A/HRC/44/48 breaking with the status quo in support of a rights-based paradigm shift. That shift must be welcomed as necessary for the future credibility of the profession. It is troubling to see such voices dismissed by the conventional (and dominant) psychiatric profession and its leadership.10 Those who speak against coercion and support the view that alternatives are safe are not unethical, negligent or derelict in their duty of care, neither do they represent “anti-psychiatry”. On the contrary, the Special Rapporteur has reviewed alternatives that have applied a harm reduction lens for decades and have diligently ensured risk minimization. 17. The combination of a dominant biomedical model, power asymmetries and the wide use of coercive practices together keep not only people with mental health conditions, but also the entire field of mental health, hostage to outdated and ineffective systems. States and other stakeholders, specifically the professional group of psychiatry, should critically reflect on this situation and join forces already on the way towards abandoning the legacy of systems based on discrimination, exclusion and coercion. C. Standardization and practice-based evidence 18. Many global mental health tools and technologies, including the WHO mental health gap action programme intervention guide (mhGAP-IG), are designed to be universal, meaning they are often standardized. While standardization is important for global work, it also overlooks understanding and practices that resist standardization owing to complexity or locality. 11 The design and implementation of such guidelines are never neutral and involve ethical and political work. Guidelines and protocols are shaped by the assumptions and life experiences of those who design and use them, by available evidence and by the local health infrastructure.12 19. Global guidelines in mental health, such as the WHO intervention guide, are evidence-based, with recommendations for interventions based on systematic reviews of randomized controlled trials. Locating guidelines in evidence-based medicine is important for political buy-in, but reliance on randomized controlled trials, which are mainly carried out on pharmacological interventions and are often funded by the pharmaceutical industry, may skew treatment recommendations towards drugs. Furthermore, far more randomized evidence is generated in specialized provider settings in high-income countries, which has questionable application in primary care settings in low- and middle-income countries. 20. A rights-based pathway to achieving more local relevance in global mental health might be to move away from evidence-based practice to practice-based evidence, which takes as its starting point local realities, possibilities and understanding of care. Research shows that mental health system reform in fragile and conflict-affected areas emerges through creative practices, experimentation, adaptation and the application of knowledge, as people deal with uncertainty and complexity in contexts where fundamental resources are sometimes lacking.13 10 11 12 13 6 See Niall Maclaren, “Ready, fire, aim: mainstream psychiatry reacts to the UN Special Rapporteur”, Mad in America, 26 January 2020. See Sara Cooper, “Prising open the ‘black box’: an epistemological critique of discursive constructions of scaling up the provision of mental health care in Africa”, Health, vol. 19, No. 5 (September 2015). See China Mills and Kimberley Lacroix, “Reflections on doing training for the World Health Organization’s mental health gap action program intervention guide (mhGAP-IG)”, International Journal of Mental Health, vol. 48, No. 4 (2019). See Hanna Kienzler, “Mental health system reform in contexts of humanitarian emergencies: toward a theory of ‘practice-based evidence’”, Culture, Medicine and Psychiatry, vol. 43, No. 4 (December 2019).