'Mental Illness' and Compulsory Treatment

In another thread:

http://boards.straightdope.com/sdmb/showthread.php?threadid=113744

the subject of compulsory treatment for people with ‘mental illness’ came up with a specific question about treatment in the UK. By treatment I mean- medication, social intervention, detention, talking-therapies for mental problems, and medical intervention for physical illness.

What do other people feel about the morality of enforcing treatment on people who have been diagnosed as mentally ill.

What are the limits on individual rights and what are the rights of the state and the public in these matters?

Should ‘Mental Illness’ affect a citizen’s rights, or should they be treated the same as a ‘Mentally Well’ person?

Similarly, what limits should apply to people with ‘Developmental Disabilities’, ‘Learning Disabilities’, or ‘Retardation’- what limits to treatment are there here.

Similarly, what limits of intervention are there for people who are said to have ‘Personality Disorders’ (especially those previously described as Psycopathy or Sociopathy)?

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That really depends on the mental illness I would think. Unless that person poses an immediate risk to life and limb of themselves or others there’s not much the majority should do to force treatment. Of course the answers to all your questions really depend on the severity and type of mental illness a person might have.

**

Unless the state has a compelling interest they should pretty much keep out of a mentally ill persons life. I imagine some mental illness can affect the rights of a citizen. For example a mental illness can render them incompetant to stand trial or a reason to incarcerated them against their will.
Marc

This is a tough issue. On the one hand, if it’s relatively easy to enforce treatment on someone, then law-abiding people may find themselves confined. Furthermore, confinement may be deliberately sought, e.g., by someone with a financial motive.

OTOH, many of today’s homeless are mentally ill. If they were confined and their medicines were supervised, many of them would lead much better lives.

My wife was able to eventually get her aunt into a supervised living structure, although it was quite difficult to get permission for her to act on the aunt’s behalf. We had to wait until the aunt was in such a bad state that she could be considered a danger to herself.

Also, confining some of these mentally ill people would help the rest of us. Some of them are dangerous or unpleasant.

I do not know of a perfect answer.

I, along with many other people, have been diagnosed with a mental illness by a psychiatrist. (I have also been subjected to forced treatment, although not for any sustained duration, thank God).

The medical model of mental illness (the one you’re probably familiar with) says that the manifestations in thought feeling and behavior that cause the diagnosis of mental illness to be applied are symptoms of an underlying biological condition of some sort. The proponents of this belief are either right or wrong, and we either do or don’t have some underlying biological conditions setting us apart from other people. Just for the sake of argument, let’s pretend that they are right (despite lack of convincing evidence).

Dear Psychiatric Establishment: You’re calling my built-in difference a disease doesn’t make it so Oh, are we “different”? Cool. We want affirmative action, babes. Protection against discrimination in employment and housing. Proportional representation everywhere. Bumper stickers: I’m schizophrenic and I vote. But on an individual-by-individual basis, if we don’t seek treatment or otherwise indicate that we find our “differences” to be a problem for us, they don’t constitute an illness. Just a difference. Like being gay or something. Now there’s a movement to emulate.

But What Are You Gonna Do About [Insert Horrible Violent Crime by Crazy Person Here]?

Well, either the behavior you wanna do something about is a crime, or it ain’t. If it is, prosecute. If not…well, OK, let’s move on to the next step, shall we? Either we go with a social system in which individuals are at liberty to behave except in ways explicitly proscribed by laws, and afforded the right to defend themselves if arrested and charged, and are liable only for things they actually did and not things that some charlatan thinks they mightdo, or we go with a social system in which we agree, openly, that yes we lock up people for being weird, for being unpredictable, for causing disturbances, etc., and that no we don’t accord people the right to be accused of a specific crime and to defend themselves against it, we’ll just trust the judgment of some experts. But if we’re going to go with that one, let’s leave “mental illness” out of it. It’s a red herring. The presence or absence of this hypothetical built-in biological difference is not something that can be determined on the basis of behaviors that are as loosely defined as the behaviors for which people can be committed as “mentally ill and dangerous”. (In most jurisdictions, it is defined no more precisely than = “in the opinion of a psychistrist licensed to practice in the state of XXXX”, meaning any damn thing the expert finds to constitute “dangerous”.)

But What Are You Going to Do About the Guy Standing in the Middle of the Fucking Freeway? Yeah, the one who thinks he’s “blessing” the inhabitants of the automobiles as they whiz by. Or the guy talking to people who ain’t there in the subway, dressed in old rags in minus 11 degree weather in January. Well, either these individuals would lose a competency hearing if one were to be held, in which case they would cease to be adults for most legal purposes, and someone else would make many of their decisions for them in loco parentis…or else they would NOT lose such a hearing, despite making a lot of judgment calls that you’d find weird and self-destructive. The competency hearing exists because the law recognizes the importance of giving an individual the opportunity to disprove allegations of senility or delirium – otherwise the greedy kids could have rich old Grandpa put away and his millions placed in their administrative hands! So once again “mental illness” is a red herring. It doesn’t matter WHY a person is or is not competent. I should have the right to make my own decisions as a legally competent schizophrenic.

But What If They Don’t Realize That the Meds Would Help Them? Fine, I’m all in favor of informed consent. It isn’t practiced much in the lunatic bins, that’s for sure. The more complete the information placed at our disposal regarding the pills and procedures they recommend for us, the better. I’d love to see a mandatory double-blind test with a control population of nonschizzies and a 50/50 division of treated and untreated and a ten-year followup for every pharmaceutical and convulsion-induction and neurosurgical assault they have in their arsenal of psychiatric treatments, and the results required to be made available to every diagnosed person who is asked to consider submitting themselves to them! (Any of you “normal” people wanna volunteer to be part of the control population?). Meanwhile, though, a psychiatric treatment once refused should not be “offered” repeatedly, especially not in a confined setting, or the right to refuse is pretty meaningless. As in, “I said NO, now don’t ask me again”.

I went to get my drivers license renewed and they asked me if I had ever been a patient in a mental hospital. I did not know that they could ask you that! Much of the basis of the success of mental treatments is the privacy involved, and here it’s going to be noted on your driving record if you spent even a couple of days in a hospital for depression!!

BTW, I said no.

As for enforced treatment, well, look. Anyone without the means to get private therapy here today knows the nightmarish and often lacking therapy anyone mentally ill gets through disability. Medication is often expensive and unobtainable while programs to provide medication are overloaded and often iffy. The system is overloaded and under staffed as well as being under funded by the government for almost 10 years. State Mental Hospitals have been closed down forcing them to dump thousands of barely functional people on the street or reduced tremendously in size. Conversely, private hospitals and private care has grown into big business but only for those who have the money.

So, government funded, forced therapy in the USA is unlikely. It is about as likely to happen as getting the gas conglomerates of the US to stop cheating us on gas prices.

As a result of personal (if somewhat peripheral) experience, I am a staunch advocate of forced treatment (within sound judicial bounds), even if the threat is not immediate or imminent!

If forced treatment were a fact, then the judges and others would have been able to act responsibly to prevent a horrible tragedy and spare not only the life of a wonderful woman, but also her children’s trauma and pain. A schizophrenic man murdered his mother in a horrible fashion out of some extreme distortion of love, in order (in his mind) to “spare” her from an utterly preposterous and non-existent danger that he believed was threatening her.

The man had no history of violence, but since deciding to stop taking his medication was known to often be separated from reality and subject to extremely exaggerated fears for the safety of himself and his loved ones. He drew up exorbitant lists of enemies and perceived threats; a classic paranoid. He was being cared for by his mother (the woman he would eventually murder), but no matter how desperately she pleaded with mental health providers, social workers, and judges, they lacked the power to force him to take his medication or to remain hospitalized. The day came when his fears for his mother’s safety grew to such insane proportions that he butchered her to “protect” her from this imaginary danger.

But the horrible damage his madness wrought didn’t end there: Another son discovered the nightmare of his slaughtered mother and now must try to cope not only with that, but with his brother’s illness as well. The insane man is likely to be found not guilty by reason of mental defect, and his once-healthy brother must somehow deal with him back in the real world, but STILL without any way to force him to take his medications!

There must be a pact between the seriously mentally ill and society: They have a right to live among us if, and only if, they keep up with their medical regimen. If they forgo that responsibility, they forgo that right!

We MUST find a tolerably humane way within our legal system of enforcing such a pact. The choice would remain with the seriously mentally ill: Take your medication or abdicate your right to your physical liberty.

Well, that’s certainly a lot better than the people who want forced treatment based on what one doc says (I’ve seen that before on this board). But, the ‘judicial’ part worries me - are you talking about a snap ‘restraining order’ type of proceeding, or a full jury trial? I think that the appropriate standard for forcing treatment on someone should be a jury trial - you’re not talking about temporarily mildy restraining someone, after all, you’re talking about imprisoning them and making them take mind altering drugs. Surely, someone who’s only accused of being insane, not even of having done anything wrong, deserves the same due process protection as one of the 9-11 hijackers.

And the ‘even if the threat is not immediate or imminent’ is just plain scary. That seems an awfully, awfully broad standard, and doesn’t seem at all to fit with the entire concept of innocent until proven guilty. Are we going to use psychiatrists or psychics to make these judgements? This seems an awful lot like allowing people to say ‘I don’t approve of his behavior and, even though he’s not dangerous, let’s give him some mind-altering drugs to make him less annoying’.

The important thing to remember in this sort of debate is not just what happens to the paranoid schizophrenic who starts killing people; it’s what happens to someone a bit outside of the normal curve. Gays are an obvious example; until relatively recently, homosexuality was considered a mental illness. Would your system of forced treatment have been able to lock up gays by the psychiatric standards of a few years ago? What about people who don’t like a particular powerful group, are libertarians going to risk being forced into ‘treatment’ for not trusting the government, or greens for not trusting corporations? Sounds like paranoia to me, they certainly need some treatment. What about anti-abortion types - some of them bomb clinics, so even though the threat is ‘not immediate or imminent’ we really need to treat all of them. And anyone involved with a suicide bombing plot is obviously insane, so instead of bothering with trials, evidence, etc. for the accused 9-11 hijackers, why don’t we just get a shrink or two in front of a friendly judge to have them declared insane; then we can lock them up without this pesky ‘speedy trial’ nonsense, and we can give them whatever regimen of drugs we feel are appropriate.

Involuntary committment has been abused before in the US, and was a really popular sport in the old USSR. People who want to lock other people up and force drugs on them without a trial or even a standard of imminent threat scare me.

You used to be able to easily force treatment on an individual, but things have changed. I cannot recall the famous guys name, but a movie was made about the case, where, he, being hideously wealthy and very politically connected, resented the fact that he had a rebellious daughter who chose not to listen to him. She was out on her own and she defied him once too often so he had her committed and ordered a frontal lobotomy on her.

They did the deed, leaving her docile and dependent and no one ever went to jail over this butchery.

Years ago, it did not take much to get a person shoved into an institution and that power was abused terribly. Now, things have rebounded and patients have justifiable rights, though in some instances, these rights may trample on the rights of others.

december:

Some of you normal folks are pretty disgusting yourselves.

Ambushed writes:

Actually many of us would prefer that we not have to live among you. Why don’t you leave? Hmmph, I suppose that isn’t practical. There really should be a pact between you people and us: You have a right to go unmolested if, and only if, you quit trying to change the way our brains work. If you forego that responsibility, we have the right to …[insert grisly slasher-movie sound effect].

So are you saying that you’d be just fine with a system in which a cohort of MDs (or some other flavor of designated expert) decides who is or is not a nut, and in which all people so determined to be nuts are forced to take neuroleptic drugs? You aren’t interested in any protections against being labeled in this fashion yourself? Are you really so goddam sure that you’re so different from me that it could never happen to you? Are you naive enough to think that all of the MDs (or other experts) will always be relatively unbiased, culturally eclectic enough to view a wide range of human behaviors as ‘normal’, sociologically informed enough to distinguish between behaviors that are symptoms of situations and behaviors that are symptoms of neurological/biological circumstances?

Are you ignorant of the stats on the reliability of psychiatric diagnoses?

Are you stupid enough to think that none of this matters?

Hey, AHunter3, I’ve seen you post a couple times that there’s “a lack of convincing evidence” that mental disorders (not my favorite term) have a biological basis. Could you provide a cite for that? I don’t disagree with you; I just don’t know anything about the topic, and I care very much.

Sure!

I’m en route home at the moment but I’ll compose it for you later this evening.

OK, a http://members.aol.com/ahunter3/psych_inmates_libfront/vol_1/Hill/Hill_InadeqData.html]cite and some discussion.

The link goes to my own web site, where I have excerpted with the author’s permission some chapters from David Hill’s The Politics of Schizophrenia. It is somewhat out of date, but the situation with regards to empirical demonstrations of the existence of mental illness in the medical-model sense of the word had not changed. (Also, while Hill is focusing on schizophrenia specifically, his logical arguments apply equally well to other subforms of mental illness).

To pick up with Hill’s main arguments, let us consider the medical profession overall, and the notion that a diagnostic category has to meet some criteria in order to be useful. A diagnosis of “polio”, for example, is useful in large part because several doctors would independently arrive at that diagnosis after examining the same patient. The medical description of “polio”, and the ways in which you can test for it, the telltale signs of it, etc etc, are clear-cut enough that the same patient would receive the same diagnosis regardless of which doctor was doing the assessment. Also, and this is important, it is a sufficiently rarefied diagnosis that you could not attribute the concurrence of all those doctors to a tendency on the part of doctors to diagnose practically everyone who has a little bit of difficulty walking with “polio”. Polio can therefore be distinguished from what it is not. It can be distinguished from the ordinary healthy condition of people who don’t have polio, and it can be distinguished from a wide variety of other ailments that a person might have instead.

Not every medical diagnosis passes this test of diagnostic usefulness. Some diagnostic categories are considered controversial, e.g., Epstein-Barr and Multiple Chemical Sensitivity and fibromyalgia. Some doctors might say that it isn’t clear that the diagnostic criteria sufficiently differentiate the diagnosed person from a person who experienced subclinical degrees of tiredness and pain, and some doctors might say that the diagnostic criteria do not sufficiently differentiate the diagnosed person from people suffering from a different ailment instead. (In the case of fibromyalgia, for example, there is a Dr. Lowe who believes that most “fibromyalgia” is undiagnosed or undertreated thyroid conditions).

Now let us move on to mental health and mental illness. An extremely wide range of behavioral and emotional circumstances can cause an individual to be either unhappy themselves or disturbing to others, ranging from bad marriages to bad hormones, malignant bosses to malignant brain tumors, depressed neurotransmitter function to repressed political expression. The “mental illnesses” are of course among them.

Our species has entertained and continues to entertain a wide variety of theories about the causes and possible remedies for these things, ranging from religion to hobbies to involvement in the creative arts as an avenue of expression, but the best success stories came from the medical research laboratory. Understanding the causes of epilepsy, syphilis, brain tumors, and whatnot often led to cure or at least a notion of how to maintain the afflicted individual. In the 19th century, it was believed by early researchers that the remaining causes of these human malaises would similarly be known soon. But the ones that are still called “mental illness” are mainly the ones that didn’t yield up any specific secrets. The “mental illnesses” are still diagnosed on the basis of behaviors and self-reported mental and emotional experiences. Despite all the theories and optimistic assertions that schizophrenia or bipolar disorder or depression would soon be proven to be an inherited ailment of the neurotransmitter system, the research that would nail it down and cause them to yield their etiological secrets just hasn’t taken place yet.

Meanwhile, let’s look at those “mental illnesses”. First you’ve got your basic schizophrenia. Then there is bipolar disorder (the artist formerly known as manic-depressive psychosis). Finally we have clinical depression. Those are your big three. Can each of them be distinguished from the other two and from the normative healthy person’s array of emotional and psychological states? In order to be able to answer “yes”, it would have to be true that the same individual if seen by different doctors, each of whom had no awareness of any prior diagnoses for that particular individual, would receive the same diagnosis. David L. Rosenhan’s famous article, “On Being Sane in Insane Places”, is a typical indicator that such is not the case. Basically what you’ve got is one category for nuts who simply don’t make sense (schizophrenia), one category for miserable folks who wish they were dead (clinical depression) and one for people who have mood swings (bipolar disorder). The overlap of all three categories with what they are not is huge and frightening.

Does mental illness “exist”? Well, certainly there is something (or many somethings) from which many people suffer, much as the misery of people who have gone to their doctors and received diagnoses such as Epstein-Barr or fibromyalgia is real misery. But do we know what it is, what causes it, how it “works” to cause the suffering, and what, ideally, is to be done about it? No, not really. Some people do find blessed relief by taking psychiatric meds, but others find them worse than the sufferings they are supposed to help. And to be sure, most of the psychiatric treatments were adopted because of their efficacy at controlling symptoms for institutional convenience, and they are still widely used as immobilizing agents or punishments for unwanted behaviors. Does “mental illness” exist? Possibly. Lunacy exists. Madness exists. The only thing we know about them that we didn’t know in the 19th Century is that a century’s worth of attempts to find the etiology and dynamics of the “mental illness” yields damn few findings. To some folks’ way of thinking, that would tend to indicate that they are looking in the wrong place, and that lunacy and madness are caused by other things instead.

First, great post, Hunter. I have often thought that mental illness diagnostics were a crap shoot. But I don’t know what the answer is. The majority of schizophrenics are NOT a danger to themselves or others, from what I’ve read, but society seems to focus on the few in the extreme.

You’ve stated that you believe lunacy and madness exist. When a person has a history of violent behavior, what do you do?

I’m not being judgmental here, either. I tend to lean against any sort of government intrusion into a person’s body. But do we just let a known violent patient live and work freely in society? We do it with people that AREN’T “mentally ill”, such as Mike Tyson, O.J. Simpson, and any number of gangbanging sorts that have been locked up for a stint in jail and then released.

We live in a free society, and that ain’t perfect! I am very interested in hearing what alternative you think would serve us well.

Exactly. Equal treatment for equal behavior. Equal standing before the law and all that. Mind you, I’m not saying the criminal justice system is any great shakes at curing criminality, either, but I see no reason that a schizophrenic asshole jerk should not be free to continue acting like a jerk under circumstances where a sane asshole jerk gets to do so.

So what do YOU think should be done? Personally, I think my chances of getting fucked up by a mental patient are worse than getting fucked up by the kid down the street. But that doesn’t really solve the problem, does it? When do we weigh the odds? I suppose the “3 strikes” law attempts to level the playing field, but I don’t buy into that, either.

I have always had an interest in psychiatry and I have diagnosed my fair share of people with mental illnesses. To simplify pychiatric diagnosis to merely three disorders is to to reduce it to absurdity. I’m not saying that AHunter3 does not make some good points – she does. But I’ve seen the other side of the coin too, and some of the points made in this thread need correcting.

Most importantly, the facts are schizophrenics do NOT constitute an increased danger to other people, and acts of violence to others are rare. More commonly, schizophrenics are abused and exploited by others. I do not wish to perpetuate the myth of the schizophrenic axe-murderer. On the other hand, people with schizophrenia and major depression have a very significant risk for suicide, as high as 40% in some populations. Many people would consider that this means they do pose a significant danger to themselves; some would insist on their right even to suicide and who am I to say what’s right?

Most diseases are diagnosed on the basis of certain criteria that the medical profession by and large agree on. (As an aside, it is interesting when they do not agree. The American Diabetes Association suggests a diagnosis of diabetes be made when the blood sugar exceeds 7.0 mMol/L. Most hospitals use 7.8 mMol/L as their cut-off. Using one or the other would create an additional three million diabetics, many of whom will never have problems with their “diabetes”. Some will be benefit by being detected by earlier screening; many are merely labelled as diabetics and pay higher insurance and suffer other problems for the sake of a definition). The criteria for fibromyalgia are agreed upon, the etiology is hotly debated.

Since the tests for psychiatric disease are not as concrete as doing a blood test, diagnosis relies on the consensus opinion of psychiatrists in the DSM-IV, etc. Reducing the diagnosis to criteria does mean different psychiatrists are likely to make the same (or very similar) diagnosis. When they do not make the same diagnosis, it may be because the patient shared a different piece of their past and does not necessarily mean this approach is flawed. But even many psychiatrists concede the approach is problematic – if the DSM is designed not to miss people with a diagnosis (be “sensitive”), it is less sensitive (people without the “illness” are labelled as having it. The reverse is also true, and good psychiatrists are reluctant to label people they have not seen on multiple visits. Polio eithr exists or it doesn’t; psychiatric disease can exist at some times and be gone during others.

But when I read in Adbusters or Scientology or other Liberator writing that the problem is psychiatry, I get concerned. Sure, psychiatry is far from perfect. I certainly agree with your concerns regarding consent issues in institutionalized patients. But many of the medications used for treating depression and psychosis and anxiety work and many of the people who take them think their lives are better for having done so. And when you see a lot of patients with illnesses, you see the criteria listed in the DSM-IV make sense and can be applied fairly consistently. I do not agree with all of the DSM-IV criteria: for certain diseases the criteria are too general (e.g. while I think Attention Deficit Disorder is real, I also think it is uncommon and for this disorder, people without the disease satisfy the criteria too easily). But the criteria for schizophrenia and other diseases on the manic-depressive spectrum are better written. I don’t think they are a crap shoot. I think both psychiatrists and other doctors are aware of the limitations of psychiatry.

Does mental disease exist? I think it does, but when 5% of the population has a problem, you do have to wonder to what extent it is a normal variation. This cannot be done (the line you draw is always wrong), but for people with extreme dysfunction, life can be made better through psychiatry, although without doubt psychiatry makes the lives of some people worse (just like being labelled a “diabetic” with your blood sugar of 7.3) If we knew more about neurology, I’d feel more comfortable with psychiatry, perhaps in the same way I’d feel better about fibromyalgia if I could see it on an X-ray; the problem is our diagnostic tools aren’t good enough. Individual rights are pretty important to me and anyone should have the right to vote and be equal under the law. But the notion of preventing harm is important too. People who are impulsive for 0.1% of the time can easily kill themselves during their acute mania; this isn’t so much a well-reasoned individual choice but a random act of self-violence without pre-medititation that harms families and harms society. Some people do need to be protected from themselves, but who watches the watchmen?

Echokitty, I will compose a post later on in which I will voice my opinions on what I think should be done instead, but let me be clear on this much: my inability to provide a viable alternative in no way excuses imposing forced psychiatric treatment on competent people. Sorry, but one of our classic pet peeves is people asking us “But if forced treatment is wrong, what are the alternatives?”. Well, gee, one alternative is “don’t do it”. There may be other things that can also be done, but there’s no reason that discovering them should be our responsibility, is there? The inherent wrongness of forced psychiatric treatment stands regardless.

Dr Paprika, you are right at least to a degree. Certainly there are people who benefit personally from psychiatric drugs, and more power to them (and their supportive shrinks!), as long as this isn’t used to excuse forced treatment. And I do acknowledge that I’ve oversimplified the range of psych diagnostic categories. Nevertheless, “mentally ill” is used as an explanatory device whenever otherwise inexplicable and disturbing behavior rears its proverbial head, and once the label has been applied, the behaving person is at severe risk of depersonalization and stigmatization, not just the informal kind pertaining to people’s attitudes and beliefs about them but also the formal kind having to do with fundamental freedom and rights and access to social privileges enjoyed by those not so labeled.

Right now, in this thread, we have a self-identified mental health professional stating that anyone who would attempt to have sex with their pets is mentally ill. And, indeed, I would not be remotely surprised if a person who was found to be doing that were to be escorted to the emergency room and committed on the basis of that behavior to involuntary psychiatric incarceration. But I could not have concocted a better example of the conflation of “crazy disturbing lunatic behavior we don’t understand” with “mentally ill” if I’d been left to my own devices, and therein lies a good portion of the problem: if, as you say, the formal diagnostic criteria for the various name-branded mental illnesses are considerably tighter than I’ve described them, the fact remains that in practice, especially with regards to forced treatment, those criteria are applied in a very loose manner.

The first time you sit in a NARPA convention hall stuffed with people who were involuntarily subjected to forced treatment for being “nuts” (usually in ways considerably less weird than shtupping the puppy), it modifies your perspective on the issue in a really fundamental and permanent way.

As opposed to being subjected to forced treament of one’s own accord, of course…

:o

AHunter

So as long as you’re still in denial, you aren’t really ill? Does this apply to other forms of illness? Is your arm not “really” broken if you refuse to see a doctor about it?

[
I think this is a false dichotomy. “Treat them like everyone else” and “put them in jail” aren’t the only two options. I don’t think we should put blind people in jail ,but that doesn’t mean we should treat them the same as everyone else. For instance, we shouldn’t give them driver’s licenses.

This is not a good analogy. A broken arm causes pain and prevents you from functioning properly; therefore, it needs to be fixed. Not everyone who is “mentally ill” is in pain or has any trouble functioning. Why fix what’s not broken?