In Whom Do We Invest

It was June. A man and I had eaten fish and white wine at a lakeside eatery and were strolling through Minneapolis’ East Isles neighborhood, when the topic turned to my mentally ill mother.

“She’s struggling with an eating disorder, again,” I told him.

Then, with barely a pause, I delivered the two sentences that would begin the final unraveling of our relationship: “Even though she’s the one with the eating disorder, I worry more about my dad. I just don’t invest that much time and energy worrying about my mom, anymore.”

The man grew quiet, and I listened to the sound of our shoes slapping pavement. Birds chirped, and we meandered past a brick condominium with ivy curling up its walls.

“What’s wrong?” I said.

That’s when he exploded.

“You’re so mean to your mom,” he said, his face flushed and twisted. “I don’t think you realize what a mean person you are!”

I tried to justify my remark. The reason I worry more about my father is because he’s my mother’s caretaker, and that’s a monumental, 24/7 task. And the reason I don’t invest that much time and energy worrying about my mother, anymore, is because she isn’t going to get better.

At least I don’t think so.

***

My mother is fifty-seven, though some might mistake her for sixty-seven or seventy-seven. In 2003, she was diagnosed with anorexia nervosa and borderline personality disorder.

For over a decade, she’s received medical and psychiatric treatment at world-renowned facilities like Mayo Clinic and The Emily Program.

She’s tried day treatment, inpatient treatment, electroconvulsive shock therapy, cognitive behavioral therapy, family and marriage therapy, pharmaceutical drugs, mindfulness meditation, yoga, Tai Chi, light boxes, vitamin B, vitamin D, omega-three, self-help books, and writing.

She’s tried psychiatrists, psychologists, internal medicine doctors, nutritionists, nurses, and nurse practitioners.

And despite the tries, despite the estimated $700,000 that has been spent on her health care, she’s shown little improvement.

She doesn’t have a job. She doesn’t contribute to conversations. She’s doesn’t seem interested in the future. And she’s tried to end her life on several occasions. Eleven years after the diagnoses, she’s actually regressed in most areas.

My mother is an “unusually difficult case,” one doctor put it.

***

In 2013, I became a program coordinator for Hennepin Health, a health care delivery program that serves Medicaid recipients in Hennepin County, Minnesota.

Many of my clientele are “unusually difficult cases,” too. Forty-two percent are mentally ill, 45 percent are chemically dependent, and thirty percent have at least one chronic physical condition. Thirty-two percent have unstable housing. They’re heavy users of expensive acute care services.

My mother would likely be a member of Hennepin Health if she hadn’t married my father, if he wasn’t earning six figures.

When I interviewed for the job, I explained my rationale for applying: I’ve worked in public service my entire adult life, first as a West Point cadet, and later as an active duty Army officer. I mentioned veterans, the ones I know with post-traumatic stress disorder and chemical dependency, the ones sleeping in shelters, and under bridges. Some qualify for our services, and this job would allow me to continue helping them.

I didn’t mention the real reason for applying.

I didn’t mention my mother.

***

In 2012, the National Institute of Mental Health (NIMH) estimated that 43.7 million American adults had Any Mental Illness (AMI).

To be counted, a person met three criteria: a mental, behavioral, or emotional disorder; a diagnosis within the past year; and a disorder of sufficient duration to meet diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (4^th Edition).

NIMH’s estimate underreported the number of Americans with AMI, for it only covered residents of households and non-institutional group quarters (e.g., shelters, boarding houses, college dormitories, halfway houses). It excluded persons who had no fixed address (e.g., homeless, transient), were on active military duty, or resided in institutional group quarters (e.g., correctional facilities, mental institutions, long-term hospitals).

NIMH also estimated that roughly 9.6 million adults had severe mental illness (SMI). People with SMI met a fourth criterion: their disorder resulted in “serious functional impairment” that interfered with major life activities like eating, bathing, dressing, managing money, taking prescribed medication, or functioning in social and vocational contexts.

Mental health practitioners determine impairment by administering tests like the Global Assessment of Functioning (GAF) scale, which assigns people a score between zero and 100. A GAF score of one to ten equates to “persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death.”

My mother has gone days without showering, brushing her hair, or changing into clean clothes. And she’s tried to commit suicide, too — by overdosing on pills, starving herself, and sitting inside a running car parked inside a garage.

What this means is that many times since her diagnoses, my mother has had a GAF score in the one to ten range.

 ***

On the June day that we argued, the man and I reached my apartment. Here, his accusations continued. Each felt tantamount to violence — a slap to the face, a jab to the ribs.

“I understand why your dad confided in your sister about your mom’s eating disorder, but not in you,” he said. And later, “I don’t think you even love your mom.”

Throughout the onslaught, I said very little, because I’ve never been good at thinking on my feet. I felt trapped and shamed and I wondered why my comment had elicited this reaction.

When he threatened to leave, I retreated to the bathroom, tasted bile in my throat, and knelt over the toilet to vomit, but nothing came up. Then I sat defeated in the dark, on the linoleum, trying to breathe.

The apartment grew silent, except for my breathing. After some time I realized that I hadn’t heard him exit my apartment.

Yet, I longed for him to exit.

Few accusations have hurt so much.

***

After I started working for Hennepin Health, I became fascinated with the population we serve. Due to my mother’s illness, it’s a population that is familiar to me, yet foreign, too, because, for my most of my life I’ve inhabited a different socioeconomic sphere than my clients.

Some of my best insights into the population came from the people who interact with clients on a daily basis. TJ, a caseworker, is one of them.

TJ is six foot four, blond, and bearded, and he provides intensive case management to the ones who frequent acute psychiatric services (APS) and emergency departments (ED). To qualify for TJ’s services, Hennepin Health members must have visited the ED or APS at least three times in the past four months.

After he began collaborating with Hennepin Health, TJ learned where the county’s homeless cluster. “I didn’t realize there were so many [encampments],” he told me, over coffee one evening. One of the largest is located just blocks from where we sip espresso — it’s near the I-35W corridor, behind an auto repair shop, along the Mississippi River.

Recently, TJ was summoned to Hennepin County Medical Center to attend to a Hennepin Health client who lived in this encampment before she relocated to the grounds of a nearby church.

The woman was bruised and broken, a domestic violence victim. Her partner, the perpetuator, is another Hennepin Health client. In addition to beating her, he threw her shoes off a highway overpass, and TJ brought her another pair. At the hospital, TJ found it difficult to communicate with the woman because she was intoxicated; she drinks “about a gallon per day,” he explained.

After she was discharged, the woman went to a domestic violence shelter, and her partner called TJ frequently, demanding to know her whereabouts, screaming at TJ through the phone.

I met TJ at the coffee shop because I wanted to know more about these “unusually difficult cases.” What works and what doesn’t, who can be saved and who can’t? Who is worth the investment?

“You’ve got to meet a person where he’s at,” TJ said, in response to my questions. “If you wait for him to change, to sober up, you’ll be waiting forever.

TJ then told me that he is able to make a determination, shortly after meeting a new client, as to whether his interventions will be effective. The people who’ve cycled through numerous providers are the most challenging. As are the ones with post-traumatic stress disorder and personality disorders. “You know, like borderline personality disorder,” he added.

I told him I got it; “I know someone with borderline,” I said.

***

I’m old enough to remember my mother before borderline. She was somewhere between 25 and 35, and she was sensitive, soulful, spontaneous, fun.

She was always on the floor with me, messing with play-dough, paper dolls, and Lincoln Logs, laughing, reading me so many books I committed a few to memory. Our days consisted of parks and public libraries, lemonade stands, candy stores, nature centers, dance lessons, dashing through the sprinkler.

That was her glory decade — she was born to have children, and by the age of 30, she had four. I’m now the same age as my mother during that decade, and sometimes I wonder if we’d be friends if I could meet her when we were the same age.

I’m sure we’d get along, but I’m not sure we’d relate to one other, for we were born for different things and our lives are nearly black and white. But we’d have one thing in common, it seems, for I, too, have entered my glory decade, or rather my glory days. It happens when you’re doing the things you were born to do — because you know what they are, because you’re physically, mentally, and emotionally healthy enough to do them.

I wish her glory days had extended beyond a decade, and I pine for what once was. Because she was gifted, so much more gifted, at her glory days than I am at mine.

The idea that she won’t return to her former self was once too painful to process. And in trying to process it, I searched for recovery in all sorts of places — in alcohol, exercise, sex, relationships, writing, and work. The only true recovery happened the day I accepted that I can’t control the outcome.

The day I accepted that not everyone who’s sick gets better.

***

The morning after we argued about my mother, the man and I lay in bed. Milky daylight streamed through the blinds and freckled the duvet.

“I’m sorry,” he said. “I was only trying to point out that you carry so much anger toward your mom, that I feel bad for how much pain you’ve experienced.”

No, I thought. That’s not what you said.

We edged closer until my head rested on his chest, a place that had always made me feel protected.

I remembered what he’d said the night before, the thing that stung the most — that I didn’t love my mother — and I began to sob.

“I love her,” I countered, fifteen hours after the fact. “I think she’s an amazing person. I think she’s done amazing things. I think she would have done more amazing things if she hadn’t gotten sick. I love her, OK?” My voice broke. “But don’t you see, Adam? Not everyone who’s sick gets better. Not everyone gets better.”

“I need to be more careful with your feelings,” he replied.

And I forgave him.

At least I thought I did; already, something had shifted between us.

***

Later that morning, we strolled, again, through the East Isles neighborhood. The sun was blinding, and sweat trickled off our bodies.

We held hands, and lattes from Lucia’s, and we talked about moving in together at the end of the year. We pointed out apartments and condominiums along Humboldt and Irving Avenues. We determined that this would be a good location to live.

I think about that conversation, sometimes, and about how we were lying to one another, professing plans we had no intention to keep. Three weeks later, we broke up.

***

The man is a staunch mental health advocate who publishes books about mental illness. And so, my comment about my mother must have come across as an assault on the very people he’s trying to serve.

Yet, I struggle with his accusations.

Because mental health advocacy is not only about advocating for the mentally ill, it’s also about advocating for their friends and families — the ones who perform the bulk of the caretaking, the ones most emotionally affected.

It’s about showing compassion and withholding judgment when friends and family admit anger, impatience, resignation, and a host of other “negative” emotions.

But also because his accusations imply resistance to the notion that not everyone who’s sick gets completely better — is capable of getting completely better — to the idea that maybe, after a certain point, it makes sense to invest our finite financial and emotional resources elsewhere — in the caretaker, for instance, in the sick who are capable of getting better, in the people who aren’t sick at all.

 ***

The day after the man told me that I don’t love my mother, I sobbed for several reasons.

The primary reason was the injustice of his statement. To declare that a person loves or doesn’t love another person is authoritarian; the speaker has assumed the role of subject matter expert. Yet, the man knew next to nothing about my mother, about the millions of moments that had transpired between us.

He had no idea what it felt like to be 15 years old and to witness my mother start to pull away from me for no apparent reason.

She began to hole up in her bedroom. She locked the door and slept for hours, often in the middle of the day. When she was awake she lashed out at me, again for no apparent reason, ridiculing my newfound acne, my changing body. She wouldn’t take me to get my nails done, to buy bras or makeup, like the mothers of other adolescent girls. She wouldn’t take me prom dress shopping, so a friend did, instead.

Her withdrawal felt deliberate, like desertion, for she was my mother, the person who was supposed to love me more than anyone in the world.

She had been adept at caring for children, but she seemed incapable of caring for an adolescent. In retrospect, it seemed as though she was in denial over what she was witnessing in me, as though it terrified her, and I didn’t understand why until my sister offered a theory, 16 years later, in a vineyard in Delano, Minnesota.

We shared a bottle of wine under a sprawling tree. I wept when she described the unspeakable things my mother’s ex-boyfriend did to my mother when she was an adolescent or young adult.

Things — we theorized — that made her associate adolescence and young adulthood negatively. Things that were comparable to being shot at, blown up, watching another soldier die — the types of things that have led to post-traumatic stress disorder in veterans I’ve known. Post-traumatic stress disorder is closely related, or equivalent, to borderline personality disorder, a Mayo Clinic doctor explained to me once.

The man had no idea what it felt like to watch my mother lose so much weight that she was down to ninety-something pounds, to spend New Year’s Eve in the eating disorder clinic, to hear while I was deployed to Afghanistan — and still trying to come to terms with the killing of three soldiers by a suicide bomber in Jaji Province — that my mother had tried to kill herself multiple times.

He had no idea what it felt like to watch my mother sabotage her own recovery again and again by not following through with doctors’ orders to eat x number of calories or exercise x number of minutes or socialize with x number of people x number of times per week. And in the aftermath of her repeated noncompliance with their orders, he had no idea what it felt like to wonder again and again how much control she had over her mental illness.

Because if she had some control and she was not getting better then it meant she wasn’t trying hard enough to get better. And if she wasn’t trying hard enough to get better then it meant that me and my sisters and my father weren’t worth trying hard enough to get better for.

***

In whom do we invest?

I’ve worked in public service for thirteen years, and this question hasn’t gotten easier; I struggle with social welfare — with who deserves it, and how much, and for how long. The dividing lines between whom we invest in a lot and whom we invest in a little seems arbitrary to me, fraught with conflict.

For instance, in 2014, the Affordable Care Act expanded the income threshold for Medicaid from 75 percent of the federal poverty guidelines to 133. In its eligibility calculations, the government subtracts five percent off the income of persons earning 133 percent or greater, so anyone earning up to 138 percent is eligible for Medicaid, too. In 2014, this equates to $16,104 for a single adult with no dependents.

But what about people earning 139 percent, a mere $117 more? Are they less deserving of fully funded health care? Where do we draw the line?

 ***

Prior to 2003, my ethical struggles with “in whom we invest in” were virtually non-existent. But then my mother was diagnosed with AMI and SMI, and they became personal.

Before Congress signed the Affordable Care Act, I watched my father agonize over the possibility that my mother’s health care costs could bankrupt him. That’s because, prior to the ACA, health insurance companies could cap their policies. My father’s cap was one million dollars, and my mother was almost there.

After exceeding the cap, he’d be compelled to pay for her care out-of-pocket, a frightening proposition, considering the cost of a single psychiatric inpatient hospitalization, emergency department visit, or electroconvulsive shock therapy treatment.

My father spoke to several attorneys. Their advice was universal: if my mother’s health care costs exceeded one million dollars, his most lucrative option would be to divorce her, and have a judge declare her a “ward of the state.”

Definitions vary, but a ward of the state is generally a person with no relatives, friends, or other parties who are willing or able to serve as their guardian. Wards often have developmental disabilities, mental illness, or are otherwise mentally or physically incapacitated, and they usually live in institutions that are funded by the state and federal government.

Again, laws vary, but were my mother to be declared a ward of the state, Minnesota would garnish half of my father’s estate. But that would be better than going bankrupt.

It’s easy to say “that’s life,” but my father has advantages that others don’t. He possesses an advanced degree and three decades of experience in mechanical engineering, a field whose average starting salary ($61,000 in 2013, according to the U.S. Department of Labor) already exceeds America’s median household income ($51,000 in 2013, according to the Census Bureau). Additionally, he’s had the foresight to live below his means; he consistently forgoes cable, a second car, a gym membership, and restaurants.

The point: if this ethical struggle could have happened to my father before the ACA, it could have happened to almost anyone.

***

In the days after we argued about my mother, Adam grew distant. He withheld sex, hugs, kisses; he stopped returning text messages, voicemails, and emails; he didn’t want to hang out.

At first, he denied that anything was wrong, but later he acknowledged that something was, that he was letting go, that his body — which no longer wanted to touch me — was ahead of his mind.

A few days before we broke up we walked, yet again, through the East Isles neighborhood. Near the lake, we encountered one of Adam’s old co-workers, and he introduced me, simply, as “my friend.” I knew, then, for sure, that it was over.

***

The argument about my mother was difficult, but we’d weathered others, too, and they invariably followed the same pattern: me saying something seemingly innocuous, Adam responding with an eruption of anger, a tantrum, and storming away.

For me, this anger was my “arbitrary line,” my “eligibility criteria,” my “138 percent of the federal poverty guideline,” the thing that informed whether or not to invest in him, in our relationship. On several occasions, I’d stated this clearly: If the eruptions and tantrums continue, I will end our relationship.

He understood, he said.

***

On a Sunday in late June, Adam returned from a weekend in Wisconsin. He was “sunburned and sad,” and he’d decided we should break up. “I’ve given some long thought about my eruptions and tantrums,” he wrote. “They’re not acceptable. To you, of course. But to me either. That’s the thing when you have such emotional reactions; they feel horrible to me as well. I haven’t been able to shake them, and I’m sure you haven’t either.”

And this line, which haunted me: “We have such joy and love between us, and that’s so rare, and I’m so upset to disrupt it. ”

We decided to disrupt it, nonetheless.

***

The day I met Adam, he interviewed me for an article he was writing about veterans. The interview lasted an hour, and afterwards we talked for another hour about running, reading, and writing. He told me I shouldn’t wait to get published again. That’s the power of the Internet, he explained. For the first time in history, writers don’t need permission to share their writing with the world. They can just put it out there.

Later, when my father asked about my interview, I told him that the best part was the journalist.

Soon after, we had a date at Mona’s. I brought him Rick Bragg’s It’s All Over But the Shouting and Janine Giovanni’s Ghosts by Daylight.

He was a 44-year-old editor and I was a 31-year-old ex-Army-officer-turned-public-health practitioner; our backgrounds were dissimilar, but we couldn’t stop talking. When I admitted I was struggling with my decision to return to Minnesota after a nomadic, 12-year, out-of-state existence, he lent me the quintessential Minnesota love letter: Bill Holms’ The Heart Can be Filled Anywhere on Earth.

In those early days of our courtship, I sent him essays I’d written on my mother and the war, a sending that’s always difficult, a contract of trust, an intimate exchange.

What followed was a 10-month relationship that revolved around reading and writing. And, other infatuations, too: meditation, cycling, cabins in Wisconsin, Prosecco, mental health advocacy, Harry Nilsson, New Orleans, Neil Diamond.

We talked about marriage and children, traveling the world together. “I can’t imagine not being with you,” Adam said. And I agreed; even though he was rooted to Minnesota, even though I was rooted to travel, even though we knew that balancing these desires would be a challenge.

Sometimes we whispered to each other the stories of our past loves. I knew a bit about the three women he’d loved; he knew a bit about my men. “But you’re my favorite,” he once assured me, a few weeks before we broke up. And I felt the same.

Afterwards, I found myself obsessing over the argument we’d had about my mother, and after some self-analysis, I identified a reason why: he’d condemned me for not investing emotionally in my mother when he’d chosen not to invest emotionally in me, his “love,” his “favorite” love.

***

In July, Adam and I met for brunch at Hell’s Kitchen, and we ate lemon-ricotta hotcakes, and drank champagne.

We spoke about the “in whom do we invest” quandary and he encouraged me to present a solution. But the more I wrote, the more I realized that this piece is not about the solution as much as the struggle.

The struggle over who we invest in, and how much, and for how long.

The struggle over where we draw the arbitrary lines — like the 138 percent of the FPG — that determine whom we invest in a little and whom we invest in a lot.

The struggle to decide — once, and if, we manage to stabilize a person or a situation — if it’s ethical to strive for something greater, a “return to a former self” or what could be, when our financial and emotional resources are finite, when we know that this investment may likely prevent investment or further investment in other deserving people, like my college-aged sisters who are burdened with student loan debt, like another lover.

It’s the most universal struggle of them all, a struggle familiar to anyone in any type of relationship with any type of human being:

When do you stop investing?

When do you let go?

 ***

On a Thursday in July, I met my parents at an ice cream parlor in the Linden Hills neighborhood. It was an overcast, balmy evening, and the mosquitoes weren’t out yet, so we ate our desserts in a courtyard behind the restaurant. My father and I had sundaes; my mother ate triple berry ice cream out of a sugar cone.

Eating triple berry ice cream is daunting when you have an eating disorder, and my mother ate so slowly that rose rivulets of melted ice cream streamed down the cone, between her bony fingers, and onto the table.

My father and I talked. My mother listened, but didn’t contribute to the conversation. At one point, I looked over. Her eyes had gone bug-eyed, as though invisible fingers were stretching apart her upper and lower lids. In situations where I’ve seen people display this expression, they’re usually in a state of shock, surprise, or fear, and their pupils are fixated on an object. But my mother’s pupils floated lazily, as though in a daydream. Her eyes remained that way for several minutes, even while my father got up for napkins and it was just the two of us.

I felt a crush of sadness, then, for I finally recognized that look; I’d seen it while volunteering at a nursing home in high school. At the facility, I’d been a candy striper and I delivered juice and water. Some residents were conversational when I arrived with their beverages. They gave me butterscotch candies and showed me pictures of their friends and family. Another group sat silently in their rooms, or in the corners of common areas, or at the ends of hallways. They were neglected by nursing staff because they weren’t demanding of anything, because they appeared oblivious, content.

This second group was my mother.

***

Later in the evening, after we’d finished our ice cream, the light drained from the day and the first mosquitoes emerged, pricking us. We got up and walked to our cars. Before I got inside my car, my mother reached out and wrapped her frail arms around me. “Good bye, honey,” she said.

It was one of the only thing she’d said all evening.

But what stayed with me most was the strength of her embrace.