United States District Court, D. South Dakota, Western Division
MEMORANDUM OPINION AND ORDER
VERONICA L. DUFFY, United States Magistrate Judge
Claimant and Third-Party
Testimony at Administrative
Issues Raised by Ms. Seay in this
Disability Determination and the Five-Step
Whether the ALJ Erred by Finding Ms. Seay's Fibromyalgia
was not "Medically
Commissioner's Guidance for Evaluating
ALJ Did Not Find Ms. Seay's Fibromyalgia was a Medically
Determinable Impairment, but the ALJ Incorporated Limitations
from Fibromyalgia into the Physical
ALJ Did Not Err in Failing to Obtain Dr. Frost's
Whether the ALJ Erred by Assigning Considerable Weight to Dr.
Whether the ALJ Erred in Evaluating the Weight Given to the
Whether the ALJ Applied the Proper Standard to Determine the
Credibility of Ms. Seay and Her Mother's
Law Applicable to Credibility
Summary of Ms. Seay and her Mother's
Analysis of the ALJ's Credibility
Whether the ALJ Erred By Relying on Total Numbers of Jobs in
the United States at Step Five?...............116
Katrina Joy Seay, seeks judicial review of the
Commissioner's final decision denying her payment of
disability benefits under Title II and Title XVI of the
Social Security Act. Ms. Seay filed a complaint and has
requested the court to reverse the Commissioner's final
decision denying her disability benefits and to enter an
order awarding benefits. Alternatively, Ms. Seay requests the
court remand the matter to the Social Security Administration
for further hearing. The Commissioner asks this court to
affirm its decision. The matter is fully briefed and is ready
for decision. For the reasons more fully explained below, the
Commissioner's decision is reversed and remanded.
appeal of the Commissioner's final decision denying
benefits is properly before the district court pursuant to 42
U.S.C. § 405(g). This matter is before this magistrate
judge pursuant to the consent of the parties. See 28
U.S.C. § 636(c).
A. Procedural History
31, 2013, Seay applied for SSD benefits, alleging that she
had been disabled since October 16, 2012. AR236. On June 20,
2013, she applied for SSI. AR238.
filed a previous claim for SSI on February 25, 2011, which
was initially denied on July 21, 20ll. AR96, 109.
to hearing, she was sequentially represented by Kay Cox, TANF
Disability Advocate (AR120-21); Christine Gingras, a
non-attorney (AR122, 234); and Larry Plank, attorney
hearing was held in Rapid City on July 22, 2015. AR54.
Testifying were Katrina Seay, claimant; Robert Pelc, Ph.D.,
the ALJ's [Administrative Law Judge] medical expert;
Wilma Goehring, the claimant's mother; and Barry Brown,
vocational expert. JSMF 55. Seay was not represented. AR56.
J. Denney, ALJ, issued an unfavorable step five decision on
August 26, 2015. AR25-47. On September 6, 2016, the Appeals
Council denied the request for review. AR1. Ms. Seay
thereafter filed her appeal of the Commissioner's
decision with this court on October 20, 2016. Docket No. 1.
was born in 1983 in Oklahoma City. AR62, 511. She never knew
her father, and her mother was alcoholic, bipolar, and
addicted to gambling. AR511-12. She had three stepfathers by
age 16, and was first sexually abused by a stepfather at age
seven or eight. AR511. At age 15 she was abusing cocaine,
methamphetamine, marijuana, and alcohol, completed treatment,
and remained abstinent. Id.
lived in approximately seven foster homes, two residential
facilities, three detention facilities, and ran away multiple
times. AR511. She was a "cutter." AR668.
reported struggling with her classes in school. AR69. She
dropped out of school in the ninth grade due to pregnancy.
Id. She obtained her GED at Wichita Area Tech
College and stated that school was difficult for her. AR512.
gave birth to her first child at age 16 while in foster care,
and the child was taken by Child Protection Services. AR511.
She had another child at age 20, gave him up, and regretted
married Nicholas Seay in 2004 in Alabama; they separated in
October 2006. AR237, 239.
lost parental rights to her two youngest sons in 2010 in
South Dakota and exhausted her final appeal of the parental
termination order in 2011. AR511. She became pregnant with a
fifth child and moved to Kansas. Id. She had her
sixth child in January 2015. AR844.
time of hearing she was five feet, eight inches tall, and
weighed 325 pounds. AR62. She was right-handed. Id.
She was divorced and lived with her two children, ages three
and six months, in a rent-subsidized apartment in Belle
Fourche. AR62-63, 239. She received TANF and food stamps.
by Ms. Cox, TANF Disability Advocate, stated in her
disability report that she had worked discontinuously as a
cashier in a retail store, fabricator and packager in a meat
packing business, fuel attendant at a truck stop, and
refrigerator stacker in a retail business. AR281.
testified that she left her last job, as a "fabricator
and packager, " due to sexual harassment. AR65. Before
that she had a full-time job as a fuel attendant, but when
she "told the employer that I had medication that I
needed to take in order to keep staying working there, they
dropped me to part-time and dropped my benefits."
Id. When she was hired full-time in this job, Social
Services dropped all services. Id. When the employer
cut hours to part-time, resulting in loss of benefits, Seay
asked her employer to send a letter to Social Services
"so that I could provide for my daughter ... and they
refused to do that." AR66.
that she worked as a cashier. The ALJ asked, at hearing,
"Did that not work out?" Seay responded,
I have a lot of things that wind up being wrong in social
settings when I work....If something that happens while
I'm working triggers a PTSD [post-traumatic stress
disorder] issue from my past, whatever that traumatic thing
might have happened in my past, I get really anxious. I tense
up really bad. I feel almost claustrophobic like I can't
get out of the situation.... I want to run away and I want to
get away from it, but whenever you're in a work
environment, you can't tell your employer, oh, I'm
sorry, I'm having an anxiety attack, I need a break....
When I have said that in the past to an employer, they let me
say that a couple of times before they fire me.
asked about a job at Walmart from "June up to February
of 2010." AR67. The ALJ asked Seay why she left that
job. Seay testified:
The manager supervisor of my department who initially hired
me, understood my disabilities, understood that I was on
medication to keep working. He unfortunately did not put that
in the file and when he died suddenly which no one expected,
the management that took over said I'm sorry, we
don't have any leniency for you because nothing's in
your file that says you take medication or you're given
certain exception. And when that happened, they required me
to do other things outside the scope of the work that I had
been doing.... And it made my physical and emotional
disabilities worse than they were. I tried three different
positions in that store after that in the course of a few
weeks and none of those were working. I got pregnant with my
daughter.... I asked management if I could move to another
location in the store that wasn't lifting heavy boxes or
in a freezer situation because I was pregnant and they said
they didn't have anything available.
detailed work history is reported at ¶ 248-51. The
report shows that from 1999-2012, she was employed by PNS,
Inc. ($60.51), Burger King ($278.13), TB of America ($961.41
in 2000, $62 in 2001), McDonald's ($66.94), ITI Holdings
($30), King Soopers ($2569.83), Lane Holding Co. ($64.08),
Westaff USA ($1078.38), K-Mac ($390.60), JAK ($3.78), Four
Aces Hotel ($94.65), Time Out Lounge & Bottle Shop
($1158.66), Midwest Motels of Deadwood ($58.50), Mineral
Palace Hotel & Gaming ($519.39), Decker's Food Center
($452.45), Wendy's ($156.48), Wal-Mart ($1541.22), Labor
Ready Southwest ($10.13), HMC Hotel ($45.50), Wal-Mart
($472.36 in 2008, $6821.90 in 2009, $9077 in 2010, $2747.85
in 2011, and $157.67 in 2012), National Beef Packing
($3343.98), and Garden City Travel Plaza ($1996.79).
reported having worked in 20 or more jobs. "I was let go
from all of my jobs because I missed too much work because of
migraines, or because I was not able to socialize with
customers, co-workers or the boss, or because I asked them to
accommodate my limitations and they were not willing
stated that her most successful work was at Walmart. She had
worked for Walmart in Spearfish but missed too much work and
was fired. AR341. She later worked for Walmart in Rapid City
stocking from the refrigerator to the floor. Her boss let her
work most of her shift in the cooler. Id. "I
had an awesome boss who understood my problems, my
limitations and the effect of my medications. He was a kind
man. He said you can stay in the cooler, stock shelves, take
your time; we will go by your limitations." This went
well for a long time and then he died. AR342. The job lasted
a month after that.
could not tolerate being out of the cooler, walked out and
never came back.
Health Physician flow sheets show that Seay's weight
ranged from 275 pounds on November 23, 2010, to 290 pounds on
October 2, 2013. AR435.
August 5, 2012, Seay sought ER treatment for headache with
nausea, "similar to previous headaches." She was
treated with Percocet and Phenergan. AR394-95.
September 11, 2012, Seay sought ER treatment for dizziness,
lightheadedness, and headache that started at work. AR375-79.
The sole abnormal finding was obesity. AR379. On September
12, 2012, she saw Ajay Thakur, MD, to obtain a return-to-work
form. She stated that she felt better except for generalized
fibromyalgia pain. Dr. Thakur discussed with her the unclear
nature of her illness and advised tests to rule out
September 12, 2012, she sought treatment at C&S Medical
Clinic, where Marcia Snodgrass, NP, assessed shortness of
breath, muscle weakness, fibromyalgia, and unspecified chest
pain. AR401-02. Ms. Snodgrass prescribed Vicodin,
Tramadol,  and Lisinopril. AR402.
October 10, 2012, C&S Medical Clinic saw Seay for muscle
weakness, unspecified chest pain, shortness of breath, and a
skin mass. AR403-04. Ms. Snodgrass refilled Lisinopril and
November 29, 2012, Seay sought ER treatment at the Spearfish
Regional Hospital for a headache that was worse on the left
side. Don Potts, MD, recorded a long history of migraine
headaches, that she used to be on Vicodin and Tramadol and
this decreased the frequency. He said symptoms were positive
for photophobia, nausea, vomiting and neck stiffness. He said
she had been diagnosed with fibromyalgia. Dr. Potts treated
Seay with Toradol and Phenergan IM. AR521.
December 12, 2012, Seay was seen at Behavior Management
Systems for a Needs Assessment by Colleen Casavan, B.S.,
Therapist, and her clinical supervisor, Jenny
Greslin, MSN, QMHP. AR510. She had been living
in Kansas, recently returned to Spearfish, and wanted to
resume CARE (Continuous Assistance, Rehabilitation, and
Education for individuals with severe and
persistent mental illness) services. She was staying with her
mother in Belle Fourche along with her one-year-old daughter
and boyfriend. Id.
discontinued CARE services in 2010. Ms. Casavan reported that
she had a clear direction on what she wanted: "I need
case management again.
really bad anxiety, can't focus, and know I get
'sketched out' more than other people do. I don't
trust anybody." AR510.
Casavan reported that Seay feared her daughter could be taken
away if the Department of Social Services (DSS) knew she
returned to the area since parental rights to her two sons
were terminated in 2010. She was trying to secure an
apartment and might want to apply for disability again.
Casavan summarized her prior treatment: in 2009 she had
therapy, case management, and medication management. AR510.
In February 2009 she was hospitalized at Rapid City Regional
West (psychiatric hospital) because, after Child Protection
Services (CPS) took her sons, she had a suicide plan.
January 2010, angry with providers for not advocating to have
her children restored to her custody, she terminated
services. During this time she saw a private therapist in
Black Hawk and thought the therapist was helpful until her
therapist went against her in court. Id.
Casavan summarized additional longitudinal history:
psychiatric hospitalization at age 18 after becoming homeless
and losing her daughter; hospitalization at age 15 for
attempted suicide by overdose, followed by drug and
psychiatric treatment. AR510. She had been treated with
Depakote, Trazodone,  Zoloft,  Prozac,  and
Abilify and did not recall any psychotropic
medication being notably helpful. Her records indicated
non-compliance. She was currently on Tramadol and Vicodin for
Casavan reported that Seay had a history of five C-sections.
AR510. Prior records showed that at age 15 she was beaten up
in a group home, had a CT scan, and a pineal cyst was found
but not followed up. AR510-11. She had had migraine headaches
since age 11. At age 5 she broke her arm and at age 6 she
broke her leg (falls). AR511.
16 she had had three stepfathers. She had an older
half-brother and younger half-sister. AR511. She reported a
childhood marked by physical, emotional, and sexual abuse.
Id. At age 7 a stepfather sexually abused her. Twice
she lived with maternal grandparents. Id. She was in
about seven foster homes from age 14-18. She was in two
residential facilities and three detention facilities. She
ran away multiple times. Id.
gave birth to her first child at 16 while in foster care. She
gave birth to four more children, and the youngest was a year
old. AR511. She was married from 2004-06. During the marriage
her husband was incarcerated and she had a boyfriend. Child
Protection Services removed her sons due to reports of her
boyfriend physically abusing them. Her rights were terminated
and she exhausted her appeals in 2011.
moved to Rapid City, became pregnant with her [sixth] child,
and shortly before that child's birth moved to Kansas.
AR511. She "struggled" with public assistance in
Kansas and returned to South Dakota, bringing her boyfriend.
substance use, Ms. Casavan recorded that Seay entered
treatment at age 15 for multiple substance and alcohol abuse
and she denied further use of drugs. AR511.
Casavan related that Seay had several jobs, mainly
cashiering, that she was unable to keep because the hours did
not work with the day care schedule. She planned to keep
looking for employment. AR512.
Casavan reported that appearance, affect, and posture were
appropriate. Mood was anxious, appropriate, depressed, and
relaxed. Thought content was paranoid with suicidal ideation.
Body movements were appropriate. AR512.
Casavan reported that remote memory was fair, insight was
poor, judgment was fair, and energy level was moderate.
AR512-13. Ability to manage daily living activity and make
major decisions was fair. AR513. Speech was appropriate.
Thought process was concrete, organized, and rigid. She
related to the examiner in a way that was
"average." Id. Facial expressions were
appropriate and provocative. Id.
Casavan discussed a diagnostic formulation of "Mood
Disorder NOS." AR513. She listed symptoms that supported
the diagnosis: anxiety, difficulty concentrating, poor focus,
excessive worry on a daily basis, restlessness, and extreme
irritability. Id. Seay reported minimal symptoms of
depression. Id. She reported at times experiencing
racing thoughts, distractibility, and poor decision-making,
but not the extreme ups and downs that might indicate a
strong bipolar disorder diagnosis at this time. Id.
A "rule out of personality disorder NOS" was
appropriate as Seay had a long history of relationship
conflicts including personal and work related, and
inappropriate behavior within the community, specifically the
court system. Id. She admitted to deceitfulness and
Casavan listed Seay's strengths: she sought services on
her own and recognized the importance of finding a sense of
stability to improve her and her daughter's life. She was
very independent and articulated her needs well. Although she
struggled with trusting others she seemed willing to seek the
help she needed. AR513.
the heading "SPMI" (severely and persistently
mentally ill) Criteria, introduced by the general criterion,
"The individual's severe and persistent emotional,
behavioral, or psychological disorder has resulted in at
least one of the following, " Ms. Casavan checked these
boxes: "A single episode of psychiatric
hospitalization" and "Has undergone psychiatric
treatment more intensive than outpatient care more than once
in a lifetime." Under the category "impaired role
functioning, " requiring the presence of three criteria,
Ms. Casavan checked: "Is unemployed or has markedly
limited job skills and/or poor work history;" "Lack
of social support systems in a natural environment;" and
"Requires public financial assistance for out of
hospital maintenance." AR514. Ms. Casavan recommended
the CARE Program -Intensive. Id.
December 27, 2012, Ms. Casavan saw Seay to develop a case
service plan tailored around securing income to support her
and her daughter, managing her anxiety through case
management, medications through her primary care provider,
and therapy. AR505.
December 29, 2012, Seay sought treatment for migraine
headache at the Spearfish ER. She had photophobia, said she
was unable to keep anything down, and endorsed eye pain. On
exam she had a facial droop on the right side; the patient
said this was normal and had occurred during the delivery
January 15, 2013, Samantha Martinez, BMS case
manager, said Seay's appearance was
disheveled and her mood was anxious. She wanted Martinez to
go to a meeting with her at the DSS office where she was
applying for a cash credit program but was hoping to not have
to work, volunteer, or apply. Martinez told her she had to
comply with the regulations. AR503. Seay wanted Martinez to
sign a document so she would not have to work, volunteer, or
apply, but Martinez told her that was not an option since her
case was newly opened; she suggested that she could write a
letter that Seay was receiving services. Id.
January 22, 2013, Seay called Ms. Martinez threatening to
pack her van and leave because no one was helping her. AR500.
Martinez explained that she was being treated the same as
everyone else. Seay again wanted Ms. Martinez to sign a
document stating that because of her mental disability she
was not able to work. Ms. Martinez suggested that Seay sign a
ROI for her Needs Assessment to be released to DSS.
Id. Seay did not want to release it: "[D]o you
not understand.... This is how I lost my kids last time why
would I do that same thing again." AR500-01. Seay told
Ms. Martinez that she was not allowed to come to her house,
to stay away, and then hung up. AR501.
January 23, 2013, Seay sought treatment for migraine headache
at the Spearfish ER. AR525. She stated she'd had one a
month for three months. She said that Tramadol made the
headaches much less frequent but she was out. Id.
Her blood pressure was 140/100. Lee Bailey, MD, treated her
with Toradol, Benadryl,  Zofran,  and IV fluids. He gave
her a small amount of Tramadol and Vicodin. Id.
January 28, 2013, Forrest Brady, MD, Regional Health
Physicians in Spearfish, saw Seay for the first time. AR431.
She reported migraines, a right wrist cyst, fibromyalgia,
anxiety, hip and back pain. Id. Dr. Brady recorded
that she had an extensive history involving fibromyalgia
diagnosed by Dr. Steven Frost at the pain clinic in 2010.
Id. He had recommended injections but Seay had
needle phobia and chose not to. Seay told Dr. Brady that her
headaches were markedly better so long as she took Tramadol
or Vicodin regularly. She stated that she took Promethazine
for migraines, which were provoked, frequently, by anxiety.
Id. Dr. Brady diagnosed Anxiety State, unspecified;
Chronic Pain Syndrome; and Lumbago. AR432. Dr. Brady noted
that Seay was accompanied by her mother. Id. He said
she weighed 281 pounds, BMI 42.7, and was obese. He placed
her on Cymbalta and gave Seay a prescription for
Hydrocodone prn for any pain not covered with the
February 11, 2013, Dr. Brady said that on Cymbalta 30 mg.
Seay was using a little less Vicodin. She felt quite a bit
better and more wakeful. AR429.
February 14, 2013, Shannon Howard, LPC, QMHP, BMS
therapist, reported her and Seay's first session. AR516.
The focus was grief and loss over the loss of her two sons to
the State. She feared this could happen with her daughter,
was stressed and worried all the time. Id. Ms.
Howard assessed SPMI criteria, which were unchanged.
AR516-17. Ms. Howard and Seay planned counseling 1-4 times a
month, and stated the measure of success:
She will know she is successful when she is able to go out in
public and not look over her shoulder, which she does all the
time; when she is not isolating as much; and when she feels
she has dealt with her grief and is not triggered by visual
reminders to the point that she is overwhelmed with sadness
March 4, 2013, Ms. Howard recorded that Seay felt trapped in
her home out of fear of seeing people she did not want to
see. She had gained little insight. She did refrain from
impulsively moving forward with a homeless man she met on
March 6, 2013, Ms. Casavan reported that Seay was "very
disturbed" because an agency contacted her for help
finding her ex-husband to serve civil papers. AR495. The
State was also pressuring her for information about the
father of her child as she was receiving assistance and this
was a requirement. Id. She said she wanted nothing
to do with the father, would not say who he was, and planned
to talk with her DSS worker about it. She lived in constant
fear of CPS entering her life again. Id.
March 12, 2013, Ms. Casavan reported that Seay "focused
on her recent lottery win" and the stress of deciding
what to do with it. AR493.
March 15, 2013, Dr. Brady saw Seay for a complaint of
"bad migraines." AR422. She said her back pain was
better on Cymbalta, "knows when she misses a dose."
She gave a history of "[h]umongous stress and
anxiety." She was interested in seeing a chiropractor
for her migraines. Id. Dr. Brady again assessed
chronic pain syndrome; anxiety state, unspecified; and
headache. He agreed to refer her to a chiropractor. Dr. Brady
prescribed medications including Cyclobenzaprine, Cymbalta,
and Hydrocodone, noting that she was "quite
careful" with use of Hydrocodone. Id.
March 19, 2013, Seay had therapy with Shannon Howard. AR491.
On March 20, she had a session with Ms. Casavan. AR489. On
March 26, 2013, she had a therapy session with Ms. Howard.
April 1, 2013, Seay met with Ms. Casavan. AR485. She said she
was seeing a chiropractor. Id.
April 15, 2013, Dr. Brady assessed her conditions, reported
that she weighed 279, and reported their discussion of her
possible pregnancy and how to address it. AR414.
April 15, 2013, Ms. Casavan recorded Seay's complaint of
a lot of anxiety, said she was in a pleasant mood but was no
longer on speaking terms with the girl she developed a recent
friendship with, who has been staying with Seay, along with
her son. AR481. Seay would not allow her back into her home
while drunk, and the girl accused her of kidnapping her son.
Id. No charges were made. Id. Ms. Casavan
commended Seay for ending the friendship. Id. Ms.
Casavan stated, "Katrina also shared she found out she
is five weeks pregnant." Id. "She has
concerns about having to get off pain killers due to her
chronic pain." Id.
April 16, 2013, Ms. Howard recorded that Seay had met a man
on the internet and now she was pregnant with her "6th
whoops" pregnancy. AR479. She had immediately weaned off
medication but said she could not function without it.
"Katrina was very disorganized in thought today and
scattered from subject to subject, seemingly overwhelmed with
this news." Id.
April 24, 2013, Seay saw Regan Hill, MD, Regional Health
Physicians, Spearfish, for obstetric care.
April 26, 2013, she met with Ms. Casavan to talk through
problems and conflicts. AR477.
5, 2013, Seay was treated at the Spearfish ER for
14, 2013, Ms. Howard provided therapy and helped Seay process
her loss. Ms. Howard reported that Seay spoke in a slow,
deliberate, focused manner; had a flat affect; and had met a
man amidst this crisis. "Katrina will not financially
help this man come see her." AR474-75.
21, 2013, Seay met with Ms. Howard. She was upset and angry
because she saw her old therapist, involved in a past child
custody case, in the waiting room. Ms. Howard helped her work
through the anxiety. AR473.
22, 2013, Seay was brought to the ER by emergency medical
services after she swerved to miss an animal and ended up in
three inches of water in the ditch. Dr. Krista Birkelo wrote,
"She is terrified of water and had an anxiety
attack." She had paraspinal tenderness, was alert and
oriented with intermittent confusion. The clinical impression
was concussion and neck strain. AR530.
of her thoracic spine showed multiple small Schmorl's
nodes, small anterior and lateral osteophytes, and mild
septum pellucidum was revealed by a brain CT in the course
of workup after her May 22, 2013 car accident. AR533.
4, 2013, Skylar Bransky, BMS CARE Emergency Services,
reported a 54-minute phone call from Seay. AR467. Seay stated
she wanted to leave her house, take off and run away from
everything. AR469. She'd had an argument with the car
mechanic about getting her car back, the police came to her
door at 6:30 p.m., and she would not let them in. They said
they would get a warrant, and she finally talked to them.
Id. They told her that her only option to get her
car back was small claims court. They wanted to know if she
was going to hurt herself. She said no, and they left. On May
31, 2013, she had gone to tow her car away from the mechanic
because he had not fixed it and she needed to turn in her
rental car. Id. He called the police and she spent
the night in jail. Ms. Bransky reported that Seay agreed that
Ms. Bransky and Ms. Howard would come up with a plan of
action before she resorted to disappearing. Id.
7, 2013, Heather Armstrong, LPC, QMHP, Behavior Management
Systems, reported that Seay was having stress related to law
enforcement, her mom, a limited social support system, and a
mechanic not fixing her car. AR466. Seay stated that police
had come to her house twice this evening because of a theft
her mother reported via the internet. Seay said she would not
answer the door, she feared arrest and loss of custody of her
daughter, and this was creating significant anxiety.
Id. She denied stealing money from her mother. She
talked about relocating to an area where she could address
her anxiety in a more supportive environment. Id.
10, 2013, Ms. Howard reported that Seay was very emotional,
her face was flat, and her emotions were blunted. Her
daughter was with her and Seay showed patience and proper
parenting skills. AR471. Her Camaro was still in the
possession of the mechanic. She had given him half the money
to fix it, and he would not fix or return the car until he
received the rest of the money for repair. Id. Her
van was broken down, she had used her insurance money to fix
the Camaro, and had to return the rental car. She had been
arrested for disorderly conduct when she went to get her car
and had to be in court on June 28, 2013. Id. Ms.
Howard helped her process her irrational thoughts about
leaving Belle Fourche just because of her mom. It was decided
that Seay would "focus on what she can control, Zy,
herself, and finding a way to fix the car." AR471.
18, 2013, Ms. Howard reported that Seay was excited because
"a businessman" paid for her car to be towed and
repaired, lent her a car, charged her only $1, 000, and asked
her to pay what she could. AR463. Seay "processed her
disbelief that there were good people out there."
27, 2013, Ms. Casavan and her clinical supervisor, Randy
Allen, reported a six-month review. AR577-79. During this
period, Seay had found housing, accessed DSS and other
programs, began therapy, and received medications from her
primary care physician. AR578. She was pregnant, miscarried,
and processed those feelings fairly well with her therapist.
Id. In June she was in crisis over financial
difficulties with her vehicle; was in conflict with her
mother, who accused her of theft via the internet; and there
was police involvement and an arrest for disorderly conduct.
Id. She indicated she still feared Child Protection
Services involvement, but had been successful avoiding
further involvement. The BMS reviewed listed factors
constituting medical necessity for continued services: Seay
struggled with ongoing anxiety, struggled with
problem-solving skills and poor decision-making, had a
limited support system, and struggled with interpersonal
relationship issues. Id. Without services she could
turn to impulsive decision-making leading to legal issues,
CPS involvement, and setback in the progress made toward
mental health recovery. Id.
9, 2013, Ms. Howard recorded that the man Seay dated for a
week was in jail for violating a TRO. "When he is bailed
out she will let him move in...."AR572. "Therapist
challenged Katrina that ... she must focus on the red flags
she sees instead of the feelings. Therapist also reminded her
she has only known him for one week...." AR571.
17, 2013, Ms. Howard wrote, "She did listen to her
instincts and did not use her car title for bail but instead
used the money he had which he was upset about but later
understood. Her issues include his smoking, drinking, and
potential for wanting to use her money...." AR569. On
the other hand, he was "good with Zy, goes to work, a
good mechanic, and treats her nice." AR570.
18, 2013, Ms. Casavan reported that this man stole gas from
her vehicle, tried to steal her pain medications, and she
filed a police report. AR568. "She seems to realize she
needs to get to know someone before allowing them to stay
with she [sic] and her daughter or try to fix their
issues." Id. Ms. Casavan added that Seay had
made it to court last week regarding her disorderly conduct
charge "involving heated argument with an officer while
trying to get her car back from a mechanic."
23, 2013, Ms. Howard wrote that she continued in the
relationship, that the man had agreed to treatment, and Seay
hoped he could get his drinking under control. AR566.
25, 2013, Ms. Casavan and Seay discussed the relationship
with this man and her lack of financial stability. Seay was
in the pre-contemplative stage with regard to finding
30, 2013, Seay sought ER treatment for a migraine. She stated
that she'd had a headache more than a week, had sought
chiropractic treatment earlier in the day without
improvement, and had vomited four times. AR535. A pregnancy
test was negative. AR536. The ER provider treated her with
Toradol and Zofran. Id.
August 19, 2013, Ms. Casavan called Seay, who said she
was doing "okay, " and reported that there was a
warrant for her arrest for failing to appear in court last
month. AR562. Ms. Casavan attempted to offer solutions
"but Katrina struggled with accepting any responsibility
with the situation nor how to address it." Id.
Ms. Casavan wrote that the case manager "encouraged
[Seay to] consider having her mother watch her daughter in
case she needs to go to jail, " but Seay stated
"she would rather have CPS step in than have her mother
watch Zi." Id. Seay said she had little money
and had used most of her resources and the communities'.
Ms. Casavan offered to travel to Belle Fourche to see her,
but Seay did not answer the phone when Ms. Casavan called
back to set a time. Id.
August 21, 2013, Seay returned Ms. Casavan's call and
spent a great deal of time talking about finding affordable
car insurance. AR560. Ms. Casavan asked about the
warrant for missing her court date. Seay did not want to
"figure" that out right now. Ms. Casavan explained
the consequences and Seay said little. Id.
August 27, 2013, Ms. Howard wrote that Seay reported ending
the relationship with "Billy." AR557. Seay talked
about her fears of being alone, of being like her mom, and
bringing men in and out of her daughter's life. Seay
reported feeling overwhelmed, alone, and frustrated. They
agreed that she would try to stop going on websites to find
August 28, 2013, Ms. Casavan reported, "Katrina said her
TANF has been shut off for the month of September due to not
complying with child support paperwork identifying the father
of her child. She is very angry about this...." AR555.
She subsequently was told that if she completed her paperwork
by Friday she would receive her benefits again. Seay
expressed anxiety about having her daughter's father
involved in the future. Id.
August 30, 2013, Seay told Ms. Casavan she was "a little
happy as she met someone on-line. She does seem to have some
insight as she recognizes this may not be a good place to
start a relationship however is in the precontemplative stage
of change." AR553. Seay was ambivalent about her car
dilemmas, whether to get rid of one to be able to repair the
other. "CM followed up on Katrina's plans regarding
her missed court date however she doesn't plan to address
this at this time despite negative consequences that may
September 10, 2013, Ms. Howard reported that progress was
minimal, and isolating had increased. AR540. Ms. Howard
assessed overall progress as "unsatisfactory."
"Katrina has had many issues that have taken away from
her ability to meet her goals.... Without continued services
Katrina is most likely to report an increase in mental health
September 12, 2013, Ms. Casavan reported that Seay had
requested a meeting in the park instead of her apartment,
which was being inspected. AR549. She felt too anxious to be
in her apartment "as she doesn't like people in her
home." There were several things she had been told to
fix that she had not gotten to. "CM encouraged her to
take responsibility by following through and addressing
concerns before they turn into issues leading to increased
anxiety. Katrina was receptive however did not commit to
changing her behaviors." Id.
September 17, 2013, Ms. Howard reported a therapy session.
AR547. She "challenged irrational thoughts ... and
encouraged Katrina to take things slow with
September 24, 2013, Ms. Howard reported a therapy session in
which Seay tearfully processed the relationship with the man
she was with when her children were taken. AR545. Ms. Howard
noted that Seay was "struggling that she still has
feelings for him." Id. "The session ...
focused on these feelings of loneliness and not being
understood." Id. The plan: "Katrina will
try to get out of the house once this week."
September 27, 2013, Seay sought ER treatment for "acute
on chronic back pain" after moving furniture at her
apartment. AR590. She had difficulty moving her right leg due
to pain. She was treated with Toradol and Norflex, and given
a prescription for Flexeril. She had a prescription for Norco
at home. Id.
October 2, 2013, Ms. Casavan wrote, "Katrina reports
that she has been struggling with severe anxiety related to
stressful situations." AR543. She had gone off her
Cymbalta when she miscarried and had a PCP appointment to get
back on. Id. She reported an extensive history of
back issues. Id.
October 2, 2013, Dr. Brady referred Seay to an obstetrician,
with the note: "Pregnant, trying to decide if she can
continue with pregnancy." AR411. Height and weight were
68 inches and 290 pounds. AR409.
October 8, 2013, Ms. Howard reported that therapy focused on
Seay's issues with her mother. The plan: "Katrina
will think about attending a social at her daughter's
head start program to meet other moms and try to build social
October 14, 2017, Ms. Casavan reported that Seay continued to
have car issues, hoped SSI would resolve this, and seemed
disinterested in other alternatives. AR645. She had been able
to get back on medication and was starting to feel that she
was managing her stress better. She was afraid to renew her
driver license due to the outstanding warrant. Id.
Regarding a former alcoholic boyfriend: "She said she
plans to drop him off at his halfway house today."
Id. Ms. Casavan supported this. She said that due to
CARE restructuring, Seay was to be assigned to a new case
October 15, 2013, Ms. Howard reported that the focus of
therapy was the male friend who was in rehab. AR643.
"Katrina will not accept phone call[s] from this man
this weekend as she is gaining insight that she puts herself
around others that are needy to avoid rejection...."
October 22, 2013, the new case manager, Dana Studt, reported
that Seay discussed stressors revolving around
transportation, and struggled to follow through with ADLs
like bathing, cleaning, and laundry. She often felt
October 29, 2013, Ms. Howard reported the focus of therapy
was Seay's disappointment in her mother and a growing
friendship with a female friend, Jenna. AR639.
November 5, 2013, Ms. Howard worked with Seay on the pros and
cons and potential boundaries she needed to set so as not to
be drawn into a relationship she did not want. AR637.
November 8, 2013, Ms. Studt helped Seay find a dentist who
took Medicaid. AR635. Ms. Studt wrote that Seay had concerns
about anxiety levels and Ms. Studt helped her compile a list
of concerns to take to her PCP at an appointment this
November 8, 2013, Seay saw Dr. Brady. AR585. She wanted
medication to get through the anxiety of seeing the dentist.
She told Dr. Brady that the anxiety about just making an
appointment was almost too much for her. Id.
"She apparently does not always think things out well at
the time...." Id. Dr. Brady increased her
Cymbalta to 90 mg. AR588. He prescribed
Lorazepam 1 mg. an hour before the procedure and
she could repeat at the time of the procedure if she needed
November 12, 2013, Seay saw Ms. Howard, reporting a plan to
get a guy to buy a car that she would use. She had mixed
feelings about this, and Ms. Howard reviewed pros and cons
and how to maintain boundaries. AR633. Also on November 12,
Shawn Bitz of BMS reported that "Katrina called in
tears" because her dentist said to take four Lorazepam
tablets before her visit, and she did. AR631. The dentist
appointment was then canceled. She stated that she had been
"out of control and sedated" all day and her mother
took care of her child but left before Seay was ready for her
to leave. Id. "Katrina called in an almost
panicked state, afraid she would not be able to take care of
her child." Id. She was able to walk, was aware
of her surroundings, knew the date and day, and calmed down
in the course of the conversation. Id.
November 13, 2013, Ms. Studt spoke with Seay on the phone
after Seay failed her appointment. Seay said she had taken 5
mg of Lorazepam the day before, for a dentist appointment,
and blacked out. Seay said she would call her case manager
when she felt recovered enough to drive. AR628.
November 22, 2013, Ms. Studt wrote that she "phoned
Katrina back after she left CM a frantic voicemail stating
that she needed help." AR627. Seay was currently pulled
over, with her daughter and a friend, and a policeman wanted
to arrest her on her bench warrant. Seay demanded that Ms.
Studt drive to Belle Fourche to either give her $275 to pay
the fine, to keep her from being arrested, or to take her
daughter. Id. Ms. Studt reviewed the limitations of
case management. Seay was not receptive, again made demands,
and Ms. Studt "enforced boundaries." Seay hung up
on the CM. Id.
November 25, 2013, Ms. Studt reported a phone conversation
with Seay, who said she was calmer today and had arranged
with the police to address the warrant. Seay told Studt that
she should have come on Friday, when told to, as the case
manager was her primary support. Ms. Studt "validated
feelings, " reviewed Seay's role in this, and Seay
"hung up on CM." AR625.
November 26, 2013, Ms. Howard reported a conversation in
which Seay related that she had been pulled over for a
license plate violation and was informed that she had a bench
warrant. AR623. She spent 45 minutes trying to finding
someone to give her $200 or watch her child, and she was not
able to get ahold of her mother. Id. Seay said this
resulted in her "losing it on Dana" and was unsure
if the relationship could be fixed. She found out she was
getting $15 too much for housing and would be evicted if she
could not pay $200 by the end of the day. Id. This
put her in "emotional tailspin" and "she fled
to Keystone" to the house of a man she has been talking
to on a dating site. "Everything was perfect about the
night except the location of where he is living and lack of
running water." Id.
December 9, 2013, Ms. Studt stated that Seay acknowledged
behaving poorly during the last interactions with her CM.
AR616. Seay was again seeing someone she met on a dating
site. "CM expressed concern that Katrina's boyfriend
is already living with her and expressed possible safety
concerns regarding her daughter. Katrina...agreed to not
allow her boyfriend to have unsupervised contact with her
daughter until she knows him better." Id.
December 10, 2013, Ms. Howard stated the main features in a
Katrina reports that things with Mike have evolved to going
up there for Thanksgiving and him coming home with her.... He
has been with her a few weeks and she has no issues. She
feels he is motivated to get a job, willingly looks for work,
and is helpful with Zy and supportive of her. One concern is
his cigarette and drinking habits that she is supporting now
while he looks for work but feels he is communicating that he
... will reimburse her.
AR619. Ms. Howard encouraged her to "please take things
slower...." She met Mike "who was polite and
appeared attentive to Zy." Id.
December 11, 2013, Dr. Brady recorded that Seay was doing
much better on Trazodone for sleep and planned to use
Trazodone for her next dental appointment. AR925. Assessments
included chronic pain syndrome; anxiety state, unspecified;
sleep disturbance, unspecified. AR927. He continued
Hydrocodone for pain. Id.
December 16, 2013, Ms. Studt helped Seay "process
stressors" on the phone. AR617. She stress the
importance of "addressing things in a timely manner as
this tends to be easier than fixing them down the road."
Id. "Katrina did not agree to apologize for her
behavior today." Id.
December 17, 2013, Ms. Howard reported that Seay expressed
frustration and anger that "Mike has left.... She is
also reporting she is pregnant due to a mix of antibiotics
while on birth control. She is upset that mom was willing to
buy Mike liquor, cigarettes, a phone card and drive them up
there to drop him off yet she never offers to help her
financially." AR614. Now she was "strapped for cash
as he contributed nothing." Seay was discouraged and
upset. Zy was extremely disruptive in session. Id.
December 23, 2013, Ms. Studt stated that Seay continued to
have difficulty taking responsibility but did acknowledge her
part in her current situation, adding, "I just don't
want to talk about that right now." AR612. She vented
and expressed some sadness that her relationship was over and
her former boyfriend was already living with someone else.
January 7, 2014, Ms. Howard observed that Seay looked
"high" and upset. AR610. Seay stated that she had
so much anxiety having to leave her apartment that she took
three Valium instead of the normal two. Seay stated that her
pain was so high, and anxiety so high, she was having a hard
time functioning at all. Id. She said her house was
not in the normal clean state as she spent time scrubbing her
mattress and had thrown out all sheets. Id. She was
upset that she had not protected her daughter and felt guilty
that she allowed this man into her home. Zy had no idea what
happened, was not alone with the man, and did not witness
anything. Seay reported that she was raped in her bedroom, a
knife was involved, and she would not go into further detail
but blamed herself for letting him in. Id. Now she
was taking care of Zy but that was it. Id. "She
crashes when Zy sleeps and has not been able to leave the
house yet reports not even feeling safe in her house as it is
where the rape occurred." Id. "She states
that the cops have informed her there is not enough evidence
to press charges as it is her word against his."
Id. "She had difficulty gaining insight due to
being on higher dose of medication" Id.
January 21, 2014, Ms. Howard reported therapy focusing on how
Seay could get her life back on track and pull herself out of
a financial mess. AR608. She did not want to discuss the
rape. She would focus on not bringing someone into her life