### In the



# United States Court of Appeals

For the Seventh Circuit

____________________

No. 14

‐ 2303

K EVIN V OIGT

, Plaintiff

‐ Appellant

,

v.

C AROLYN W. C OLVIN

, Acting Commissioner of Social

Security,

Defendant

‐ Appellee

.

____________________

Appeal from the United States District Court for the

Western District of Wisconsin.

No. 3:13

‐ cv

‐ 00170

‐ bbc

— Barbara B. Crabb

, Judge

.

____________________

A RGUED M ARCH 3, 2015

— D ECIDED M ARCH 26, 2015

____________________

Before P OSNER

, K ANNE

, and T INDER

, Circuit Judges

.

P OSNER

, Circuit Judge

. The plaintiff had applied to the So

‐

cial Security Commission in 2009 (when he was 40 years old)

for benefits to which he claimed to be entitled by reason of

being disabled from gainful employment as a result of psy

‐

chiatric disorders (primarily depression and bipolar disor

‐ der), chronic back and hip pain, and an anal fissure (cut or

tear). The administrative law judge to whom his application2 No. 14

‐ 2303

was referred (John H. Pleuss) denied his claim on the

ground that he’s capable of performing unskilled sedentary

work and is therefore not totally disabled. The district court,

to which the applicant turned, upheld the denial of benefits,

precipitating this appeal.

Voigt had been trained as a machinist, and until 2002 (the

claimed onset date of his total disability) had worked inter

‐ mittently as a machinist and as an assembly

‐ line worker,

jobs that the administrative law judge agreed he was no

longer capable of doing, because of his physical and mental

problems. Between 2001 (possibly earlier) and 2008, Voigt

had taken prescription antidepressant medications such as

Paxil, but he quit taking them because of their adverse side

effects.

In the fall of 2009, having abandoned the antidepressant

medications, he sought the help of “crisis workers” at a men

‐

tal health clinic. The intake report of his visit to the clinic

summarizes his confused and rather wild description of his

mental state. In a subsequent visit to the clinic he told the

crisis worker who interviewed him that he thought it might

be good for him to be in prison, where he might (he

thought—we know not on what basis) get some additional

experience as a machinist and earn money that he could

save. Yet he also told that same worker in a later interview

that his goal was to own a restaurant, which was and is both

unrealistic given his mental condition and irrelevant to im

‐ proving his skills as a machinist.

He was examined at the clinic by “an advanced practice

psychiatric nurse” (see APNA, “What Is an Advanced Prac

‐

tice Psychiatric Nurse?” www.apna.org/i4a/pages/index.cfm

?pageid=3866#1, visited March 15, 2015, as were the otherNo. 14

‐ 2303 3

websites cited in this opinion). The nurse, Debra Day, diag

‐

nosed him as suffering from depression (no surprise), but

two years later (after his eighth examination by her), she

submitted a report to the Social Security Administration in

which she described Voigt as bipolar (oddly she did not

mention depression, though of course depression is an as

‐

pect of bipolar disorder, which used to be called “manic de

‐ pression”) and opined that his mental illnesses would cause

him to miss work more than four days each month—which

the vocational experts on whom the administrative law

judges rely testify disqualifies a person from gainful em

‐ ployment. Garcia v. Colvin

, 741 F.3d 758, 760 (7th Cir. 2013);

Pepper v. Colvin

, 712 F.3d 351, 361 (7th Cir. 2013); Treichler v.

Commissioner of Social Security Administration

, 775 F.3d 1090,

1096 (9th Cir. 2014); Ghanim v. Colvin

, 763 F.3d 1154, 1159

(9th Cir. 2014). To qualify for gainful employment one must

be able to work on a “sustained basis,” defined as eight

hours a day five days a week, see 20 C.F.R. §§ 404.1512(a),

416.912(a); Rollins v. Massanari

, 261 F.3d 853, 859 (9th Cir.

2001); SSR 96

‐ 8p, “Purpose,” ¶ 1, and to be incapable of gain

‐

ful employment is to be totally disabled within the meaning

of the Social Security Act. 42 U.S.C. §§ 423(d)(1)(A),

1382c(a)(3)(A). To miss four workdays a month would re

‐

duce one’s average workweek from five to four days, which

would not constitute working on a sustained basis as de

‐

fined by the Commission.

Day’s report listed a total of 13 symptoms exhibited by

Voigt of poor psychological and social functioning, ranging

from paranoia to “oddities of thought, perception, speech or

behavior.” She deemed him “unable to meet competitive

standards” (requirements for gainful employment) of punc

‐ tuality, of “sustain[ing] an ordinary routine without special4 No. 14

‐ 2303

supervision,” of “work[ing] in coordination with or proximi

‐

ty to others without being unduly distracted,” and of being

able to “complete a normal workday,” “accept instructions,”

“get along with coworkers,” and “deal with normal work

stress.” (We omit five other requirements of gainful em

‐ ployment that Nurse Day deemed Voigt unable to satisfy.)

At her first examination of him, in October 2009, Day

gave him a GAF score of 50. “GAF” stands for Global As

‐

sessment of Functioning, and a score of between 41 and 50

signifies serious psychiatric illness. The American Psychiat

‐

ric Association has since eliminated the GAF scale from its

Diagnostic and Statistical Manual of Mental Disorders as being

unreliable—but this occurred after the administrative law

judge issued his decision, which was in January 2012. (The

length of time it’s taken the case to get to us is lamentable.)

Day prescribed an antidepressant medicine called Cym

‐

balta. Voigt reported improvement in his mental states and

absence of the side effects that he’d experienced with the an

‐ tidepressant medications that he had been taking previously.

On the basis of that report, Day raised Voigt’s GAF score to

55. That brought it into the range of “moderate symptoms”

or “moderate difficulty in social, occupational, or school

functioning (e.g., few friends, conflicts with peers or co

‐ workers).” He continued making progress, and after examin

‐ ing him again, Day raised his GAF score to 65, signifying

“mild symptoms” and “generally functioning pretty well.”

During two of their sessions she gave him a score of 70. GAF

scores bounce around a great deal, however, because they

depend on how the patient happens to feel the day he’s ex

‐

amined. See Punzio v. Astrue

, 630 F.3d 704, 710 (7th Cir.

2011); I. H. Monrad Aas, “Guidelines for Rating Global As

‐No. 14

‐ 2303 5

sessment of Functioning (GAF),” Annals of General Psychiatry

10:2, pp. 4–5 (2011). Overall Voigt’s GAF score rose from 50

at his first examination by her to 65 at the last one, consistent

with her treatment notes, which state that Voigt reported

that the medication was working, enabling him to control his

irritation and other negative emotions better. It’s not surpris

‐ ing that his mood improved over the course of his visits, as

he got to know her better and the therapy she prescribed

took effect. His GAF scores were computed anew at each vis

‐

it; what they would have been had they been computed

elsewhere by a practitioner whom he was being examined

by for the first time is unknown. The critical question, how

‐

ever, was whether the medication that Day prescribed so

improved his mental health as to enable him to qualify for a

full

‐ time job. She thought not.

Meanwhile he’d been visiting another clinic because of

physical distress that included the anal fissure, the back and

hip pain (he described the hip pain as “sharp” and “stab

‐ bing”), and hemorrhoids (possibly related to the fissure). An

osteopath designated by the Social Security Commission to

examine Voigt after he applied for disability benefits report

‐

ed that he suffers from lower back pain and trochanteric

bursitis (an inflammation near the hip that causes pain in the

hip, see Cleveland Clinic, “Trochanteric Bursitis,”

http://my.clevelandclinic.org/health/diseases_conditions/hic

_Bursitis/hic_Trochanteric_Bursitis). The osteopath also ob

‐

served that Voigt walked with a “slow and painful gait.”

Another physician and a psychologist examined Voigt’s

medical records and concluded that despite his physical and

psychiatric problems he was capable of performing un

‐

skilled sedentary work. Neither examined him, however.6 No. 14

‐ 2303

After many months of gradual improvement, Voigt com

‐ plained to Day, and to another licensed professional counse

‐

lor as well, of a deterioration in his mental condition. He re

‐ ported “raging in the parking lot” of the mental health clinic

and becoming “very angry and upset” at a Super Bowl

game. Day left Voigt’s GAF score at 65, but the other counse

‐

lor reduced it to 51 to 60. (The administrative law judge

erred in stating that Voigt’s lowest GAF score was 55.) This

discrepancy in their scores is consistent with the probability

noted earlier in this opinion that one’s GAF score will rise as

one builds up a relationship with the practitioner who is

scoring him.

Day believed that Voigt’s deterioration was attributable

in part to his drinking, taking Vicodin (a pain

‐ relieving

drug), and smoking marijuana, and that these behaviors

were retarding his progress in therapy. But while they were

a big concern, she didn’t think they played the primary role

in his problems. (This is important, since if Voigt’s deteriora

‐

tion were attributable solely to drug and alcohol abuse he

might well be barred from obtaining benefits no matter how

serious his disability. See 42 U.S.C. § 423(d)(2)(C); Kangail v.

Barnhart

, 454 F.3d 627, 628 (7th Cir. 2006).)

The administrative law judge went far outside the record

when he said that if Voigt were as psychologically afflicted

as Day thought, he “would need to be institutionalized

and/or have frequent inpatient treatment”—a medical con

‐ jecture that the administrative law judge was not competent

to make, see Browning v. Colvin

, 766 F.3d 702, 705 (7th Cir.

2014); Goins v. Colvin

, 764 F.3d 677, 680 (7th Cir. 2014); Pate

‐

Fires v. Astrue

, 564 F.3d 935, 946–47 (8th Cir. 2009), and that

was implausible to boot. The institutionalization of the men

‐No. 14

‐ 2303 7

tally ill is generally reserved for persons who are suicidal,

otherwise violent, demented, or (for whatever reason) inca

‐ pable of taking even elementary care of themselves. Voigt is

none of these things, and so cannot be institutionalized

against his will: “a State cannot constitutionally confine

[against his will] without more a nondangerous individual

who is capable of surviving safely in freedom by himself or

with the help of willing and responsible family members or

friends.” O’Connor v. Donaldson

, 422 U.S. 563, 576 (1975). But

it doesn’t follow, as the administrative law judge may have

thought, that Voigt is therefore capable of gainful employ

‐

ment.

The judge remarked that because Voigt’s “parents appar

‐ ently pay his rent and expenses

..., these facts raise a ques

‐

tion as to whether [his] continuing unemployment is actual

‐ ly due to medical impairments.” No, it doesn’t, because if he

can’t work, he has to be supported by someone or by some

agency. More to the point is the administrative law judge’s

remark that Voigt had had only sporadic employment in the

decade preceding the claimed onset of his disability in 2002.

He may have been a malingerer, mooching off his parents,

or he may have been more psychologically disturbed than

anyone realized. In any event his parents may be continuing

to support him because whatever his physical and mental

state in the decade ending in 2002 he may now no longer be

capable of working.

The administrative law judge also contradicted himself

about whether Voigt is currently a malingerer when later in

his opinion he remarked that Voigt had “made statements

during treatment suggesting he actually is eager to work,

but is unable to find work, which suggests that the claimant8 No. 14

‐ 2303

is not unemployed due to disability.” Actually those state

‐

ments were consistent with his wanting to lead a normal life

yet being unable to land a job because he’s disabled from

gainful employment by a combination of physical and men

‐

tal problems that a prospective employer would quickly no

‐

tice. Voigt acknowledged that having been unemployed for

such a long time makes it harder for him to get a job, but

that’s not inconsistent with his being disabled. A disabled

person may want to work, may seek work, and in some cas

‐

es may land work. We’ve noted cases in which although the

claimant is not only working but also “earning a decent

wage, he really is permanently disabled from engaging in

gainful activity. Maybe his boss feels desperately sorry for

him and is retaining him on the payroll even though he is

incapable of working. That act of charity ought not be pun

‐

ished by denying the employee benefits and thus placing

pressure on the employer to retain an unproductive employ

‐

ee indefinitely. Maybe a seriously disabled worker is able to

work only by dint of his extraordinary determination and

the extraordinary assistance extended to him by kindly fel

‐

low workers.” Jones v. Shalala

, 21 F.3d 191, 192 (7th Cir. 1994)

(citations omitted).

The only other witness at the hearing was a vocational

expert, who testified on the basis of what the administrative

law judge found that Voigt could and could not do that

while he could no longer work as a machinist he could do

simple sedentary work such as that of an office assistant

(whatever that means), security guard (very doubtful—a se

‐ curity guard with significant mental health problems is like

‐ ly to be a danger to himself and others), an assembler, or a

packager. The vocational expert said that there are 23,000

such jobs in Wisconsin (where Voigt lives), but did not ex

‐No. 14

‐ 2303 9

plain where he’d gotten that figure. He added that anyone

who would miss work two or more days per month (not just

three or more) more than occasionally would not qualify for

gainful employment.

Although concluding that Voigt was not totally dis

‐

abled, the administrative law judge characterized Voigt’s

trochanteric bursitis, fissure, depression, and bipolar disor

‐

der as severe, while discounting his back pain on two

grounds. One was that “he ha[d] not taken any narcotic

based pain

‐ relieving medications.” He had, however, taken

Vicodin (albeit illegally), which though an opiate rather than

a narcotic is a powerful pain reliever. The other ground was

Voigt’s failure to undergo “intensive treatment[,] like injec

‐

tions, which would be expected [to be prescribed for] a per

‐

son experiencing disabling pain.” Injecting steroids or other

drugs is sometimes suggested for treating back pain, see

Web MD, Back Pain Health Center, “Injections for Back Pain

Relief,” www.webmd.com/back

‐ pain/guide/back

‐ pain

‐ injec

tion

‐ treatments, but the administrative law judge offered no

reason for thinking that it would have been appropriate for

Voigt. Nor did he note the natural reluctance of a person

with psychiatric problems (perhaps of any person) to take

powerful pain medications, as they can have serious side ef

‐

fects if not carefully used. A mentally ill person is more like

‐ ly to abuse opiates like Vicodin (see National Alliance on

Mental Illness, “Opiates and Mental Illness,” www2.nami.

org/Content/NavigationMenu/Hearts_and_Minds/Smoking_

Cessation/Opiate_Abuse_and_Mental_Illness.htm) than a

healthy person. In addition, opiates can increase symptoms

of bipolar disorder. See La Hacienda Treatment Center,

“Opiates,” www.lahacienda.com/resources/articles/opiates/;

cf. Beardsley v. Colvin

, 758 F.3d 834, 840 (7th Cir. 2014); Myles10 No. 14

‐ 2303

v. Astrue

, 582 F.3d 672, 677–78 (7th Cir. 2009); Craft v. Astrue

,

539 F.3d 668, 679 (7th Cir. 2008).

At the hearing Voigt described some of his psychological

symptoms but also emphasized health problems resulting

from his anal fissure, including bleeding, and poor bowel

control that requires him to spend 40 consecutive minutes on

the toilet about four times every month. The administrative

law judge discounted these problems by noting Voigt’s re

‐

fusal to undergo a colonoscopy between 2006 and 2008 and a

rectal examination in 2010, but failed to note that Voigt testi

‐

fied that he’d been told that he would have to have surgery

to repair the fissure and that he was fearful of having a co

‐ lonoscopy—a common fear, known as “colonoscopy jitters.”

See, e.g., Riverside, “Got the Colonoscopy Jitters?”

www.riversideonline.com/servic es/cancer/colon/colonoscop

y

‐jitters.cfm; cf. Beardsley v. Colvin

, supra

, 758 F.3d at 840;

Craft v. Astrue

, supra

, 539 F.3d at 679; Orn v. Astrue

, 495 F.3d

625, 638 (9th Cir. 2007).

The administrative law judge discounted Voigt’s mental

problems on the ground that they had been solved by his

taking Cymbalta. That was contrary to Day’s report, howev

‐

er, which said that his mental state continued to be dis

‐

turbed, and though it was exacerbated by his substance

abuse she did not consider that the primary cause of his ina

‐ bility to relate to people in a normal way. The administrative

law judge gave “very little weight” to Day’s report, howev

‐

er, on the ground that a mere nurse is not an “acceptable

medical source,” and that Day had seen Voigt on only a few

occasions and had given him a pretty high GAF score, and

further that as mentioned earlier “if the claimant were as

limited as indicated in [Day’s] opinion, the claimant wouldNo. 14

‐ 2303 11

need to be institutionalized and/or have frequent inpatient

treatment. These inconsistencies render the opinion less per

‐

suasive, and it is due very little weight.”

These were not adequate reasons for rejecting Day’s re

‐

port and therefore turning down Voigt’s application for dis

‐ ability benefits. As for Day’s not being an “acceptable medi

‐

cal source,” the administrative law judge failed to note that

“evidence from other sources,” including nurse practition

‐

ers, may be used to “show the severity of [the applicant’s]

impairment(s) and how it affects [his or her] ability to

work.” 20 C.F.R. §§ 404.1513(a), (d), (d)(1), 416.913(a), (d),

(d)(1); see also SSR 06

‐ 3p. As for the number of visits, Day

had examined Voigt eight times in two years and the admin

‐

istrative law judge did not say that the visits were too infre

‐

quent to have enabled Day to assess the trend (first up, then

down) in Voigt’s condition. Most questionable of all is the

judge’s statement that if Day’s description of Voigt’s symp

‐

toms were accurate he would have to be institutionalized or

hospitalized (if hospitalization is what the administrative

law judge meant by “inpatient treatment”). Cymbalta may

have enabled Voigt to keep out of mental or other hospitals;

the question is whether it enables him, despite acute difficul

‐

ties that Cymbalta has not dispelled in dealing with other

human beings, to obtain gainful employment.

The administrative law judge committed the further error

of thinking that how one uses his time at home is compelling

evidence of whether or not one is employable. See Beardsley

v. Colvin

, supra

, 758 F.3d at 838; Bjornson v. Astrue

, 671 F.3d

640, 647 (7th Cir. 2012); Garrison v. Colvin

, 759 F.3d 995, 1016

(9th Cir. 2014). Voigt apparently spends much of his time at

a computer conducting research on his medical problems12 No. 14

‐ 2303

and playing video games. The administrative law judge cit

‐

ed treatment notes, and testimony, that indicated that Voigt

is “able to persist at activities like online research,” and en

‐ joys “playing computer games—for hours.” But whether

Voigt’s online research or playing such games is inconsistent

with his having severe back pain would depend on the pre

‐

cise nature of the pain, how comfortable the chair he sits on

while using the computer is, and what his alternatives are—

he can’t spend all day standing or lying down even if sitting

is painful. These issues were not explored.

Nor did the administrative law judge explain his as

‐ sumption that doing limited online research or playing vid

‐

eo games online requires the same concentration as is re

‐ quired for full

‐ time employment. In Powers v. Apfel

, 207 F.3d

431, 435 (7th Cir. 2000), we expressed skepticism about an

administrative law judge’s assertion that “ability to watch

television for several hours indicates a long attention span.”

Playing a video game is less passive, hence more intellectu

‐ ally challenging, than watching television. But the adminis

‐

trative law judge did not consider the extent to which expe

‐

rience in playing video games would equip Voigt for any of

the jobs that he might otherwise be incapable of performing.

And finally the administrative law judge fully credited

the vocational expert’s testimony. He did this even though

the testimony did not explain the source of the expert’s esti

‐

mate of the number of jobs that Voigt could perform, and

even though the inclusion of “security guard” among those

jobs should have nudged the administrative law judge to

explore the expert’s basis for thinking that someone with

Voigt’s psychiatric problems would be able to perform such

a job without danger to himself and others. Nurse Day hadNo. 14

‐ 2303 13

noted Voigt’s “problems with irritability and [with his]

sometimes explosive behavior.” Among the people he

doesn’t get along with are police officers—which doesn’t

augur well for success as a security guard.

The administrative law judge said that “the vocational

expert’s testimony is consistent with the information con

‐

tained in the Dictionary of Occupational Titles,” but as we

and others have explained, the DOT does not contain infor

‐

mation on which to base an estimate of the number of avail

‐

able jobs of a particular kind. Browning v. Colvin

, supra

, 766

F.3d at 709; Herrmann v. Social Security Administration

, 772

F.3d 1110, 1113–14 (7th Cir. 2014); Brault v. Social Security

Administration

, Commissioner

, 683 F.3d 443, 446–47 (2d Cir.

2012) (per curiam); Guiton v. Colvin

, 546 Fed. App’x 137, 143–

45 (4th Cir. 2013) (concurring opinion); Coppernoll v. Astrue

,

2009 WL 1773132, at *8 (W.D. Wis. June 23, 2009); Jon C. Du

‐

bin, “Overcoming Gridlock: Campbell After a Quarter

‐ Century and Bureaucratically Rational Gap

‐ Filling in Mass

Justice Adjudication in the Social Security Administration’s

Disability Programs,” 62 Administrative L. Rev. 937, 964–71

(2010); Peter J. Lemoine, “Crisis of Confidence: The Inade

‐ quacies of Vocational Evidence Presented at Social Security

Disability Hearings (Part II),” Social Security Forum

, Sept.

2012, p. 1.

As we said in the Browning case, we “have no idea what

[is] the source or accuracy of the number of jobs that voca

‐

tional experts (including the one in this case, whose esti

‐

mates the administrative law judge accepted without com

‐

ment) claim the plaintiff could perform that exist in the

plaintiff’s area, the region, or the nation. There is no official

source of number of jobs for each job classification in the14 No. 14

‐ 2303

Dictionary of Occupational Titles

, and while there are unoffi

‐

cial estimates of jobs in some categories, the vocational ex

‐

perts do not in general, and the vocational expert in this case

did not, indicate what those data sources are or vouch for

their accuracy. And many of them estimate the number of

jobs of a type the applicant for benefits can perform by the

unacceptably crude method of dividing the number of jobs

in some large category (which may be the only available da

‐

ta) by the number of job classifications in the category, even

though there is no basis for assuming” that there is the same

number of jobs in each narrow category. 766 F.3d at 709

(emphasis added). There is no indication that the estimate of

the number of jobs that the applicant in this case could fill (if

the administrative law judge’s estimate of his capacity to

work is correct, as it may very well not have been) is any

more accurate than it was in Browning

.

The judgment of the district court is reversed and the

case remanded to that court with instructions to remand it to

the Social Security Administration for further proceedings

consistent with this opinion. We do not say that Voigt is in

fact totally disabled from gainful employment, however—

only that he’s entitled to a more careful analysis of his claim

by the Social Security Administration.