rejected. 

See Def.’s Mot. (dkt. 30) at 21; see also AR at 26 (where the ALJ explains Dr. Savon “concedes” 

that her opinion was “reliant upon them”). Lastly, Defendant justifies the ALJ’s rejection of 

Therapist Crowley’s opinion because “there were not treatment notes or clinical findings from Ms. 

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Crowley that could support the significant limitations she endorsed.” Id. at 21. The ALJ’s stated 

reason for rejecting Therapist Crowley’s opinion was that “the record does not include 

accompanying treatment notes in support of her assessment.” AR at 26. However, the record did in 

fact include more than 60 pages of very detailed treatment notes that pertained to each of the 

weekly treatment sessions Plaintiff underwent between August of 2016 and January of 2018. See 

id. at 45-109. 

The court finds that these explanations and justifications fall short of the above-described 

standards. Initially, the court will note that this is a case where the record clearly shows a 

progressively deteriorating state of mental health. Born in 1971, Plaintiff experienced the abovedescribed history of trauma and abuse throughout her childhood. Nevertheless, she managed to 

function and maintain employment for much of her life. Then, in 2014, after losing her sister and 

mother to cancer, and after being diagnosed with cancer herself, Plaintiff’s mental health 

symptoms began to intensify. This deterioration continued until she became unable to work, and 

eventually became homeless for nearly two years beginning in June of 2015. Accordingly, the 

ALJ erred in relying so heavily on a consultative evaluation from August of 2015 (Dr. Dixit), in 

order to discount the subsequent opinions of two examining psychologists who performed more 

thorough evaluations in February of 2016 (Dr. Kalich) and April of 2017 (Dr. Wiebe), as well as 

the opinions of Plaintiff’s treating psychiatrist (Dr. Savon) and longtime therapist (Therapist 

Crowley), both of whom rendered their opinions in July of 2017, after a course of treatment. See

Young, 803 F.2d at 968 (in cases of progressively deteriorating conditions, the most recent medical 

report is the most probative). 

Putting aside the deterioration of Plaintiff’s condition, and the temporal problems with 

crediting Dr. Dixit’s 2015 opinion over more recent opinions, including those of Plaintiff’s 

treating physician and therapist, the ALJ’s stated justifications for how these opinions were 

weighed, as well as Defendant’s arguments in this court, are independently unpersuasive. First, 

Dr. Dixit did not venture to delve into Plaintiff’s history of trauma, and therefore her opinion 

seems less relevant than those of Dr. Kalich and Dr. Wiebe. Second, neither the ALJ, nor 

Defendant, have addressed the fact that Dr. Dixit expressly stated that due to Plaintiff’s anxiety 

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symptoms, she needed “counseling and psychiatric treatment for her psychiatric issues.” AR at 

765. Thus, Dr. Dixit’s functional opinions, rendered from a psychological standpoint, and to the 

effect that Plaintiff only had mild difficulties in dealing with the public, or that she could perform 

simple tasks, was in fact an admittedly incomplete assessment due to Dr. Dixit’s express caveat 

that Plaintiff had “psychiatric issues,” which needed “psychiatric treatment.” Plaintiff then sought 

and secured psychiatric treatment from Dr. Savon, who opined in 2017 that Plaintiff “struggles 

with psychotic symptoms which are incompatible with successful employment . . . [and] that Ms. 

Sabr requires a period of removal from the work force in order to address her psychological issues 

through psychotherapy as well as to optimize her psychotropic medications.” Id. at 1406. Thus, it 

was error to formulate a RFC that was largely based on Dr. Dixit’s incomplete psychological 

opinion as to Plaintiff’s functional limitation, especially in light of Dr. Dixit’s statement that 

Plaintiff required psychiatric treatment. The ALJ should have given the greatest weight to Dr. 

Savon’s opinion because of the fact that Dr. Savon was Plaintiff’s treating physician, and also 

because greater weight is due to the “opinion of a specialist about medical issues related to his or 

her area of specialty.” 20 C.F.R. § 404.1527(c)(5); Revels, 874 F.3d at 654.

Regarding the ALJ’s rejection of the opinions of Dr. Kalich and Dr. Wiebe for the stated 

reason that they “rely heavily” on Plaintiff’s “reported symptoms and responses to self-assessed 

inventories” (AR at 25-26), Defendant argues that those opinions “were inconsistent with the 

evidence in the record . . . and appeared to be based on Plaintiff’s own self-reports.” Def.’s Mot. 

(dkt. 30) at 19. First, Defendant’s suggestion that these opinions were inconsistent with other 

evidence in record is unpersuasive because Defendant generally only points to isolated notations 

here and there to the effect that Plaintiff had good grooming on one occasion, was cooperative on 

another occasion, or appeared to have a “normal” mental status during a physical examination. 

The court finds that there are no such inconsistencies. Second, it was error to for the ALJ to 

discount the findings, diagnoses, and opinions of Dr. Kalich and Dr. Wiebe because of any notion 

that they “rely heavily on Claimant’s reported symptoms.” In addition to gathering a detailed 

social history for Plaintiff and administering diagnostic tools for the measurement of trauma and 

depression symptoms, Dr. Kalich also made a series of clinical observations as to Plaintiff’s 

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psychomotor agitations and her need to avoid eye contact. Likewise, in addition to records review 

and a clinical evaluation, Dr. Wiebe administered no less than 11 different diagnostic tests in an 

effort to “determine her current cognitive and emotional functioning.” See AR at 878. Thus, the 

ALJ erred in rejecting these opinions in this fashion, because it is well established that psychiatric

or psychological evaluations based on the patient’s self-reporting may not be automatically 

disregarded because these “[d]iagnoses will always depend in part on the patient’s self-report, as 

well as on the clinician’s observations of the patient . . . such is the nature of psychiatry.” Buck v. 

Berryhill, 869 F.3d 1040, 1049 (9th Cir. 2017).

Additionally, as the ALJ suggested, Defendant now argues that Dr. Savon’s opinion was 

due to be given “little weight” because she “admittedly relied on the opinions from Drs. Wiebe 

and Kalich,” and therefore, “Dr. Savon’s opinion merited little weight for the same reasons.” See

Def.’s Mot. (dkt. 30) at 21; see also AR at 26. Defendant’s argument is based on a flawed and 

incorrect premise. When Dr. Savon opined that Plaintiff’s psychotic symptoms are “incompatible 

with successful employment,” and that Plaintiff requires a period of removal from the workforce 

such as to optimize her psychotropic medications, these opinions did not rely on the opinions of 

Drs. Kalich and Wiebe. The record leaves little room to doubt that Dr. Savon’s opinions were 

rendered based on her own relationship with Plaintiff as her treating psychiatrist. In the course of 

explaining her opinion, Dr. Savon also related that she had relied on the evaluations performed by 

Drs. Kalich and Wiebe “in order to expand on [her] preliminary view of Ms. Sabr’s functioning,” 

which is not the same as saying that Dr. Savon’s psychiatric opinion about her own patient was 

only based on two previous psychological evaluations performed by others. Accordingly, the ALJ 

erred in giving Dr. Savon’s opinions “little weight” due to the incorrect notion that Dr. Savon was 

merely parroting Drs. Kalich and Wiebe. 

Lastly, to reject the opinion of Therapist Crowley, the ALJ was required to give reasons 

that are germane to that witness. Instead, the ALJ incorrectly stated that “the record does not 

include treatment notes in support of her assessment . . . [and] the assessment is at odds with 

contemporaneous treatment records documenting unremarkable mental status . . .” AR at 26. 

However, as noted above, the record contains more than 60 pages of detailed notes documenting 

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Plaintiff’s ongoing therapy with Ms. Crowley from August of 2016 until January of 2018. See id. 

at 45-109. As to the “records documenting unremarkable mental status,” the ALJ again points to 

isolated snippets from elsewhere in the record where it would be noted that Plaintiff was 

“apartment hunting,” or that merely state “depression better,” or “anxiety decreased.” Id. at 26. 

Because these explanations are based on the incorrect statement that the record does not contain 

Therapist Crowley’s treatment notes, or on logical fallacies or non sequiturs (such as the fact that 

Plaintiff had good grooming or that she may have searched for an apartment), the court finds that 

the ALJ erred in rejecting Therapist Crowley’s opinion while failing to provide reasons that would 

be germane to that witness. 

In the end, the ALJ failed to provide any specific or legitimate reasons for rejecting the 

opinions of Drs. Kalich, Wiebe, and Savon. Likewise, the ALJ failed to provide any germane 

reasoning for rejecting Therapist Crowley’s opinion. It is not technically necessary for the court to 

determine whether or not Dr. Savon’s 2017 psychiatric opinion was ‘contradicted’ by Dr. Dixit’s 

2015 psychological opinion, because the ALJ’s explanation for rejecting Dr. Savon’s opinion does 

not even rise to the level of specific and legitimate reasons – let alone clear and convincing 

reasons. Nevertheless, as discussed above, the record in this case reflects a worsening of Plaintiff’s 

condition between 2015 and 2017, and further, Dr. Dixit’s psychological evaluation was rendered 

with the specific caveat that Plaintiff would need psychiatric treatment for her psychiatric 

symptoms, which were beyond Dr. Dixit’s expertise. Thus, Dr. Savon’s 2017 psychiatric opinion 

is uncontroverted. See Ferrando v. Comm’r of SSA, 449 F. App’x 610, 611 (9th Cir. 2011) (“The 

record demonstrates that the opinions of the examining psychologist relied on by the ALJ and the 

treating psychiatrist rejected by the ALJ do not conflict because Ferrando’s medical records 

indicate that his mental impairments worsened between the examining psychologist’s evaluation 

in April 2005 and the treating psychiatrist’s evaluation in February 2007.”).

The above discussed errors led to the formulation of a RFC that was inconsistent with the 

body of medical evidence pertaining to Plaintiff’s mental health, and consequently an erroneous 

finding at Step 5 that Plaintiff can work as an assembler, a hand packer, or a machine feeder. At 

the hearing before the ALJ, the VE testified that if Plaintiff were off task 20% of the time due to 

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her symptoms, “that would preclude all work.” See AR at 138. In February of 2016, Dr. Kalich 

assessed Plaintiff as struggling with intermittently severe deficits in concentration, attention, and

activities of daily living, and opined that Plaintiff would be unlikely to complete a normal 

workday without symptoms-based interferences. In April of 2017, Dr. Wiebe opined that the 

combination of Plaintiff’s psychiatric, cognitive, and personality functioning impairments would 

make it difficult for her to function effectively and reliably in a full-time job for “likely two 

years.” In July of 2017, Plaintiff’s treating psychiatrist, Dr. Savon, opined that Plaintiff still 

struggled with psychotic symptoms that “are incompatible with successful employment,” and that 

Plaintiff needed to be removed from the workforce “in order to address her psychological issues 

through psychotherapy as well as to optimize her psychotropic medications.” Also in July of 2017, 

and after a lengthy treatment relationship, Therapist Crowley opined that Plaintiff’s impairments

would interfere with concentration and pace up to 40% of the time during working hours, and that 

Plaintiff could be expected to be absent from work due to her symptoms for more than 4 days per 

month. Had this improperly rejected evidence been credited, the ALJ would have been required to 

find Plaintiff disabled at Step Five based on the VE’s testimony. Accordingly, having been 

improperly rejected, the opinions rendered by Drs. Kalich, Wiebe, and Savon, as well as Therapist 

Crowley, will be credited as true for the reasons discussed below.

NATURE OF REMAND

Having found that the ALJ committed error by not finding Plaintiff disabled at Step Five, 

the court must now decide if remand for further proceedings is appropriate. It is well established 

that “[i]f additional proceedings can remedy defects in the original administrative proceeding, a 

social security case should be remanded [for further proceedings].” Lewin v. Schweiker, 654 F.2d 

631, 635 (9th Cir. 1981). It is equally well established that courts are empowered to affirm, 

modify, or reverse a decision by the Commissioner, “with or without remanding the cause for a 

rehearing.” 42 U.S.C. § 405(g); see also Garrison v. Colvin, 759 F.3d 995, 1019 (9th Cir. 2014). 

Generally, remand with instructions to award benefits has been considered when it is clear from 

the record that a claimant is entitled to benefits. Id.

The credit-as-true doctrine was announced in Varney v. Sec’y of Health & Human Servs., 

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859 F.2d 1396 (9th Cir. 1988) (“Varney II”), where it was held that when “there are no 

outstanding issues that must be resolved before a proper disability determination can be made, and 

where it is clear from the administrative record that the ALJ would be required to award benefits if 

the claimant’s excess pain testimony were credited, we will not remand solely to allow the ALJ to 

make specific findings regarding that testimony . . . [instead] we will . . . take that testimony to be 

established as true.” Id. at 1401. The doctrine promotes fairness and efficiency, given that remand 

for further proceedings can unduly delay income for those unable to work and yet entitled to

benefits. Id. at 1398.

The credit-as-true rule has been held to also apply to medical opinion evidence, in addition 

to claimant testimony. Hammock v. Bowen, 879 F.2d 498, 503 (9th Cir. 1989). The standard for 

applying the rule to either is embodied in a three-part test, “each part of which must be satisfied in 

order for a court to remand to an ALJ with instructions to calculate and award benefits: (1) the 

record has been fully developed and further administrative proceedings would serve no useful 

purpose; (2) the ALJ has failed to provide legally sufficient reasons for rejecting evidence, 

whether claimant testimony or medical opinion; and (3) if the improperly discredited evidence 

were credited as true, the ALJ would be required to find the claimant disabled on remand.” 

Garrison, 759 F.3d at 1020.

It should also be noted that “the required analysis centers on what the record evidence 

shows about the existence or non-existence of a disability.” Strauss v. Comm’r of the Soc. Sec. 

Admin., 635 F.3d 1135, 1138 (9th Cir. 2011). Thus, even though all conditions of the credit-astrue rule might be satisfied, remand for further proceedings would still be appropriate if an 

evaluation of the record as a whole creates serious doubt that a claimant is, in fact, disabled. 

Garrison, 759 F.3d at 1021. On the other hand, it would be an abuse of discretion for a district 

court to remand a case for further proceedings where the credit-as-true rule is satisfied and the 

record affords no reason to believe that the claimant is not, in fact, disabled. Id.

The first part of the credit-as-true test requires the court to determine whether the record 

has been fully developed and if further administrative proceedings would serve any useful 

purpose. As discussed above, two examining psychologists, as well as Plaintiff’s treating 

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psychiatrist, and her therapist, all essentially concurred that Plaintiff does not enjoy the requisite 

mental and emotional health to be able to function in any capacity in the employment setting for 

the time being. The record leaves little room, and gives no reason, to doubt these opinions, given 

that Plaintiff was the frequent victim of assault and abuse during the formative years of her 

personality, essentially having grown up in a state of trauma, enduring the murder by burning of 

her brother, the deaths of her loved ones by cancer, and her own battle with cancer while enduring 

long periods of homelessness. The court, therefore, finds that the record has been fully developed 

and that further administrative proceedings would serve no useful purpose. The court also finds, as 

discussed above, that the ALJ has failed to provide legally sufficient reasons for rejecting the 

work-preclusive opinions of Drs. Kalich, Wiebe, and Savon, as well as Therapist Crowley, and 

that if this improperly discredited evidence were credited as true, the ALJ would be required to 

find Plaintiff disabled at Step Five on remand. Lastly, upon evaluation of the record as a whole, 

the court finds nothing that could give rise to any serious doubt that a Plaintiff is, in fact, disabled. 

See Garrison, 759 F.3d at 1020-21. Accordingly, this matter is remanded to the Commissioner for 

calculation and award of appropriate benefits.

CONCLUSION

For the reasons stated above, Plaintiff’s Motion for Summary Judgment (dkt. 24) is 

GRANTED, and Defendant’s Motion for Summary Judgment (dkt. 30) is DENIED. The ALJ’s 

finding of non-disability is REVERSED and this case is REMANDED for the calculation and 

award of appropriate benefits.

IT IS SO ORDERED.

Dated: March 16, 2020

ROBERT M. ILLMAN

United States Magistrate Judge

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