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Critical thinking and professional judgement for social work

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Critical Thinking and Professional Judgement for Social Work (Post-Qualifying Social Work Practice Series)

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Critical Thinking and Professional Judgement for Social Work (Post-Qualifying Social Work Practice Series) Paperback – 17 Nov. 2011

There is a newer edition of this item:.

ISBN-10 0857257536
ISBN-13 978-0857257536
Edition Third
Publisher Learning Matters
Publication date 17 Nov. 2011
Language English
Dimensions 16.51 x 0.64 x 24.13 cm
Print length 96 pages
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About the author.

Lynne specialises in professional educational development within post-qualifying (PQ) and continuing professional development (CPD) programmes at the National Centre for Post Qualifying Social Work and Professional Practice at Bournemouth University. Here she has helped design and develop a number of units for both health and social care markets. She facilitates learning about critical thinking, professional reasoning and judgement, evidencing professional learning, leading and enabling others, and service improvement methodology. Lynne’s professional and research interests focus on the nature and development of professional reasoning and judgement, and her Professional Doctorate has helped create a unique set of assessment criteria for their development and evaluation within academic written work.

Keith holds professional qualifications in nursing, social work and teaching; and academic qualifications in nursing, social work and management. He has worked in the education and training field for over 30 years, working for three universities and three local authority social work departments. Currently he is the Director of the National Centre for Post-Qualifying Social Work and Professional Practice at Bournemouth University and the Director of the Centre for Leadership Impact and Management at Bournemouth. In 2005 he was awarded the Linda Ammon Memorial Award, sponsored by the then Department for Education and Skills, a prize awarded to the individual making the greatest contribution to training and education in the UK. His main academic interest lies in the fusion of academia and professional practice to help improve professional thinking and practice.

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Publisher ‏ : ‎ Learning Matters; Third edition (17 Nov. 2011)
Language ‏ : ‎ English
Paperback ‏ : ‎ 96 pages
ISBN-10 ‏ : ‎ 0857257536
ISBN-13 ‏ : ‎ 978-0857257536
Dimensions ‏ : ‎ 16.51 x 0.64 x 24.13 cm
154,017 in Social Sciences (Books)

About the author

Lynne rutter.

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Critical Thinking and Professional Judgement for Social Work

Lynne Rutter - Bournemouth University, UK
Keith Brown - Bournemouth University, UK

This is a terrific little text that outlines the importance of critical reflection and gives some really good advice about writing. Short and easy to read, this book has been recommended to social work practitioners undertaking postgraduate qualification alongside their full-time work commitments.

Critical thinking is the area of practice that most of my students have difficulty with. This book is accessible to them, and provides clear definitions, explains them, and provides practical suggestions on improving this vital skill.

As someone who teaches ASYE modules, this books has provided practical and theoretical support for a number of qualified workers.

The book is very easy to navigate and sets out the basic principles of critical thinking in language accessible to social workers. An excellent choice for any practitioner.

A very good resource with some very well presented,accessible and useful examples in relation to key concepts explored to help students with previous social work experience to develop critical thinking skills.It provides a rich resource for continuous professional development. The series of examples presented are very helpful for students seeking tools to help them be more critical in their academic work.

Perhaps a wider range of formats might have been used to present some of the material, inspire creativity and to suit a wider range of learning styles especially given the target audience of those with more practice experience but perhaps less confidence in their academic writing skills. More attention might also have been given to critical thinking and presentation of ideas within the interprofessional context of practice.

A very useful addition to any aspect of a social work programme focussing on development of core skills of reflective practice.

Lynne Rutter

Keith Brown

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Article Contents

Introduction, research design.

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Social Work as a Human Rights Profession: An Action Framework

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Didier Reynaert, Siebren Nachtergaele, Nadine De Stercke, Hildegard Gobeyn, Rudi Roose, Social Work as a Human Rights Profession: An Action Framework, The British Journal of Social Work , Volume 52, Issue 2, March 2022, Pages 928–945, https://doi.org/10.1093/bjsw/bcab083

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Human rights are foundational to social work, as recognised in the global definition, leading many to consider social work a human rights profession. Although human rights has become an important compass for social work, comprehensive frameworks for understanding the ‘practice’ of human rights in social work are still limited. Only recently attempts have been made to fill this gap. This article seeks to continue these efforts and contribute to a better understanding of how social work constructs, deconstructs and reconstructs ideas of human rights in daily practice. We investigated the following research question: ‘How do social workers “act” when using human rights as a framework for practice?’ We used a qualitative research design consisting of ethnographic research and focus groups, with both social workers and service-users participating. Based on our research, we developed five building blocks for an action framework for human rights in social work: (i) systemworld-oriented action; (ii) lifeworld-oriented action; (iii) participatory action; (iv) joined-up action and (v) politicised action. These building blocks give a comprehensive account for the discursive practice of human rights in social work.

Human rights are foundational to social work, as recognised in the global definition, leading many to consider social work a human rights profession ( Healy, 2008 ; Staub-Bernasconi, 2016 ; Mapp et al. , 2019 ). Staub-Bernasconi (2016) , together with Gatenio Gabel (2015) , among others, acknowledges the historical connection of social work with human rights. In recent years, the recognition of social work as a human rights profession gained renewed attention in social work scholarship. In his book ‘ Practicing rights. Human rights-based approaches to social work practice ’, Androff (2016) makes a comprehensive account of the state of human rights in social work. He shows how (inter)national social work organisations adopted human rights in their codes of ethics, how social work scholars increasingly published books and articles on human rights or how social work education developed a range of training materials and educational programmes on human rights. Based on his analysis, Androff concludes that ‘The growth of scholarship and education focused on human rights suggests that the field is turning towards human rights, rediscovering its rights-based roots. It is now undeniable that there is a consensus that human rights are important and relevant to social work.’ ( Androff, 2016 , p. 10). These observations are in line with conclusions of Cubillos-Vega (2017) , who conducted a study on the scientific output on human rights in social work based on articles published in international indexed journals between 2000 and 2015. She notes that in recent years, the academic output on social work and human rights gradually increased. However, Cubillos-Vega’s (2017) study also reveals that published articles were primarily of theoretical nature. From the fifty-seven articles analysed, hardly one-third (sixteen) were of an empirical type. This trend is striking, Cubillos-Vega argues, because of the nature of the discipline of social work, taking a position between theory and practice. Already in 2012, Ife came to a similar conclusion: ‘Much of the academic debate about human rights remains at the theoretical level; less has been written about the practice of human rights. … There is little articulation of what it means in practice for professionals to claim that their work is based on human rights, and so human rights remain a “nice idea” rather than a solid foundation for the development of practice theories and methodologies.’ ( Ife, 2012 , pp. 10–11). Despite the ground-breaking work of several pioneers in the domain of social work and human rights (e.g. Reichert, 2003 ; Wronka, 2008 ; Ife, 2009 , 2012 ; Lundy, 2011 ), the practice of human right still remains a black box. To date, social work scholarship insufficiently succeed to gain practical knowledge showing how social workers ‘act’ when using the framework of human rights. Together with Ife, we acknowledge the presumption that human rights in social work have a discursive character, as they need to be permanently constructed, deconstructed and reconstructed throughout social work practice. ‘Social workers need to see themselves as active participants in this discursive process, and indeed social work practice itself can be seen as part of the ongoing process of the reconstruction of human rights. It is partly through social work practice that human rights are operationalised, and hence defined.’ ( Ife, 2012 , p. 133). Social work should recognise its actorship or agency in constructing human rights and social work scholarship should conscientiously scrutinise this construction process of human rights through social work practice.

Recent launches in social work scholarship rose to this challenge. In 2015, the SpringerBriefs in Rights-Based Approaches to Social Work were launched. The series aims to develop a social work practice grounded in human rights by presenting and reflecting on new methods ( Gatenio Gabel, 2015 ). The Journal of Human Rights and Social Work, established in 2016, has similar aims. In the inaugural issue, the editors-in-chief state that the journal ‘offers the opportunity for educators, practitioners, administrators, and students in this and related disciplines to have a voice and to expand their knowledge base on issues within human rights practice, knowledge of human rights tools, and to develop skills practicing from a human rights perspective’ ( Gatenio Gabel and Mapp, 2016 , p. 1). Additionally, several social work scholars have been developing practice approaches for human rights in social work. Androff (2016 , 2018 ), for instance, seeks to integrate the five-principles framework of human rights (human dignity, non-discrimination, participation, transparency and accountability) into the social work arena. According to Androff, this framework can offer an integrative account across a wide range of social work practices (see also Mapp et al. , 2019 ). One step further is the proposal of McPherson ( McPherson, 2015a ; Mapp et al. , 2019 ; McPherson and Abell, 2020 ), which contains a comprehensive framework for human rights practice in social work (HRPSW). It comprises three pillars of practice: a human rights lens, human rights methods and human rights goals. McPherson (2015a ) explains that the HRPSW model can be useful for both social work practice and social work education. What these practice models demonstrate is the increased academic interest in practice approaches of human rights in social work ( McPherson, 2015b ).

In this article, we build upon these efforts and present an action framework for human rights in social work. Our action framework expands the above mentioned models in an important way. It provides an understanding of human rights in social work in the context of a different welfare regime. Both the studies of Androff and McPherson are USA based, thereby confirming Cubillos-Vega’s (2017) observation of an Anglo-Saxon hegemony in social work scholarship on human rights. However, different social welfare regimes show different traditions of social work ( Lorenz, 2001 , 2008 ), associated with different understandings of human rights ( Alseth, 2020 ). Our study was conducted in Belgium, which is generally conceived as a conservative welfare state, distinct from the liberal welfare regime of the USA. Conservative welfare regimes have a certain tradition with social rights in particular. Additionally, conservative welfare regimes are characterised by a welfare state architecture of corporatism, balancing civil society’s interest and state power ( Esping-Andersen 1990 ; Lorenz, 2001 ; Dean, 2002 ). It is within this corporatist structure that human rights take shape with social workers developing a human right-based practice.

Because of the open character of our research question (‘How does social workers act when using human rights as a framework for practice?’), we chose a qualitative research design ( Shaw and Holland, 2014 ; Carey, 2012 ), developed in two parts. The first part consists of ethnographic research; the second, of focus groups.

Ethnographic research

Ethnographic research allows one to understand complex practices in their ‘natural setting’ ( D’Cruz and Jones, 2004 ) by being ‘ involved in the ongoing, daily world of the people being studied’ ( Fielding, 2008 , p. 269). Being part of and participating in human-rights-based practices in social work allows the ethnographer to get to know the logic, dynamics and meanings behind these practices. For this study, collaboration was set up with one of the eight regional institutions for community development in Flanders, Belgium. These institutions are recognised and subsidised by the Flemish government through the 1991 Act on Community Development. The overall mission of the institutions for community development is to contribute to realising the right to a decent life for people living in vulnerable life conditions. The institutions for community development explicitly use human rights as a framework to realise their mission. In particular, they focus on social rights as they are recognised in the Belgian Constitution: the right to decent housing, the right to education, the right to social security, the right to health care, the right to work, the right to a healthy living environment and the right to cultural and social development. The participatory approach is typical for the work of the institutions for community development. They are not working just ‘for’, but above all ‘with’ people living in vulnerable life conditions. Therefore, the institutions for community development are an interesting case for investigating the meaning of social work as a human rights profession. Our research took place in the institution for community development in East Flanders, one of the five Flemish provinces in Belgium. In collaboration with the institution, we decided to select two human rights domains to study: housing and education. These domains could be considered as exemplary to study social work as a human rights profession.

Research methods used in ethnographic research can be very diverse. For this study, we used a documentary review, participant observation and conversation-style interviews with key informants ( D’Cruz and Jones, 2004 ). For the documentary review, we used documents produced by social workers who are active in the institution for community development. These documents gave us an insight into the work of the institution regarding the role of social work in ‘doing’ human rights. Policy notes, minutes of meetings, annual reports, etc. were all considered. Because in ethnographic research, it is important to understand the particular historical and socio-cultural context of the practices being researched ( Bryman, 2012 ), additional documents produced outside the institution for community development were selected. They were used to develop an environmental analysis in order to ‘capture’ the work of the institution in relation to the broader policy context (demographic data, a ‘map’ of the available welfare organisations, the history of particular neighbourhoods, etc.).

For the participant observation, the relevant activities to understand the work of the institution for community development were selected in mutual consultation with a ‘gatekeeper’ ( Fielding, 2008 ) of the institution. Gradually, the researcher also spontaneously took part in a variety of activities. Participation by the researcher was always overt (see Bryman, 2012 ). Field notes were kept during or directly after the participant observation. These field notes took the form of detailed descriptions of particular events and of people’s actions in these events, as well as the researcher’s initial reflections on these events. In total, participant observations took four months and more than 400 h. Time was divided equally between the domains of education and housing.

The third method we used was conversation-style interviews with key informants. In order to guarantee the validity of the observations, provisional ideas on the findings, striking observations or remaining questions were ‘shared with the member’s world’ ( Fielding, 2008 ) and checked. These ‘ethnographic interviews’ often took the form of ‘interviews on the spot’ and gave a deeper understanding of the practice being studied. For both education and housing, 26 people participated in an interview (total n = 52). In the case of education, the group consisted of eight community development workers, twelve social workers from partner organisations (civil servants from the city, school social workers, school directors, social workers from the public centre for social welfare [PCSW], social workers from poverty-related organisations, etc.) and six service-users from the institution for community development. The service-users all had a background of living in poverty, and were selected as members of a parent group from a local school for primary education.

In the case of housing, the participants were six community development workers, eleven social workers from partner organisations (civil servants from the city, social workers from the social housing company, social workers from the PCSW, social workers from poverty-related organisations, etc.) and nine service-users. The service-users were selected based on their participation in the working group on housing that is organised by the institution for community development. This working group consists of people who all face problems with regard to housing. All interviews were audiotaped and transcribed. The researchers had no personal connection whatsoever with the institution for community development. The only professional link that the researchers had with the research context was expertise in the domain of community development and encounters with representatives of the institution in the context of education-related activities (e.g. internships).

Focus groups

In the second part of the study, focus groups were set up. While the general aim of a focus group is to discuss a specific topic ( Bryman, 2012 ), we had an additional 2-fold goal. First, we wanted to flesh out several issues that were not clear after the ethnographic research (deepening). Second, we wanted to explore whether the findings of our ethnographic research that took place in the context of community development were applicable in other domains of social work (broadening). We chose focus groups because they allow for creating rich data, enabling in-depth analysis. We selected people with a more expert profile in social work and human rights. The selection criteria used for participants were (i) being familiar with human rights in a social work context and (ii) having a generalist view on social work practice or policy. Participants from the focus group were senior staff members of various social work organisations, as well as lecturers and professors who teach social work at universities and universities of applied sciences in Flanders. Four focus groups of four to six people were organised (total n = 18). In addition, seven in-depth interviews were organised with experts who, because of practical considerations, were not able to attend the focus groups. All the focus groups were led by two people: the researcher who conducted the ethnographic research and whose role it was to bring up the content for discussion and a supervisor who was the moderator of the focus group. Each focus group lasted approximately an hour and a half, and each was organised around three statements: (i) Participatory action, as a foundation of a human rights-based approach in social work, can also exclude people; (ii) a human rights-based approach in social work contributes to individualisation and responsibilisation and (iii) a human rights-based approach that starts from rules and laws (a top-down perspective) obstructs an approach that starts from the needs of people (a bottom-up perspective). The discussion in the focus groups was organised based on the five-stage model proposed by Cronin (2008) : (1) introduction; (2) opening; (3) introductory statement; (4) key questions and (5) ending questions. Both the focus group discussions and interviews were audiotaped and transcribed.

Ethics statement

The study was approved and funded by the Research Council of the HOGENT University of Applied Sciences and Arts. It was carried out in collaboration with Ghent University in compliance with the ethical standards of both the institutions. Informed consent was obtained from all of the participants after an extensive explanation of the research project.

Data analysis

For the data analysis, an inductive approach was chosen ( Hodkinsons, 2008 ). More specifically, a thematic analysis was done on the materials obtained from the ethnographic research. The analysis was executed in two steps by the two first authors. In the first step, both authors separately analysed the same six interviews (two community development workers, two social workers form partner organisations and two service-users) for each domain (education and housing). The analysis was based on the six-step model developed by Braun and Clarke (2006 ; see also Teater, 2017 ). Initial codes were assigned to the materials and afterwards they were grouped around several themes or ‘building blocks’. To answer the question of how social work acts when using human rights, we were looking for themes or building blocks that constitute a comprehensive action-framework for human rights in social work. We were particularly looking for different or even conflicting interpretations or constructions of human rights by social work, as these different interpretations could clearly demonstrate the action component of our framework. After individual analysis by the two authors, the results were pooled and discussed. This working method increases the inter-rater reliability among the researchers ( Oluwatayo, 2012 ). The result of this first step was a first draft of an action framework for human rights in social work. In the second step, the second author continued the analysis of the remaining interviews and also analysed the documentary review and the participant observations.

Although the analysis was primarily data-driven, we, as researchers with an interest in social work and human rights, could not disengage from our pre-existing knowledge. As Braun and Clarke explain, ‘data are not coded in an epistemological vacuum’ (2006 , p. 14). So the research context of community development coloured our data to a certain extent. As explained earlier, the community development organisations explicitly use human rights as a framework for their practice. In recent years, they acquired a great deal of expertise in the field of human rights, which has been reflected in numerous reports, memoranda and suchlike. Furthermore, as social work is a practice characterised by interconnectedness with local communities, working with vulnerable people, both at the micro-level of individual support and at the macro-level of structural change, it is no coincidence that related themes emerged from the data. Altogether, the first phase analysis yielded five themes or building blocks for an action framework for human rights in social work: (i) systemworld-oriented action, (ii) lifeworld-oriented action, (iii) participatory action, (iv) joined-up action and (v) politicised action. In the next step, these findings were presented to all the authors and discussed. This did not result in any adjustments at the level of themes, but it did result in some changes to the topics included under each building block. The remaining points of discussion and things that were unclear were taken to the focus groups. After the focus groups were held, the same procedure was followed: the four transcribed focus groups and seven additional interviews were analysed by the two first authors, and then discussed with all the authors, until consensus was reached. Again, this did not result in any adjustments at the level of the building blocks.

Based on our data, an action framework for human rights in social work was developed, consisting of five building blocks. In the next part of this article, we present these five building blocks.

Systemworld-oriented action

The right to social support would be meaningless without social services; the right to education would be meaningless without schools; the right to decent housing would be meaningless without houses and the right to health care would be meaningless without hospitals. All these systems—social services, schools, houses, health care, social security, etc.—are considered parts of the systemworld . The systemworld can be defined as all the institutionalised societal resources necessary for the realisation of human rights. Access to these systems is often difficult for people living in vulnerable life conditions. They frequently experience high thresholds.

The problem is that you have to be well informed and to know the right person. … How many people know about the income guarantee for elderly people? A lot of people probably know about the premium for housing, but how many of them are actually applying for it? Definitely not that many, because it requires a lot of jargon that keeps people from applying . (a service-user)

It is a recurring complaint that social systems are inaccessible, because people who need care and support must deal with bureaucracy. The problem is not just the large number of forms that need to be filled in. Social workers also send people from pillar to post, so that ultimately people give up and do not apply for the support they are entitled to. In the end, social rights are often not realised.

We do not understand just how high the thresholds are for people who are already in a vulnerable position, who are living in difficult circumstances, and who are then confronted with a multitude of services that are not working in an integrated way, have cultural thresholds, etc. We have no idea what it means to live in poverty, how hard that is … so that support by social services and an emancipatory approach don’t mean anything. (a social worker, institution for community development)

An important topic related to creating accessible social institutions concerns the distinction between ‘universal’ and ‘selective’ social systems. Based on a human rights perspective, social workers often argue for universal social systems. However, some social workers point out the risks of this approach.

Human rights are of course for everyone. But I think that certain groups are more easily deprived of them. These are certainly socially vulnerable groups. … Other groups have more power to make their voices heard. In any case, they also have easier access to certain rights. Education, for example, is more in line with middle-class culture. (a social worker, institution for community development)

Another social worker puts it even more bluntly:

That is actually a waste of time and resources if we focus on all citizens. … In such an inclusive organisation, time and energy are not focused on the most vulnerable people. (a social worker, institution for community development)

To resolve the tension between a universal and a selective approach, some social workers argue for so-called progressive universalism. According to this line of thinking, social support should in principle be universal in orientation, and therefore should be addressed to everyone. However, these universal social systems should simultaneously develop ways of supporting people living in vulnerable life conditions who may fall through the cracks, by supplementing them with selective measures ‘within’ these universal systems. So a community centre can be open to everyone, but for people living in poverty, extra support should be provided ‘within’ this community centre to guarantee their participation.

We shouldn’t become the home of the poor either. We have to keep it a bit open without opening it up again to everyone, because then you know that the weakest people will fall out again. (a social worker, institution for community development)

Lifeworld-oriented action

Systemworld-oriented action has its counterpart in lifeworld-oriented action. Lifeworld-oriented action is about social workers making connections with the experiences from people’s everyday lifeworld. The focus is not so much on institutionalised resources, but rather on the practices that people themselves develop to cope with daily experiences of injustice and with violations of human rights.

Actually, being in the field, close to the people, makes you better able to understand the underlying causes … you can more easily contextualise situations. People don’t always say what they want to say or what they think. If you know the context, you can understand that people formulate things in a certain way but mean it differently. (a social worker, institution for community development)

People living in vulnerable life conditions often find that their living environments are insufficiently understood by social workers as well as others. At the same time, they experience difficulties in explaining their own situation to social work organisations.

A lifeworld orientation also requires that social workers facilitate the opportunities to connect different lifeworlds. Connecting lifeworlds can contribute to sharing diverse experiences and to creating connectedness.

One time there was a ‘week of empathisation’. This is good for involving citizens so they can also experience it that way. They cannot imagine what it is like. … It is good to involve them, so they get a very different view of our problems, because those people don’t normally have to deal with these problems. They should do this a lot more, through a campaign set up by the working group on housing, so these people are motivated to join our conversations and to experience what is going on. (a service-user)

Social workers also point out several risks that might be associated with a lifeworld approach. Specifically, they warn against a narrowing view on social problems where not only are social problems observed in the lifeworlds of people, but also solutions for these social problems are sought within the same lifeworlds. However, problems that manifest in the lifeworlds of people often originate from external causes, such as the labour market, the housing market or the school system. Therefore, social workers should always try to link issues raised in the lifeworld with the way social systems are organised.

That double movement has to be part of our work. That is why we say that you should not see our work merely as directed downwards. You have to work from the bottom up, but that movement must also go upwards. … You have to link the work with a broader movement of social organisations. They help to raise the issues of social inequality, and they can move society in the direction of redistribution. … It is even more necessary to set up broader alliances, so that all those little things that happen can become part of a broader context and become part of a wider environment. (a social worker, institution for community development)

The final crucial aspect of social work with lifeworld-oriented action is social duty in public deliberation.

The articulation of different needs of different groups is the core of democracy; that is a social issue. Which needs do we as a society recognise, and which not? Which needs can be defined as rights, how are they recognised, and can we organise ourselves accordingly? These are public debates. These are collective discussions, because not having your needs recognised, and, consequently, not being seen or heard in society, is usually a collective and structural problem. (a lecturer on social work)

Participatory action

Participation is a loose concept, but nevertheless a key notion when talking about an action framework for human rights in social work. After all, shaping human rights requires dialogue between social workers and citizens about how to construct human rights and for what purpose. Social workers point to two complementary features of participation. First, participatory action entails involvement, connection and reciprocity between social workers and citizens. Here, social workers focus on the ‘relational’ characteristic of the practice of participation.

Participative work cannot be one-sided. You cannot expect your client to participate in everything that comes out of your sleeve. I think the art is to participate with them, and to play it by ear: ‘What is going on here?’ If you as a social worker participate with them , you are going to exclude far fewer people than you would if you expect them to come and participate with you. (a social worker, institution for community development)

Social workers also recognise that participation is not simply a relational issue, but that it entails a ‘structural’ approach as well.

If I say that we have to be more individual, this doesn’t mean that we have to find an individual solution. What I mean is that we have to approach people individually and then hear from there what problems those people or those groups are experiencing. It is also important that policy acknowledges the stories of those people. (a social worker, institution for community development)

Participatory action comes with many pitfalls. One is the social exclusion caused by participatory practices. For social work, it is important to be aware of these processes of exclusion and to identify possible barriers and difficulties. In general, social workers indicate that ‘stronger’ people are the ones who participate in available activities, as these practices require a certain assertiveness or particular social or cultural skills.

Participation usually starts from a certain framework and not everyone fits into that framework. It also requires certain skills from clients—skills they don’t always have. So participatory practices exclude people, but at the same time, this makes us aware that we need to find a different way to involve those excluded. (social worker, institution for community development)

Another pitfall has to do with participation in social policy. One of the working methods of the institution for community development is to coach people who live in vulnerable life conditions to speak with policymakers. This involves a risk of instrumentalisation, not only by policymakers, but also by social workers, as these people adapt themselves to the preferences of social workers.

In everything we do, of course, it is important that we let people make their own choices. But to what extent we, as community workers, steer those choices … I’m not sure. … We wouldn’t say it like that, but we do come up with the solutions. … We start a project and then we involve people in it. (a social worker, institution for community development)

Joined-up action

Social work exists in many fields of practice. This can lead to physical or metaphorical borders between these fields. The over-organised professional field of social work often results in fragmentation or compartmentalisation. Social work from a human rights perspective should question these borders and even try to break through them. This is what is meant by joined-up action. Joined-up action aims to counteract structures and logic that withhold the realisation of human rights in social work.

A trend in the social field is to divide everything into separate human rights or compartments. That is how social policy is organised. A human-rights-based perspective implies an integrated or joined-up approach. This requires breaking through this administrative compartmentalisation of human rights. (a social worker, institution for community development)

Besides the limitations caused by the organisation of social work in different fields, social work is often restricted by the proliferation of rules, procedures, protocols, etc. From a human rights perspective, this requires social workers to push boundaries.

It is about pushing and crossing boundaries, looking outside the range of tasks, thinking outside the box. Laws are not violated, but rules are; these are agreements, and they can be interpreted more broadly or reinterpreted … . (a social worker, community health centre)

Social workers call for questioning rules and procedures. Joined-up action here means that social workers should use their professional discretion in order to be guided by their ethical duty instead of following fixed rules and arrangements.

Having sufficient professional discretion is very important, especially if you work with the most vulnerable groups. You need to take the side of these people instead of working with a double agenda. In any case, they will feel this immediately. But secondly, the more professional discretion social workers use in a system, the more they can defend the rights of vulnerable groups in society. … It is important that they make full use of their professional discretion in order to develop a social reflex as much as possible. (a social worker, institution for community development)

Politicising action

Politicisation concerns questioning and contesting power. Power is mostly conceived of as something that belongs to societal structures, like politics or the judiciary system. Exercising power may result in injustice and in inhuman living conditions. The role of social work is thought to be to collectivise individual experiences of human rights violations and to bring these to the public debate. Politicised social work should use political advocacy to denounce structures and systems of power that cause violations of human rights.

You can try to help the person on an individual level to realise his or her rights, but you will always come across structural issues. (a social worker, institution for community development)

Power is also something that is situated in speaking about particular social issues. These discourses of power have a significant impact on people. The role of social work is to question these dominant orders of society. A social worker from a poverty-related organisation working with young people explains:

Many of the young people who arrive at our organisation are caught up in the ‘it’s your own fault’ discourse … . These young people are caught in a system and therefore they often blame themselves: ‘I think it’s me’ … . For example, education is an often recurring subject: 90% have attended special education. How is that possible? Is it only because of the context of poverty that they are being referred to this type of education, largely determining their future? In our organisation, they learn that this is happening not only to them, but this is something systemic. We explain that it is caused by our educational system failing to give everyone equal opportunities. By doing this, we are ‘de-blaming’ them: there is an individual responsibility, but there is also a social responsibility. For them, this is a process of awareness-raising about how society works and about who decides what. In the beginning, this often alienates these young people, these issues of politics, policy, human rights. (a social worker, poverty organisation).

However, because of the often extensive subsidisation of social work organisations by the government, the politicising role of social work is frequently at odds with the autonomy and independence of the organisation.

You are actually in a sort of a split, which keeps you from going fully for human rights. We cannot just be a protest movement. We can never go full 100 per cent. We can do that, but only with the blessing of a minister. (a social worker, institution for community development)

Therefore, social workers should be aware of depoliticising tendencies that increasingly emphasise the controlling side of social work over its emancipatory character.

The pressure is increasing for social workers to exercise control. I think it is important that social workers be very conscious of this: what is my task? … You see that organisations that are not complying are experiencing consequences. … We owe it to ourselves to say why we stand for. If we don’t do that, we do not take our clients seriously. We must unite as social workers to make it clear to policymakers: this is social work and this is not social work. … We must be able to define our role as social workers: what do we serve? We cannot be used for everything. (a social worker, organisation supporting people with a migration background)

Social workers indicate that they should be much more concerned with their self-critical role. Their own actions as social workers should also be scrutinised in some form of ‘self-politicisation’.

Our qualitative research on how social work acts when aiming to realise human rights reveals five building blocks. They flesh out what it can mean for social work to be a human rights profession. It is important to consider these five building blocks in connection to one another as an action framework for human rights in social work. The key point of this framework is the recognition that human rights in social work are collectively constructed and that social workers play a crucial role in this construction process. To state that human rights are collectively constructed is to acknowledge the discursive, contested and complex nature of human rights in social work ( Cemlyn, 2008 ; Ife, 2012 ). There is no single way to construct human rights. On the contrary, trying to realise human rights is a process characterised by a plurality of potential constructions, based on the plurality of interests of the communities and community members involved. Part of our data also show opposing constructions of human rights ‘within’ building blocks. The discussion on systemworld-oriented action, for instance, demonstrates that some social workers are in favour of selective social services, while others defend universal ones. The same goes for participatory action: being recognised as an agent and being acknowledged as a partner in dialogue can conflict with instrumentalising tendencies. It is remarkable that the conflicting perspectives each underpin their opposite positions from the same framework of human rights. Another part of our data show opposing views on human rights ‘between’ building blocks. This is probably most obvious in the building blocks of lifeworld-oriented action and systemworld-oriented action, which can be considered opposites. The approach of starting from the needs experienced by communities seems to be difficult to reconcile with the bureaucratic procedures of institutions within a system, although both rely on human rights.

Our action framework has an ambiguous relationship with previous action models. It resonates only partially with Androff’s five-principles framework ( Androff, 2016 ), particularly regarding the principle of participation. The principle of accountability in Androff’s model is closely linked to the building block of politicised action. For the other principles, the two frameworks can be considered complementary. The same goes for McPhersons’s HRPSW framework (2015; see also McPherson and Abell, 2020 ). Some of the human rights methods in her model share similarities with our action framework: participation is a shared concern; accountability and activism correspond to politicised action; community and interdisciplinary collaboration are related to lifeworld-oriented action and micro/macro integration and capacity building resonate with systemworld-oriented action. On the other hand, the human rights lens and human rights goals are absent from our action framework. As for earlier research in the Flemish context, our action framework agrees with some aspects of it but not others. Vandekinderen et al. (2020) conducted a research project to explore the common ground of social work in Flanders. They identified five building blocks that are considered the DNA of social work in Flanders. Of these, politicising work is the only building block that both frameworks have in common. It is no surprise that this building block also shows up in our results, as politicising work is a main concern in the work of community development organisations in Flanders.

The observed divergences between our own action framework and the practice approaches of Androff and McPherson can be explained in different ways. In part, this is probably due to the different research contexts in which the projects took place. In our project, collaboration was set up with organisations in the field of community development. Although we included focus group discussions to see whether our findings were transferable, additional research in other social work domains could reveal different emphases or even different building blocks. Furthermore, comparative studies between countries could provide more insight into the international transferability of our action framework. As explained in the ‘Introduction’ section, the nature of social work is closely linked to the welfare regime of a country, which in turn ‘set the scene’ for understanding human rights. How different welfare regimes affect the translation of human rights in social work practice remains a blind spot in social work scholarship. However, this is of particular relevance as welfare regimes all over the world are facing far-reaching transformation that have a significant impact on how human rights in social work are understood. Further research might reveal the link between the nature of different welfare regimes and the way social workers use human rights in their practice. Finally, although we included the voices of service-users in our research project, they often remain left out of rights-based practice literature. Further research on human rights in social work should pay much more attention to the perspective of service-users and to the way that a human rights framework affects their situations and life conditions. These issues require an empirical shift in order to fully understand social work as a human rights profession. Understanding these issues could lend more nuance to the discussions on the relationship between social work and human rights, and would move this debate beyond empty slogans and catchphrases.

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Essentials of Social Innovation

Design thinking for social innovation.

By working closely with the clients and consumers, design thinking allows high-impact solutions to social problems to bubble up from below rather than being imposed from the top.

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By Tim Brown & Jocelyn Wyatt Winter 2010

A starter kit for leaders of social change.

• Collective Impact

• Social Entrepreneurship: The Case for Definition

• The Dawn of System Leadership

• Design Thinking for Social Innovation

• The Nonprofit Starvation Cycle

• Ten Nonprofit Funding Models

• The Science of What Makes People Care

• Stop Raising Awareness Already

• Rediscovering Social Innovation

• Innovation Is Not the Holy Grail

The latest social innovation essentials, delivered to your inbox .

In an area outside Hyderabad, India, between the suburbs and the countryside, a young woman—we’ll call her Shanti—fetches water daily from the always-open local borehole that is about 300 feet from her home. She uses a 3-gallon plastic container that she can easily carry on her head. Shanti and her husband rely on the free water for their drinking and washing, and though they’ve heard that it’s not as safe as water from the Naandi Foundation-run community treatment plant, they still use it. Shanti’s family has been drinking the local water for generations, and although it periodically makes her and her family sick, she has no plans to stop using it.

Shanti has many reasons not to use the water from the Naandi treatment center, but they’re not the reasons one might think. The center is within easy walking distance of her home—roughly a third of a mile. It is also well known and affordable (roughly 10 rupees, or 20 cents, for 5 gallons). Being able to pay the small fee has even become a status symbol for some villagers. Habit isn’t a factor, either. Shanti is forgoing the safer water because of a series of flaws in the overall design of the system.

Although Shanti can walk to the facility, she can’t carry the 5-gallon jerrican that the facility requires her to use. When filled with water, the plastic rectangular container is simply too heavy. The container isn’t designed to be held on the hip or the head, where she likes to carry heavy objects. Shanti’s husband can’t help carry it, either. He works in the city and doesn’t return home until after the water treatment center is closed. The treatment center also requires them to buy a monthly punch card for 5 gallons a day, far more than they need. “Why would I buy more than I need and waste money?” asks Shanti, adding she’d be more likely to purchase the Naandi water if the center allowed her to buy less.

The community treatment center was designed to produce clean and potable water, and it succeeded very well at doing just that. In fact, it works well for many people living in the community, particularly families with husbands or older sons who own bikes and can visit the treatment plant during working hours. The designers of the center, however, missed the opportunity to design an even better system because they failed to consider the culture and needs of all of the people living in the community.

This missed opportunity, although an obvious omission in hindsight, is all too common. Time and again, initiatives falter because they are not based on the client’s or customer’s needs and have never been prototyped to solicit feedback. Even when people do go into the field, they may enter with preconceived notions of what the needs and solutions are. This flawed approach remains the norm in both the business and social sectors.

As Shanti’s situation shows, social challenges require systemic solutions that are grounded in the client’s or customer’s needs. This is where many approaches founder, but it is where design thinking—a new approach to creating solutions—excels.

Traditionally, designers focused their attention on improving the look and functionality of products. Classic examples of this type of design work are Apple Computer’s iPod and Herman Miller’s Aeron chair. In recent years designers have broadened their approach, creating entire systems to deliver products and services.

Design thinking incorporates constituent or consumer insights in depth and rapid prototyping, all aimed at getting beyond the assumptions that block effective solutions. Design thinking—inherently optimistic, constructive, and experiential—addresses the needs of the people who will consume a product or service and the infrastructure that enables it.

Businesses are embracing design thinking because it helps them be more innovative, better differentiate their brands, and bring their products and services to market faster. Nonprofits are beginning to use design thinking as well to develop better solutions to social problems. Design thinking crosses the traditional boundaries between public, for-profit, and nonprofit sectors. By working closely with the clients and consumers, design thinking allows high-impact solutions to bubble up from below rather than being imposed from the top.

Design Thinking at Work

Jerry Sternin, founder of the Positive Deviance Initiative and an associate professor at Tufts University until he died last year, was skilled at identifying what and critical of what he called outsider solutions to local problems. Sternin’s preferred approach to social innovation is an example of design thinking in action. 1 In 1990, Sternin and his wife, Monique, were invited by the government of Vietnam to develop a model to decrease in a sustainable manner high levels of malnutrition among children in 10,000 villages. At the time, 65 percent of Vietnamese children under age 5 suffered from malnutrition, and most solutions relied on government and UN agencies donations of nutritional supplements. But the supplements—the outsider solution—never delivered the hoped-for results. 2 As an alternative, the Sternins used an approach called positive deviance, which looks for existing solutions (hence sustainable) among individuals and families in the community who are already doing well. 3

The Sternins and colleagues from Save the Children surveyed four local Quong Xuong communities in the province of Than Hoa and asked for examples of “very, very poor” families whose children were healthy. They then observed the food preparation, cooking, and serving behaviors of these six families, called “positive deviants,” and found a few consistent yet rare behaviors. Parents of well-nourished children collected tiny shrimps, crabs, and snails from rice paddies and added them to the food, along with the greens from sweet potatoes. Although these foods were readily available, they were typically not eaten because they were considered unsafe for children. The positive deviants also fed their children multiple smaller meals, which allowed small stomachs to hold and digest more food each day.

The Sternins and the rest of their group worked with the positive deviants to offer cooking classes to the families of children suffering from malnutrition. By the end of the program’s first year, 80 percent of the 1,000 children enrolled in the program were adequately nourished. In addition, the effort had been replicated within 14 villages across Vietnam. 4

The Sternins’ work is a good example of how positive deviance and design thinking relies on local expertise to uncover local solutions. Design thinkers look for work-arounds and improvise solutions—like the shrimps, crabs, and snails—and they find ways to incorporate those into the offerings they create. They consider what we call the edges, the places where “extreme” people live differently, think differently, and consume differently. As Monique Sternin, now director of the Positive Deviance Initiative, explains: “Both positive deviance and design thinking are human-centered approaches. Their solutions are relevant to a unique cultural context and will not necessarily work outside that specific situation.”

One program that might have benefited from design thinking is mosquito net distribution in Africa. The nets are well designed and when used are effective at reducing the incidence of malaria. 5 The World Health Organization praised the nets, crediting them with significant drops in malaria deaths in children under age 5: a 51 percent decline in Ethiopia, 34 percent decline in Ghana, and 66 percent decline in Rwanda. 6 The way that the mosquito nets have been distributed, however, has had unintended consequences. In northern Ghana, for instance, nets are provided free to pregnant women and mothers with children under age 5. These women can readily pick up free nets from local public hospitals. For everyone else, however, the nets are difficult to obtain. When we asked a well-educated Ghanaian named Albert, who had recently contracted malaria, whether he slept under a mosquito net, he told us no—there was no place in the city of Tamale to purchase one. Because so many people can obtain free nets, it is not profitable for shop owners to sell them. But hospitals are not equipped to sell additional nets, either.

As Albert’s experience shows, it’s critical that the people designing a program consider not only form and function, but distribution channels as well. One could say that the free nets were never intended for people like Albert—that he was simply out of the scope of the project. But that would be missing a huge opportunity. Without considering the whole system, the nets cannot be widely distributed, which makes the eradication of malaria impossible.

The Origin of Design Thinking

IDEO was formed in 1991 as a merger between David Kelley Design, which created Apple Computer’s first mouse in 1982, and ID Two, which designed the first laptop computer, also in 1982. Initially, IDEO focused on traditional design work for business, designing products like the Palm V personal digital assistant, Oral-B toothbrushes, and Steelcase chairs. These are the types of objects that are displayed in lifestyle magazines or on pedestals in modern art museums.

By 2001, IDEO was increasingly being asked to tackle problems that seemed far afield from traditional design. A healthcare foundation asked us to help restructure its organization, a century-old manufacturing company wanted to better understand its clients, and a university hoped to create alternative learning environments to traditional classrooms. This type of work took IDEO from designing consumer products to designing consumer experiences.

To distinguish this new type of design work, we began referring to it as “design with a small d.” But this phrase never seemed fully satisfactory. David Kelley, also the founder of Stanford University’s Hasso Plattner Institute of Design (aka the “d.school”), remarked that every time someone asked him about design, he found himself inserting the word “thinking” to explain what it was that designers do. Eventually, the term design thinking stuck. 7

As an approach, design thinking taps into capacities we all have but that are overlooked by more conventional problem-solving practices. Not only does it focus on creating products and services that are human centered, but the process itself is also deeply human. Design thinking relies on our ability to be intuitive, to recognize patterns, to construct ideas that have emotional meaning as well as being functional, and to express ourselves in media other than words or symbols. Nobody wants to run an organization on feeling, intuition, and inspiration, but an over-reliance on the rational and the analytical can be just as risky. Design thinking, the integrated approach at the core of the design process, provides a third way.

The design thinking process is best thought of as a system of overlapping spaces rather than a sequence of orderly steps. There are three spaces to keep in mind: inspiration, ideation, and implementation. Think of inspiration as the problem or opportunity that motivates the search for solutions; ideation as the process of generating, developing, and testing ideas; and implementation as the path that leads from the project stage into people’s lives.

The reason to call these spaces, rather than steps, is that they are not always undertaken sequentially. Projects may loop back through inspiration, ideation, and implementation more than once as the team refines its ideas and explores new directions. Not surprisingly, design thinking can feel chaotic to those doing it for the first time. But over the life of a project, participants come to see that the process makes sense and achieves results, even though its form differs from the linear, milestone-based processes that organizations typically undertake.

Inspiration

Although it is true that designers do not always proceed through each of the three spaces in linear fashion, it is generally the case that the design process begins with the inspiration space—the problem or opportunity that motivates people to search for solutions. And the classic starting point for the inspiration phase is the brief. The brief is a set of mental constraints that gives the project team a framework from which to begin, benchmarks by which they can measure progress, and a set of objectives to be realized—such as price point, available technology, and market segment.

But just as a hypothesis is not the same as an algorithm, the brief is not a set of instructions or an attempt to answer the question before it has been posed. Rather, a well-constructed brief allows for serendipity, unpredictability, and the capricious whims of fate—the creative realm from which breakthrough ideas emerge. Too abstract and the brief risks leaving the project team wandering; too narrow a set of constraints almost guarantees that the outcome will be incremental and, likely, mediocre.

Once the brief has been constructed, it is time for the design team to discover what people’s needs are. Traditional ways of doing this, such as focus groups and surveys, rarely yield important insights. In most cases, these techniques simply ask people what they want. Conventional research can be useful in pointing toward incremental improvements, but those don’t usually lead to the type of breakthroughs that leave us scratching our heads and wondering why nobody ever thought of that before.

Henry Ford understood this when he said, “If I’d asked my customers what they wanted, they’d have said ‘a faster horse.’” 8 Although people often can’t tell us what their needs are, their actual behaviors can provide us with invaluable clues about their range of unmet needs.

A better starting point is for designers to go out into the world and observe the actual experiences of smallholder farmers, schoolchildren, and community health workers as they improvise their way through their daily lives. Working with local partners who serve as interpreters and cultural guides is also important, as well as having partners make introductions to communities, helping build credibility quickly and ensuring understanding. Through “homestays” and shadowing locals at their jobs and in their homes, design thinkers become embedded in the lives of the people they are designing for.

Earlier this year, Kara Pecknold, a student at Emily Carr University of Art and Design in Vancouver, British Columbia, took an internship with a women’s cooperative in Rwanda. Her task was to develop a Web site to connect rural Rwandan weavers with the world. Pecknold soon discovered that the weavers had little or no access to computers and the Internet. Rather than ask them to maintain a Web site, she reframed the brief, broadening it to ask what services could be provided to the community to help them improve their livelihoods. Pecknold used various design thinking techniques, drawing partly from her training and partly from ideo’s Human Centered Design toolkit, to understand the women’s aspirations.

Because Pecknold didn’t speak the women’s language, she asked them to document their lives and aspirations with a camera and draw pictures that expressed what success looked like in their community. Through these activities, the women were able to see for themselves what was important and valuable, rather than having an outsider make those assumptions for them. During the project, Pecknold also provided each participant with the equivalent of a day’s wages (500 francs, or roughly $1) to see what each person did with the money. Doing this gave her further insight into the people’s lives and aspirations. Meanwhile, the women found that a mere 500 francs a day could be a significant, life-changing sum. This visualization process helped both Pecknold and the women prioritize their planning for the community. 9

The second space of the design thinking process is ideation. After spending time in the field observing and doing design research, a team goes through a process of synthesis in which they distill what they saw and heard into insights that can lead to solutions or opportunities for change. This approach helps multiply options to create choices and different insights about human behavior. These might be alternative visions of new product offerings, or choices among various ways of creating interactive experiences. By testing competing ideas against one another, the likelihood that the outcome will be bolder and more compelling increases.

As Linus Pauling, scientist and two-time Nobel Prize winner, put it, “To have a good idea you must first have lots of ideas.” 10 Truly innovative ideas challenge the status quo and stand out from the crowd—they’re creatively disruptive. They provide a wholly new solution to a problem many people didn’t know they had.

Of course, more choices mean more complexity, which can make life difficult, especially for those whose job it is to control budgets and monitor timelines. The natural tendency of most organizations is to restrict choices in favor of the obvious and the incremental. Although this tendency may be more efficient in the short run, it tends to make an organization conservative and inflexible in the long run. Divergent thinking is the route, not the obstacle, to innovation.

To achieve divergent thinking, it is important to have a diverse group of people involved in the process. Multidisciplinary people—architects who have studied psychology, artists with MBAs, or engineers with marketing experience—often demonstrate this quality. They’re people with the capacity and the disposition for collaboration across disciplines.

To operate within an interdisciplinary environment, an individual needs to have strengths in two dimensions—the “T-shaped” person. On the vertical axis, every member of the team needs to possess a depth of skill that allows him or her to make tangible contributions to the outcome. The top of the “T” is where the design thinker is made. It’s about empathy for people and for disciplines beyond one’s own. It tends to be expressed as openness, curiosity, optimism, a tendency toward learning through doing, and experimentation. (These are the same traits that we seek in our new hires at IDEO.)

Interdisciplinary teams typically move into a structured brainstorming process. Taking one provocative question at a time, the group may generate hundreds of ideas ranging from the absurd to the obvious. Each idea can be written on a Post-it note and shared with the team. Visual representations of concepts are encouraged, as this generally helps others understand complex ideas.

One rule during the brainstorming process is to defer judgment. It is important to discourage anyone taking on the often obstructive, non-generative role of devil’s advocate, as Tom Kelley explains in his book The Ten Faces of Innovation . 11 Instead, participants are encouraged to come up with as many ideas as possible. This lets the group move into a process of grouping and sorting ideas. Good ideas naturally rise to the top, whereas the bad ones drop off early on. InnoCentive provides a good example of how design thinking can result in hundreds of ideas. InnoCentive has created a Web site that allows people to post solutions to challenges that are defined by InnoCentive members, a mix of nonprofits and companies. More than 175,000 people—including scientists, engineers, and designers from around the world—have posted solutions.

The Rockefeller Foundation has supported 10 social innovation challenges through InnoCentive and reports an 80 percent success rate in delivering effective solutions to the nonprofits posting challenges. 12 The open innovation approach is effective in producing lots of new ideas. The responsibility for filtering through the ideas, field-testing them, iterating, and taking them to market ultimately falls to the implementer.

An InnoCentive partnership with the Global Alliance for TB Drug Development sought a theoretical solution to simplify the current TB treatment regimen. “The process is a prime example of design thinking contributing to social innovation,” explained Dwayne Spradlin, InnoCentive’s CEO. “With the TB drug development, the winning solver was a scientist by profession, but submitted to the challenge because his mother—the sole income provider for the family—developed TB when he was 14. She had to stop working, and he took on the responsibility of working and going to school to provide for the family.” Spradlin finds that projects within the InnoCentive community often benefit from such deep and motivating connections. 13

Implementation

The third space of the design thinking process is implementation, when the best ideas generated during ideation are turned into a concrete, fully conceived action plan. At the core of the implementation process is prototyping, turning ideas into actual products and services that are then tested, iterated, and refined.

Through prototyping, the design thinking process seeks to uncover unforeseen implementation challenges and unintended consequences in order to have more reliable long-term success. Prototyping is particularly important for products and services destined for the developing world, where the lack of infrastructure, retail chains, communication networks, literacy, and other essential pieces of the system often make it difficult to design new products and services.

Prototyping can validate a component of a device, the graphics on a screen, or a detail in the interaction between a blood donor and a Red Cross volunteer. The prototypes at this point may be expensive, complex, and even indistinguishable from the real thing. As the project nears completion and heads toward real-world implementation, prototypes will likely become more complete.

After the prototyping process is finished and the ultimate product or service has been created, the design team helps create a communication strategy. Storytelling, particularly through multimedia, helps communicate the solution to a diverse set of stakeholders inside and outside of the organization, particularly across language and cultural barriers.

VisionSpring, a low-cost eye care provider in India, provides a good example of how prototyping can be a critical step in implementation. VisionSpring, which had been selling reading glasses to adults, wanted to begin providing comprehensive eye care to children. VisionSpring’s design effort included everything other than the design of the glasses, from marketing “eye camps” through self-help groups to training teachers about the importance of eye care and transporting kids to the local eye care center.

Working with VisionSpring, IDEO designers prototyped the eyescreening process with a group of 15 children between the ages of 8 and 12. The designers first tried to screen a young girl’s vision through traditional tests. Immediately, though, she burst into tears—the pressure of the experience was too great and the risk of failure too high. In hopes of diffusing this stressful situation, the designers asked the children’s teacher to screen the next student. Again, the child started to cry. The designers then asked the girl to screen her teacher. She took the task very seriously, while her classmates looked on enviously. Finally, the designers had the children screen each other and talk about the process. They loved playing doctor and both respected and complied with the process.

By prototyping and creating an implementation plan to pilot and scale the project, IDEO was able to design a system for the eye screenings that worked for VisionSpring’s practitioners, teachers, and children. As of September 2009, VisionSpring had conducted in India 10 eye camps for children, screened 3,000 children, transported 202 children to the local eye hospital, and provided glasses for the 69 children who needed them.

“Screening and providing glasses to kids presents many unique problems, so we turned to design thinking to provide us with an appropriate structure to develop the most appropriate marketing and distribution strategy,” explained Peter Eliassen, vice president of sales and operations at VisionSpring. Eliassen added that prototyping let VisionSpring focus on the approaches that put children at ease during the screening process. “Now that we have become a design thinking organization, we continue to use prototypes to assess the feedback and viability of new market approaches from our most important customers: our vision entrepreneurs [or salespeople] and end consumers.” 14

Systemic Problems Need Systemic Solutions

Many social enterprises already intuitively use some aspects of design thinking, but most stop short of embracing the approach as a way to move beyond today’s conventional problem solving. Certainly, there are impediments to adopting design thinking in an organization. Perhaps the approach isn’t embraced by the entire organization. Or maybe the organization resists taking a human-centered approach and fails to balance the perspectives of users, technology, and organizations.

One of the biggest impediments to adopting design thinking is simply fear of failure. The notion that there is nothing wrong with experimentation or failure, as long as they happen early and act as a source of learning, can be difficult to accept. But a vibrant design thinking culture will encourage prototyping—quick, cheap, and dirty—as part of the creative process and not just as a way of validating finished ideas.

As Yasmina Zaidman, director of knowledge and communications at Acumen Fund, put it, “The businesses we invest in require constant creativity and problem solving, so design thinking is a real success factor for serving the base of the economic pyramid.” Design thinking can lead to hundreds of ideas and, ultimately, real-world solutions that create better outcomes for organizations and the people they serve.

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Critical Thinking and Professional Judgement for Social Work (Post-Qualifying Social Work Practice Series) Third Edition

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ISBN-10 0857257536
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Edition Third
Publisher Learning Matters
Publication date January 1, 2012
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Publisher ‏ : ‎ Learning Matters; Third edition (January 1, 2012)
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ISBN-10 ‏ : ‎ 0857257536
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Substance Use Stigma and Community Drug Checking: A Qualitative Study Examining Barriers and Possible Responses

Samantha davis.

1 Canadian Institute for Substance Use Research, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada

Bruce Wallace

2 School of Social Work, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada

Thea Van Roode

Dennis hore.

3 Department of Chemistry, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada

4 Department of Computer Science, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada

Associated Data

Not applicable.

Background: Community drug checking is an emerging response to the overdose crisis. However, stigma has been identified as a potential barrier to service use that requires investigation. Methods: A qualitative study explored how best to implement drug checking services to the wider population including those at risk of overdose. A secondary analysis of 26 interviews with potential service users examine how stigma may be a barrier to service use and strategies to address this. A Substance Use Stigma Framework was developed to guide analysis. Results: Drug checking is operating in a context of structural stigma produced by criminalization. People fear criminal repercussions, anticipate stigma when accessing services, and internalize stigma resulting in shame and avoidance of services. A perceived hierarchy of substance use creates stigma results in stigma between service users and avoidance of sites associated with certain drugs. Participants frequently recommended drug checking to be located in more public spaces that still maintain privacy. Conclusions: Criminalization and societal views on substance use can deter service use. Strategies to mitigate stigma include employment of people with lived and living experience from diverse backgrounds; public yet private locations that preserve anonymity; and normalization of drug checking while decriminalization could address the root causes of stigma.

1. Introduction

The illicit drug overdose crisis is an ongoing epidemic that continues to take lives at unprecedented rates. British Columbia, Canada has been identified as the epicenter in Canada, where approximately seven deaths per day are linked to unregulated substances most often including fentanyl [ 1 ]. Increasingly drug checking is being pursued as a potential response to the rapid emergence of synthetic opioids including fentanyl and the high rates of overdose related to the unpredictably of the unregulated drug market [ 2 , 3 , 4 , 5 ]. In Victoria, British Columbia, community drug checking sites have been implemented as a public health response to the ongoing overdose crisis and the unregulated illicit drug market through a community-based research project called the Vancouver Island Drug Checking Project [ 6 ]. In addition to providing anonymous, confidential, and non-judgmental drug checking services with rapid results, the project has conducted qualitative research aimed to better understand drug checking as a potential harm reduction response to the illicit drug overdose crisis and the unregulated illicit drug market [ 7 , 8 ]. The goal of the research was to hear about people’s experiences with drug checking, including people who use drugs, their family, friends, peers, and/or people who make or distribute drugs [ 7 , 8 ]. The central intention of the interviews was to gain a well-informed understanding of how people think about drug checking from a range of social locations, with the goal of making drug checking widely accessible, safe, and effective for all. Stigma related to substance use emerged as a dominant theme in our research that operated as a critical barrier that needs to be better understood in order to inform future implementation.

There is overall recognition of the need to address substance use stigma (SUS) as integral to responses to the illicit drug overdose crisis [ 9 , 10 , 11 ]. SUS is generally defined as the stigmatization of people who use drugs (PWUD) for using illicit substances [ 12 ]. In his early and well-known work on stigma, Goffman [ 13 ] identified stigma as a relationship where stigmatized qualities or stereotypes are applied to some by others, resulting in the stigmatized person being viewed as “tainted” or “discounted”. Understandings of stigma have shifted from Goffman’s interpretations of stigma as static to thinking of stigma as an ever evolving social phenomenon [ 14 ]. According to Tsai et al. [ 9 ], stigma is defined as a “process wherein people with a particular social identity are labeled, stereotyped, and devalued, unfolding within the context of unequal and often pre-existing power-relations, leading to discriminatory behaviour against people with the stigmatized identity”. According to Tyler [ 15 ], the most common form of violence in democratic societies is stigma despite rarely being considered a form of violence or abuse of power.

Moreover, existing literature has identified that attention is often focused on stigma at the individual level, which overlooks the realities of social, political and cultural contexts [ 16 , 17 ]. However, stigma can operate at different levels throughout society and function as a tool to control and oppress [ 18 ]. This has been referred to as “stigma-power” and is typically theorized as the stigmatizer having motivations to maintain status, wealth, and power, enforce social norms, and marginalize those viewed as unfit for society, and as such employs stigma processes that are easily, effectively, and indirectly accepted and enacted in society [ 18 ]. Based on this interpretation of stigma-power, the stigmatizer is not necessarily limited to a powerful individual or group, but also permeates the general public and the individual, therefore it can exist at the individual, interpersonal, and structural level. While stigma-power exists at each level, it is more easily identified at the structural level. This article looks at systemic and criminalization stigma as examples of structural stigma as the structures of agencies and laws that interact with substance use exemplify how stigma-power is at play. For example, systemic stigma is enacted and enforced by agencies, institutions, and influential individuals within groups of people and targets those who are stigmatized by attempting to manage risk and govern their interactions [ 19 ]. An important factor of systemic stigma is it protects the stigmatizer from repercussions of discrimination, because the stigmatization is embedded in norms, policies, or resources and the goals of stigmatization are achieved at the macro level Tsai et al. and Link and Phelan [ 9 , 18 ]. Additionally, criminalization is a form of systemic stigma that is closely related to substance use and is a common and effective way for governments to “control and exclude persons who are defined as threatening to an existing social order” [ 20 ]. It is often enacted through street policing and can result in reduced access to harm reduction services, rushed injection, increase in disease transmission, and increased risk of overdose [ 21 ]. Criminalization can be more common for people who use substances and who are experiencing poverty and/or are racialized or experiencing other intersecting identities [ 20 ]. It is an effective tool to “other” PWUD and maintain existing hierarchies in society and is considered a way to shift public attention from systemic inequities [ 20 ].

This paper seeks to broaden the existing conceptualizations of stigma in current literature to allow for consideration of how difference and power are created and maintained, as well as tangible ways to challenge existing norms, cultures, and structures that sustain SUS. As discussed by Parker and Aggleton [ 14 ], stigma and stigmatization function “at the point of intersection between culture, power, and difference”. Therefore, it is important to understand how people may be experiencing these different levels of stigma, as well as the interactions between them to better understand how they may be influencing successful implementation of drug checking services. This is achieved through the perspectives of the participants in this study.

Substance use stigma prevents people from engaging in harm reduction practices [ 8 , 9 , 22 ]. Further, Corrigan and Nieweglowski and Tsai et al. identify stigma as a main hindrance in adequately responding to the opioid crisis through harm reduction practices [ 9 , 22 ]. There are many ways of thinking of and conceptualizing both stigma and substance use stigma in the existing literature. The substance use stigma framework from which this article will draw includes some of the most common definitions of stigma in the existing literature.

Tsai et al. [ 9 ] identify 6 types of stigma: structural, public, enacted, courtesy, internalized, and anticipated. Additionally, Corrigan and Nieweglowski [ 22 ] identify three types of stigma: label avoidance, public stigma, and self-stigma. Earnshaw and Chaudoir [ 23 ] identify internalized, anticipated, and enacted stigma. Other scholars discuss structural stigma, which often includes discussions around laws and regulations [ 24 ]. There is a general theme of substance use stigma existing at three levels: an individual level where stigma exists within individuals, an interpersonal level where stigma exists within interactions between people, and a structural level where stigma exists at a policy level.

As drug checking is increasingly being implemented as a harm reduction response to overdose there is a need to examine how stigma may uniquely be enacted and responded to in these newer services. In its simplest form, drug checking is the process in which drugs are tested for components that are not expected in a supply and/or that could cause overdose or otherwise undesirable reactions [ 25 , 26 , 27 , 28 ]. Drug checking is a harm reduction response to help prevent PWUD from consuming substances they did not intend to purchase and to provide the opportunity to make informed decisions about drug use [ 8 , 29 ]. This approach has been adopted across European countries and in some cities in North America, which accept illicit drug use will continue despite prohibitions and opt to offer special services to drug users [ 25 , 30 ].

Dancesafe, an American drug checking organization, was founded in 1998 in response to the risks posed by adulterants (harmful additives) being found in ecstasy (Dancesafe.org, accessed on 31 January 2022). This response to party drug related overdoses was largely mirrored across Europe and America [ 31 ]. Dancesafe takes the stance that they neither condemn nor condone drug use, rather they provide non-judgmental support to PWUD. This shows that the drug checking movement began in response to young people who used party drugs, such as Ecstasy, in recreational setting likes raves and who were not being reached by existing prevention programs and supports for PWUD [ 25 ].

We have reached the sixth year of the publicly declared overdose crisis in British Columbia and there is no sign of improvements [ 32 ]. Bardwell and Kerr and Kerr and Tupper suggested drug checking may be an effective response to the opioid overdose epidemic [ 33 , 34 ]. While Canada may be considered progressive in its regulation of cannabis, Larnder and Burek [ 32 ] and Wallace et al. [ 8 ] state it is the failed drug policies that are eresponsible for thousands of overdose related deaths. The literature illustrates that drug policy is not likely to change as quickly and effectively as is necessary for lives to be saved, thus highlighting the need for drug checking as a means of harm reduction in the meantime. Existing research has not found that the presence of drug checking sites has resulted in an increase in PWUD, nor has it found that individuals who use drug checking services use more drugs than those who do not [ 25 ]. This article contributes to the existing literature by providing insight and recommendations to reduce stigma related to drug checking from community members who are living through the overdose crisis.

We aimed to specifically explore the role of SUS as it relates to community drug checking from the perspectives of people who use and/or sell drugs and others impacted by the illicit drug market. A secondary analysis of qualitative interviews was conducted to explore in depth how stigma was being experienced and could be operating as a barrier within drug checking services, and potential strategies that could address this. We conducted this research with a critical harm reduction and social justice approach that seeks to transcend neoliberal perspectives of harm reduction [ 7 , 35 , 36 , 37 ], and developed a multilevel analytic framework to guide this research that combines critical perspectives on stigma and how they can operate and intersect specific to a drug checking context [ 9 , 18 , 19 , 20 , 21 , 23 ]. We used this resulting Substance Use Stigma Framework to better understand the experiences of SUS within drug checking services and potential ways to navigate resulting tensions.

2. Materials and Methods

This qualitative study was part of a community-based research project in Victoria, BC, Canada that implements and operates community drug checking sites as a harm reduction approach to the illicit drug overdose crisis and the unregulated illicit drug market. Ethical approval was provided from the Human Research Ethics Board at the Island Health Authority (J2018–069). This research project was a collaborative inquiry with both university (B.W., T.V.R. and D.H.) and community researchers with local harm reduction organizations. The intention was to include individuals with academic training and skills and those with established trusted relationships with potential participants.

2.1. Sampling

The study sought the perspective of people who use and/or sell substances, and others impacted by the illicit drug market, such as family and friends who might benefit from drug checking services. An earlier study [ 8 ] primarily reached individuals who utilize inner-city resources, like harm reduction and health services. The objective of this study was to both include and expand beyond this demographic to reach individuals who are less likely to utilize inner-city resources, as well as people who make or distribute substances. Everyone who expressed interest was interviewed. Handbills, posters, and emails to local services were utilized to recruit participants because it allowed for third-party recruitment and increased potential to reach a wider audience. Because the objective was to reach beyond inner-city service users and those who already access harm reduction sites, recruitment posters and emails were sent to services and sites that were not explicitly focused on substance use nor inner-city health and homelessness such as neighbourhood houses, community health centres, food and employment programs, etc. Word-of-mouth also functioned as a significant recruitment strategy and no one who expressed interest was refused an interview. In the end, while most participants were not accessing existing harm reduction services, five participants had accessed drug checking. Participants were provided with a CDN$20 honorarium.

A total of twenty-six semi-structured interviews were conducted, eleven of which were conducted by the lead researcher, eight by interviewers with the drug user organization, and seven by the partnering harm reduction organization. Interviews typically lasted between 15 minutes to just over an hour, with an average time of 30 minutes. We also asked demographic questions as well as questions related to substance use and overdose, and use of harm reduction services. Most questions focused on how drug checking could best be implemented, for example; what would you hope for in a drug checking service, if you could design a perfect drug checking service how would it operate, how would a service fail to meet your expectations and what barriers do you face in accessing drug checking. Recorded interviews were transcribed verbatim by graduate research assistants and coded using NVivo 11 (led by T.V.R.).

2.2. Data Analysis

This secondary analysis focused on exploring SUS, particularly aiming to understand how it creates barriers to accessing drug checking services and potential strategies to address these. We reviewed existing literature considering how stigma is currently discussed and theorized across disciplines and within the substance use and drug checking context. As no consistent framework from which SUS is typically analyzed exists, we developed a Substance Use Stigma Framework based on existing literature which we utilized as an analytical tool.

For this SUS Framework, we drew heavily on Tsai et al.’s [ 9 ] typology of stigma related to substance use which highlights how stigma influences several facets of our lives, as well as other broader conceptualizations of stigma recognizing that stigma may operate at different levels and intersect across levels and with systems and services resulting in experiences of structural violence, and reinforcing power and oppression [ 14 , 15 , 18 ]. Our analytical framework considers SUS at three levels; individual, interpersonal, and structural. Within these levels we considered two types of SUS at each level. At the individual level, we looked at anticipated stigma and internalized stigma; at the interpersonal level, we looked at enacted stigma and episodic stigma; and at the structural level we looked at criminalization stigma and systemic stigma. While the framework presents each level of stigma as distinct levels, we recognize the complexity of SUS and the significant intersections of each level. For these reasons, the framework intentionally avoids a hierarchical approach as a strategy to acknowledge the creation and maintenance of SUS at each level, but also highlights that each level is not mutually exclusive and cannot exist without the others. A description of the framework and associated definitions and supporting references are given in Table 1 .

Analytical Framework.

Data analysis began with SD and BW reading the transcribed interviews. A preliminary coding framework was then developed using the SUS Framework’s six types of stigma function as the parent nodes and associated child nodes within these to capture “stigma barriers” and “possible solutions”. Initial coding was conducted with SD and BW coding two transcripts separately to ascertain framework fit and coding reliability. The transcripts were then deductively coded to this framework in NVivo 11. Findings were then grouped to identify experiences of stigma at each level, how these can operate as barriers to use of drug checking, and potential strategies to address these.

There were 26 participants of whom 17 identified as female, 8 as male, and one participant choosing not to disclose ( Table 2 ). There were six who identified as Indigenous and 10 who identified as lesbian, gay, two-spirit, queer, bisexual or another sexual orientation. Participants predominantly resided in urban municipalities, in stable housing, and were wage earners and/or on disability benefits. The majority [ 22 ] reported they regularly consumed illicit drugs, with about half of these reporting daily use [ 11 ], about half (n = 10) reporting they usually used alone, and the majority [ 20 ] reporting that one of the common locations for consumption was their own home. Participants included family members of people who use drugs, notably parents, some who also identify as using drugs themselves. Few participants reported using harm reduction services.

Characteristics of the sample (N = 26).

Here, we present findings according to the Substance Use Stigma Framework’s three levels with six domains. For each level, we explore experiences of SUS, potential barriers it may cause, and potential responses or solutions to these barriers.

3.1. Individual Level: Anticipated and Internalized SUS

At the individual level, we heard that the experience of anticipated (the expectation one will experience prejudice, discrimination, or judgement because of substance use) and internalized (the process of believing in and internalizing negative feelings around substance use) SUS was pervasive.

Participants noted they felt too embarrassed or afraid to access drug checking due to a fear of being seen and expected others to feel similarly. For example, as this participant stated: “stigma, others seeing you” was a significant barrier to access and another that they were “always conscious of who could see them”. For participants with intersecting identities, in particular sex work, the anticipation of additional stigmas was a serious barrier to access and would lead to avoidance of accessing drug checking services as this quote highlights:

“You know, as a sex worker, having been so deeply stigmatized and still stigmatized for that, I’m hypersensitive to any additional stigmas, so, yeah, downtown doesn’t really work for me in that regard”.

Participants with higher paying jobs or more normative careers also identified anticipated stigma as a serious barrier because they did not want to be associated with substance use or with those appearing to be poor or experiencing homelessness. For example, one participant said: “Yeah, people don’t want to get seen by people like their customers, their clients, or co-workers” and further noted that “I think people who live in the suburbs and have real jobs are less likely to be OK with it. Or to be seen as being associated with it”. Another participant indicated that this fear can extend to personal relationships including family: “I’m sure there’s so many people out there using, that are working, or, and their family doesn’t know”.

Accessing downtown resources was described as intimidating and a barrier to drug checking if located and designed as an inner-city service because of this internalized or anticipated stigma. This included harm reduction services including safe injection sites or overdose prevention services as well as non-profits and drop-in centers. Further, we heard similar stigma barriers to accessing drug checking services in small towns or on reserve as there is little opportunity to remain anonymous. This quote illustrates the high levels of stigma people may face when accessing such services and attempts to separate from this:

“But even just walking in here, today, I was just like was layered with stigma and shame, and you know, all of that and I kind of had to say to the security guard, which was quite honest … to make him very aware that I’ve never been here before and I don’t belong here”.

People expressed feeling like they had to justify their substance use with a reason like trauma or self-deficiency, viewing themselves as “at risk” or “an addict” [P8] if they used a safe injection site, and feeling concerned about looking like those around them. In contrast, some participants expressed pride at not having internalized nor anticipated stigma as a person who uses drugs and accessing harm reduction services. One participant expressed how they have “been in that world for a long time” and are pretty open about substance use, but they recognized this was not the case for most other people who use drugs.

We also heard participants mention a hierarchy of substance use, where using opioids, for example, is viewed as “pretty bad”, but doing MDMA, “that’s fine”. This internalized SUS could prevent some people from accessing spaces that serve individuals who use those substances due to how it is perceived. Internalized stigma was also attributed to public health messaging around substance use, like “don’t use alone” which was described as not realistic and has just led people to a place where they do not want to tell people they are using alone. The suggestion we heard was to find ways to open up conversations around substance use as this participant discussed:

“So, I’ve had so many conversations with people where like if you’re using alone how are we doing that safely? Who are you calling? Like what does that look like? Like, this is what I do when I use alone. Like having those conversations with people has been super important because I think people feel really ashamed to be like “Oh, I use alone”.

Potential responses to address individual level SUS focused on service models and sites that address the fear of being seen accessing drug checking services, respectful staff, as well as promotional campaigns to get your drugs checked that take care to avoid stigmatizing messages. General public settings that are less stigmatizing were suggested such as pharmacies, medical clinics, community laboratories, grocery stores, gas stations, and recreation centres. Specifically, pharmacies were described as public sites but private enough to maintain a level of anonymity and suggested a private booth for the checking process. Another solution was services that do not require the physical presence of another person such as mail in or online services, drug checking kits in dispensers in public bathrooms, drop off services, and personal testing kits that can be disposed of after use. Others recommended more confidential service options such as outreach and mobile and mail-in services.

3.2. Interpersonal Level: Episodic and Enacted Substance Use Stigma

Fewer participants identified specific examples of personal experiences with enacted (when others behave in a way that communicates judgement, prejudice, or disapproval) and episodic (isolated events where stigmatization occurs over time) stigma. It was more common for participants to identify what enacted and episodic stigma would look like to them, including judgement, rudeness, blaming, and a lack of professionalism or how they have witnessed others being stigmatized. For example, enacted stigma was described as “somebody being rude or being judged for being a junky”. There were also instances of enacted stigma being reproduced in the interviews, for example, some language that was used by participants to describe different groups of people was both stigmatizing and stereotyping as well as judgement towards others based on substance type, i.e., the hierarchy of substance use mentioned previously.

In this study, some participants stated they had not experienced enacted or episodic stigma, especially when accessing community drug checking, where they noted they felt welcome and safe. While we heard that some people many may feel unsafe disclosing substance use to their family doctor, a nurse, or drop-in clinic doctor, participants identified drug checking sites as hopefully different. One participant indicated that “Anybody but The Man” should be running drug checking, such as:

“People that care; harm reduction workers, support workers, people that have compassion for the safety and viability of others but still have no opinion about drug use one way or another. People that accept, acceptance, people that accept drugs as part of their community.”

As noted, a potential response to enacted and episodic stigma included hiring staff who are/have used substances or who are committed to harm reduction for people who use substances, viewing them as equally deserving of respect and kindness. Overall, participants felt people with lived experience would be more accepting of people who use drugs and that substance use is part of their community. However, we heard that the definition of and portrayal of a “peer” varied. Throughout the interviews, two levels of people who use drugs were typically identified consistent with a hierarchy of substance use. One level is those who use street drugs, more commonly thought of as heroin/opioids or methamphetamines. The other level being so-called recreational substances, like MDMA or cocaine. Some participants thought it was important to tailor drug checking sites to both groups of people using substances, for example having “hipster” drug checking in a storefront for the recreational group and then continuing to have drug checking in harm reduction spaces in urban or downtown areas. Another recurring theme was to reduce interpersonal stigma by normalizing drug checking, either by promoting it by word of mouth, advertising it like designated driver programs, and putting drug checking sites in common spaces “where normal people go all the time” or in spaces where people already feel safe as supported to also reduce individual stigma.

3.3. Structural Level: Criminalization and Systemic Substance Use Stigma

Structural stigma included mentions of stigma systemically produced and maintained in societal institutions and includes criminalization stigma, usually identified as fear of police and authorities relating to the illegality of certain substances. We heard the multiple barriers to accessing drug checking as it relates to police presence and criminalization and how this embeds structural stigma.

Participants noted fear of being watched and targeted by police, and how drug checking is hard to access if avoiding or hiding from police. One participant stated: “police presence isn’t causing harm reduction. Police presence is causing death” and that drug checking needed to ensure police would not be on or outside of sites. We heard that substances being illegal makes drug checking also illegal, resulting in fear and avoidance of the service due to potential criminal repercussions. It was clear that any association with police would discourage accessing community drug checking and breakdown and prevent any opportunity for trust. In particular, those distributing drugs were noted as likely to avoid drug checking because of risk of criminalization and potential for police to gather information. A fear of an internet trail that could identify substance use or distribution (even when no personal information was provided, collected, or recorded) was also indicated. A number of participants identified a fear of getting caught jeopardizing their employment or custody of their children.

We also identified that systemic SUS was attributed to promotion in the media and general public of certain areas that stigmatized entire areas because of associated substance use. In particular this applied to areas with harm reduction sites, as well as systemic stigma attached to non-profits, which can discourage some people from accessing them. For example, this participant noted the systemic stigma present when harm reduction sites were initially implemented in BC:

“People were like “oh my god, they’re going to be sitting there just shooting up”. Well, what do you think they are doing anyways, right? I just, it was just so shocking. I lived on [the mainland] at that time, and it was just, the news and everything is like “this horrible place where people are just sitting around shooting up”, it’s like what do you think they’re doing in the [area of city]? They’re not having a tea party, you know.

Potential responses to help mitigate systemic stigma again included suggestions to normalize the existence of drug checking, potentially by simply creating more sites as a means to mainstream drug checking. Other options for normalizing drug checking included promoting it on billboards and other public campaigns around drug checking and positive drug culture so people can see themselves and legitimize the service. Professional storefronts were also suggested to legitimize drug checking. Further, we heard several participants call for decriminalization, the regulation of the drug supply, institutionalizing drug checking, developing more treatment centres, and shifting to treating addiction as a medical problem to address structural stigma. Participants also noted shifting systemic stigma through promotion of harm reduction in schools and an “invitation to drug checking through education”, shifting messaging to younger people from abstinence to safe use including drug checking as it is a more realistic approach.

4. Discussion

This study explores how substance use stigma may impact community drug checking from the perspective of potential service users. In our research on how to implement drug checking as a response to the overdose crisis we consistently heard how stigma was a potential barriers and how drug checking needed to address stigma to be effective. We drew from existing literature on substance use stigma to take a unique look at how stigma may impact the introduction of drug checking as a harm reduction response to overdose. By examining substance use stigma at the individual, interpersonal and structural levels and how community drug checking projects can navigate these barriers and mitigate their impacts we have applied existing stigma theories to inform drug checking as a public health intervention. Overall, while all sources of stigma presented barriers, participants described the risk of criminalization and the anticipation of being poorly treated appear to be the most significant barriers related to stigma and that deter service use.

Being criminalized is clearly stigmatizing and the presence of police erodes safety and trust for people who use drugs to access drug checking and other harm reduction services and sites services [ 8 , 21 , 38 ]. Furthermore, criminalization disproportionately impacts Indigenous, Black and other racialized groups, expectant birth-givers, transgender and gender diverse folks, sex workers, and others who face oppression in daily life [ 20 , 21 , 39 ].

Decriminalization is a structural intervention that has the greatest potential to reduce substance use stigma both by normalizing substance use, removing criminal repercussions, and removing the morality, the view that something is either right or wrong, from our perception of people accessing drug checking sites [ 40 , 41 ]. Drug checking and decriminalization are well-aligned and arguably instrumental to each other in the absence of widely available regulated drug supply [ 42 ].

A clear theme from this research was having access to drug checking in spaces that are not currently stigmatized was suggested to ease the anticipation of being stigmatized while accessing a drug checking site. Participants identified feelings of fear and embarrassment when accessing or considering accessing drug checking sites, especially where community drug checking is viewed as an inner-city service within a non-governmental organization serving a clientele assumed to use drugs. However, cultural safety for people who use drugs varies and accessibility for some may be inaccessibility for others [ 43 ]. Fear of association with these types of services may be rooted in structural stigma as well as a hierarchy of substances identified by some of the participants. For example, there was a clear distinction between substances typically viewed as “street drugs” versus “party drugs”. Others have identified this hierarchy of substance use, where drugs are considered more socially acceptable, including marijuana, alcohol, and ecstasy [ 44 , 45 ]. The implications of SUS in this form could result in shame for those using substances that are considered more harmful and the avoidance of drug checking services if the site does not seem safe or relevant for them. Enacted stigma is defined as engaging in behavioural manifestations, including discrimination and social distancing, based on views of social and cultural unacceptability [ 9 , 46 ]. It was made clear in the interviews that enacted stigma exists amongst people who use substances, with stigma towards others based on substance type, and is therefore not limited to service providers and people who do not use substances enacting SUS. It is possible the anticipation of stigma while accessing drug checking sites could be linked to this hierarchy of substance use as some identified the avoidance of accessing drug checking sites and non-governmental organizations as they did not feel they “belonged” in those spaces.

Rather than location drug checking within inner-city harm reduction sites, participants frequently described drug checking as needing to be openly public yet still anonymous. General public and commonly accessed locations were perceived as less stigmatizing than harm reduction sites that help counter fear of identification when accessing services and potentially normalize drug checking. At the same time, privacy is essential and ensuring privacy within these public settings is necessary. While this may help to create accessible and appropriate services for some people, these spaces may be inaccessible and unsafe for others including racialized folks, women, transgender, non-binary, and gender diverse folks and people living in poverty [ 43 ]. Further, some medical professionals and spaces have been found to have negative attitudes towards people who use substances and often lack adequate training and education around substance use and critical harm reduction approaches [ 47 ]. Therefore, it is critical to recognize the experiences of interpersonal stigma that can occur within these environments and consider strategies to create safer environments.

The employment of people with lived and living experience (PWLLE) as service providers was consistently identified as a strategy for facilitating trust and reducing the stigma that service users feel when services. PWLLE bring a unique perspective to harm reduction services and have a personal understanding of how to implement effective client-centred services, policies, and programs [ 38 , 48 ]. Employment of PWLLE is also an overarching strategy that is being recommended to help address structural determinants of inequities including stigma at the structural level [ 49 , 50 ].

Our prior work has indicated how critical employment of PWLLE is within harm reduction services to counter the poor treatment and stigma service users have experienced (8). However, we heard that the definition of who fit as a ‘peer’ varied as much as the respondents did. Participants were looking for peers that reflected their own social location and the substance types they use whether that be an opioid, stimulant or psychedelic. Including peers from a broad range of backgrounds and substance types can help reduce stigma associated with substance use and allow service users to be more comfortable and better identify services as appropriate to their needs [ 6 ]. Care needs to be taken that this does not inadvertently result in exclusion of those with the most structural disadvantage and further increase stigma.

Turan et al. [ 51 ] discusses the rise of the term “intersectional stigma” which builds on Kimberley Crenshaw’s work on intersectionality [ 52 ]. Tsai et al. [ 9 ] discuss how each existing type of SUS intersect with one another and serve to reinforce the harms of each type, at each level. Thinking about the intersection of SUS with other factors in peoples lives allows for a holistic approach to understanding the issues SUS can cause for those impacted by it. This intersection of each type of SUS and the diverse identities of those who are stigmatized creates a complex and nuanced circumstance that inevitably reproduces more extreme cases of marginalization and oppression. For example, the impact that SUS has on a middle class, middle aged white male is significantly different than that of the impact SUS may have on a Black woman experiencing poverty or an Indigenous non-binary person living in a rural area. The interaction of SUS with privilege is an important nuance to understand and a particular focus needs to be given in further research to the role SUS has in reproducing other structural barriers.

The normalization of drug checking was a recurring theme to addressing substance use stigma while the ongoing criminalization of drugs and people who use drugs hinders such efforts. Recommendations to normalize drug checking included health promotion campaigns similar to designated driver campaigns, implementing drug checking within common spaces where people already go or where people already feel safe, and promoting the positive benefits of drug checking more than the harms and risks of drug use. Unfortunately, public health promotion campaigns and even anti-stigma campaigns directed at substance use and people who use drugs too often reinforce SUS highlighting the critical importance of care with messaging to address stigma at multiple levels [ 53 , 54 ]. For example, we heard that while safer use messages such as “Don’t Use Alone” that aim to shift away from anti-drug messaging, can also convey blame and shame. It is important to note, however, that some evidence shows the effectiveness of negative campaign in reducing behaviours like tobacco use [ 55 ]. In this particular instance, the focus is on stigma-reduction related to illicit substance use and therefore policy change should focus on evidence relating to such data.

5. Strengths and Limitations of the Study

A strength of this study is that it seeks the perspectives of people who use substances to understand the impacts substance use stigma has on accessing community drug checking. This study was conducted by a research team that includes community partners from local harm reduction and drug user organizations in Victoria, BC, Canada. A comprehensive substance use stigma framework was developed that incorporates critical theoretical perspectives, appropriate to drug checking, to support analysis and understanding of the multiple and intersecting levels of stigma that can influence successful implementation. This research study was impacted by the COVID-19 pandemic, which resulted in the research team ending interviews earlier than initially intended. Overall, while we were successful in reaching a diverse group within Victoria, BC, who were not accessing harm reduction services, we were unsuccessful in recruiting men in the trades, who have been disproportionately affected by the overdose crisis, or youth. Further research needs to explore substance use stigma for people outside of urban centres, including people in rural or reserve communities, to determine how stigma may be operating within these contexts. Future research is also needed to understand the level of acceptability of community drug checking moving into new spaces, such as pharmacies, medical buildings, and more and what types of promotion and messaging would be most effective for addressing stigma at different levels.

6. Conclusions

Community drug checking is increasingly being viewed as one potential response to the illicit drug overdose crisis in which unpredictable and potent drugs are linked to unprecedented levels of overdose. However, potential service users identified numerous ways in which substance use stigma operates across levels to create barriers to accessing such services. The risk of criminalization and the anticipation of being poorly treated, both consequences of a wider systemic substance use stigma, were significant barriers that can deter use of services. Further, we identified a perceived hierarchy of substance use with greater stigma associated with certain types of substances, that resulted in stigma towards others and avoidance of sites and areas associated with such substance use. Structural interventions such as decriminalization are needed to address root causes of stigma at all levels. Strategies to mitigate these tensions within the current context of criminalization included employment of people with lived and living experience from a wide range of backgrounds; public yet private locations that preserve anonymity; and normalization of drug checking.

Acknowledgments

We thank; Heather Hobbs and Piotr Burek for their supporting roles in the project, the community researchers at Solid Outreach, and from University of Victoria’s School of Social Work. We thank Jacquie Green and Graduate Research Assistants Hannah Dalton, Marina Bochar and Emily Shaw.

Funding Statement

This work was supported by the Health Canada Substance Use and Addictions Program under grant SUAP: 1819-HQ-000042, the Vancouver Foundation under grant VF: UNR17-0265, and Michael Smith Foundation for Health Research (MSFHR)’s Pathway to Patient-Oriented Research Award: 18203.

Author Contributions

Conceptualization, S.D., B.W. and T.V.R.; methodology, S.D., B.W. and T.V.R.; formal analysis, S.D., B.W. and T.V.R.; writing—original draft preparation, S.D and B.W; writing—review and Editing, S.D., B.W., T.V.R. and D.H.; supervision, B.W.; project administration, B.W. and D.H.; funding acquisition, D.H. and B.W. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was approved by the Human Research Ethics Board at the Island Health Authority (J2018–069).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the participants to publish this paper.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Congrats to our 2024 Social Work Grads!

The mission of the School of Social Work is to provide professional social work education that inspires critical thinking and lifelong learning to students who will serve in diverse social work practice areas and roles, engage in collaborative research to contribute to the well-being of populations that are vulnerable and oppressed and advance social work knowledge, and strengthen our communities through meaningful partnerships.

While we commend and celebrate all CHHS graduates, the following highlights our graduates and awardees at the BASW and MSW level. To view the full graduate list, please see the 2024 CHHS Commencement Program.

School of Social Work Student Spotlight

Angela Dominguez is a person of many hobbies, interests and completely immersed herself in campus life during her time here at CSULB. She studied abroad through the School of Social Work program. She has been to Germany, London and Paris, and has many other travel sights set on her list. She is an avid concert goer, FUNKO Pop collector and loves the shows Friends, Grey’s Anatomy, Once Upon a Time, and Schitt’s Creek, to name a few. She has been a part of the Upward Bound program as an academic advisor and Project OCEAN as a Graduate Peer Educator. Angela has interned at the Orange County Department of Education, Los Angeles Department of Mental Health and Long Beach Child & Adolescent Program, to name a few.

“I chose a career in human services before I even knew what human services was,” Angela says. “As a child, I enjoyed helping others, including my teachers and my classmates; however, I was a teenager when I decided I wanted to pursue ‘helping professions,’ especially wanting to work with women and children.”

Angela’s decision to help others was a direct result of experiencing childhood and early-adult trauma herself.

“I quickly learned there were resources all around me to help me succeed. Without the help of teachers, advisors, school counselors, social workers, victim advocates and many others, I would not be where I am today. My community is responsible for the strength and resilience I have developed over the years. I cannot think of a better way to honor the work of those who came before me than to give back to the communities that raised me.”

One of the most impactful experiences during Angela’s time at CSULB was studying abroad in Germany. While in Germany, her passions were reinforced of wanting to help the underprivileged and underserved populations of society.

“I hope to serve my community by continuing to break down the stigma associated with mental health, advocating for women’s rights, and finding creative ways to meet the needs of underserved populations.”

Angela’s story of resilience and pushing herself through the Master in Social Work program, at a time when she was going through personal trials herself, is nothing short of inspiring. Angela says she found solitude in her CSULB community.

“I was convinced I did not belong in this program. How was I supposed to help others when I could barely help myself?”

Angela remembers one particular Wednesday evening, when she arrived to class with the intention of telling her professor that she was quitting the program. Usually, Angela would arrive to Professor Colunga’s class with eagerness and engagement in class.

“On this evening though, my professor could sense I was distraught and took an interest in my wellbeing. I could tell Prof. Colunga genuinely cared, so I told her all that I was going through. This woman was compassionate, empathetic and validating. She reminded me of my ‘why’ – my reason for deciding to pursue a master’s in social work in the first place.”

Adds Angela, “Looking back, I am really glad I chose to continue with the MSW program. I have met so many wonderful people in this program and found lifelong friends!”

School of Social Work ( BASW ) Outstanding Student Citation Award

Cristina Lopez

Kianna Reynante

Samantha Truax

Cristy Toscano

Ruby Garcia

Jessica Metlak

Savanna Hernandez

Van Kim Ngoc Pham

Angelica Mae Tan Sano

Graduate Dean’s List Awards

Parisa Esfahani

Aracely Guerrero Estrada

Graduate Student Honors

Stephanie Amaya

Liliana Barroso

Ricardo De La Torre

Elizabeth Esquivel

Fatima Garcia

Carolina Hernandez Lopez

Stephanie Lezama

Ricardo Lopez

Maerie Grayce Morales

Koritza Moreno

David Moreno Guardado

Grace Navarrete

Dien Nguyen

Wynn M. Nguyen

Aarti Patel

Rachel Margaret Reyes

Bryan Sanchez

Hannah Sjogren

Adriana White

School of Social Work Outstanding Thesis

Outstanding Thesis – Project

Aarti Patel

Thesis Title : Mental Health Awareness, Support, and Linkage Assistance (MASALA): A Grant Project

Advisor – Dr. Molly Ranney

Outstanding Thesis

Elizabeth Esquivel

Thesis Title: Bereavement Needs of Incarcerated Adults: A Qualitative Study

Outstanding Applied Social Work Projects

Project Title -- Empowerment Pathways: Navigating Success for Formerly Incarcerated Students at CSULB

( Instructor : Dr. Joanna Barreras)

Rocio Becerra

Jessica Clinard-Allman

Jessica Keys

Brent Mayhew

Wynn Nguyen

Project Title -- Increasing Positive Youth Engagement in George Washington Middle School

( Instructor : Dr. Jose Hurtado Reyes)

Adriana Avalos

Yessica Campos

Janet Ceja-Garcia

Jessica Chamorro

Angela Dominguez

Project Title -- The Student Link: Fostering Campus Connection

Skarlet Castro

Phoebe Hanna

Channell Holloway-Martin

Judith Ibarra

Kala James

Dominique Jefferson

Brittany Williams

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Critical thinking can appear formal and academic, far removed from everyday life where decisions have to be taken quickly in less than ideal conditions. It is, however, a vital part of social work, and indeed any healthcare and leadership practice. Taking a pragmatic look at the range of ideas associated with critical thinking, this Fifth Edition continues to focus on learning and development ...
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Critical thinking can appear formal and academic, far removed from everyday life where decisions have to be taken quickly in less than ideal conditions. It is, however, a vital part of social work, and indeed any healthcare and leadership practice. Taking a pragmatic look at the range of ideas associated with critical thinking, this Fifth ...
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Critical Thinking and Professional Judgement for Social Work
Critical thinking as a process can appear formal and academic, far removed from everyday life where decisions have to be taken quickly in less than ideal conditions. However, now more than ever, it is seen as a vital part of social work, and indeed any healthcare and leadership practice within the current agenda for integration, and in the post Francis inquiry health care context.
Congrats to our 2024 Social Work Grads!
The mission of the School of Social Work is to provide professional social work education that inspires critical thinking and lifelong learning to students who will serve in diverse social work practice areas and roles, engage in collaborative research to contribute to the well-being of populations that are vulnerable and oppressed and advance social work knowledge, and strengthen our ...

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Critical Thinking and Professional Judgement for Social Work

Lynne Rutter

Keith Brown

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Social Work as a Human Rights Profession: An Action Framework

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Substance Use Stigma and Community Drug Checking: A Qualitative Study Examining Barriers and Possible Responses

Bruce Wallace

Thea Van Roode

Associated Data

1. Introduction

2. Materials and Methods

2.1. Sampling

2.2. Data Analysis

3.1. Individual Level: Anticipated and Internalized SUS

3.2. Interpersonal Level: Episodic and Enacted Substance Use Stigma

3.3. Structural Level: Criminalization and Systemic Substance Use Stigma

4. Discussion

5. Strengths and Limitations of the Study

6. Conclusions

Acknowledgments

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