The night before her graduation from the University of Pennsylvania, Emily Cutler could no longer fight the feelings of despair that overwhelmed her. As much as she didn’t want to die, she also wasn’t sure she could go on living.

Cutler took double her usual dose of Xanax to try and make it through the night. The extra drugs made it difficult to walk and talk, and she ended up in the emergency room. Doctors asked her if she was suicidal, and she insisted she wasn’t. She was depressed and upset, yes, and as much as she wished she might get hit by a bus, she had no plan to harm herself. The physicians weren’t convinced and placed her in a glass room for 10 hours before they committed her involuntarily to a local psychiatric hospital.

For the next 48 hours, having been strip-searched and forced to take medicine, Cutler stayed in the hospital under observation. Eventually, the psychiatrists agreed that she posed no risk to herself and discharged her. To Cutler, the experience of forced treatment was unbearably traumatic.

In the aftermath of her experience, Cutler started a group called Southern California Against Forced Treatment, which argues against Laura’s Law and any kind of forced psychiatric treatment. Her goal is to provide support for people traumatised by AOT and inpatient commitment, and she has closely followed the expansion of Laura’s Law into Stanislaus County. Cutler specifies that her group isn’t anti psychiatry; it opposes only involuntary treatment. She points to what she calls psychiatry’s double standard: “When I said I didn’t want to be locked up, when I said I didn’t want treatment, it was instantly, ‘Oh, wow, she’s so sick that she doesn’t even have insight into her own need for treatment,’” Cutler says.

“With any other issue that someone might have, if they don’t want a certain type of help for it, or they don’t want to take a certain type of action, we don’t use that, usually, to further justify, ‘Well look, they really need the treatment now, and we can really force it on them.’”

San Diego forensic psychiatrist Nicolas Badre agrees that this can lead to problems: “We have the sense that people don’t have insight sometimes, like people seem to make claims or decisions that clearly seem against what we see as reality. It’s a different sort of path to go down, because then you sort of assume that everything the patient says [that] doesn’t agree with you, that’s lack of insight, or anosognosia. And it gives you free range to not listen to the patient. And that’s the real danger with it.”

In the end, Badre says what makes anosognosia difficult in psychiatry is a lack of neuroscientific data on the topic. “I don’t think we have evidence that schizophrenia intrinsically makes the brain have this issue.”

Maybe not, argues DJ Jaffe, founder of the think-tank Mental Illness Policy Org and an advocate for the severely mentally ill, but a variety of brain-imaging data shows that the brain of someone with schizophrenia functions differently compared to a neurotypical brain.

“The way I describe it is when you see somebody walking down the street [who thinks] they have a transmitter in their head, it is not because they believe they have a transmitter in their head. They know it. Their illness tells them so. And this is the group who won’t accept treatment, and treatment can restore their free will. Being psychotic is not an exercise of free will. It is the inability to exercise free will.”

Diagnosing anosognosia does not give anyone, court or physician, the inherent right to mandate someone to treatment. What anosognosia does, Jaffe says, is provide a simple, if hard-to-pronounce, term to explain why so many people with schizophrenia and similar illnesses often behave as if they are unaware that their thinking and behaviour are so dramatically different.

Just as importantly, he says, AOT works. Six years after Kendra’s Law was implemented in New York, officials had logged a 77 per cent decrease in psychiatric hospitalisations and a 74 per cent decline in homelessness for people in the AOT programme; incarcerations had dropped by 87 per cent. In 2015, seven years after the implementation of Laura’s Law, Nevada County reported that people who had completed the AOT programme spent 43 per cent less time in hospital, 52 per cent less time in prison and 54 per cent less time homeless than before they were treated.

In North Carolina, Duke University psychiatrist Marvin Swartz randomised individuals who met AOT criteria to receive either AOT or what he termed “assertive community treatment”, the Cadillac of public outpatient treatment, consisting of social services, including help with housing, food and transportation, as well as psychological and psychiatric services. AOT won, and although it wasn’t as crushing a victory as advocates may have hoped, Swartz’s data showed that longer court orders for up to nine months of regular treatment were associated with better outcomes than three-month orders and less-intensive treatment.

“There is this effect of the court order in terms of issuing warnings and reminders to the patient about adherence to treatment, but there’s also a more aggressive attempt by the service providers to make sure the person gets the treatment plan that is intended,” he says.

However, when British psychiatrist Tom Burns conducted a trial of AOT in the UK, he found different results. The UK equivalent of AOT is known as a community treatment order, although these are often used as a step down from inpatient care rather than an order in and of themselves. (Involuntary inpatient commitment in the UK is governed by sections of the 1983 Mental Health Act; being held in a psychiatric hospital and treated against your will is commonly known as ‘being sectioned’.)

Burns found that community treatment orders had no effect on how well patients did. They weren’t hospitalised any less and didn’t show any more signs of recovery. This, combined with a meta-analysis of UK and US programmes that showed equivalent results, transformed Burns from an enthusiastic supporter of AOT to a vocal critic.

“I became aware that this intervention that I’d been very keen on for 20 years, actually if you looked in the cold light of day at the evidence, was not a good intervention,” he says.

Both sides cite the studies that support their views and criticise the ones that don’t. Jaffe says you can’t compare the UK results with what AOT is trying to do in the USA because community treatment orders and AOT are fundamentally different. Burns, for his part, says that because patients in California and New York aren’t randomised to AOT, it’s impossible to tell whether they’re getting better because they have better services or because of the court order. Randomised controlled trials like the one in North Carolina are unlikely to be repeated, which means that both sides will continue to argue their points from imperfect data.