J Relig Health DOI 10.1007/s10943-015-0064-z ORIGINAL PAPER
Substance Use in Muslim Culture: Social and Generational Changes in Acceptance and Practice in Jordan Kira B. Mauseth1 • Jordan Skalisky1 • Noe¨l E. Clark2 Ray Kaffer1
•
Springer Science+Business Media New York 2015
Abstract Through narrative analysis, this paper explores the changes in acceptance of and response to substance use in Muslim culture by evaluating data collected in qualitative interviews in Jordan in 2013. What is known and unknown about substance use in Muslim culture throughout the Arab world from previous research findings provides a foundation from which to explore new perspectives and compare themes between younger and older generations in Jordan. Trends of social change and behavioral expression influenced by dramatic political and social upheaval in the Arab world in the last 5 years will also be evaluated for the way in which they may be influencing both substance use and its acceptance among young adults in this population. Recommendations for future research and work in this area are also provided based on these findings. Keywords
Substance use Muslim culture Islam Jordan Social change
Introduction Substance use, including both alcohol and drugs, has changed dramatically in terms of both acceptance and response throughout the international community over the last several decades. In the USA, the use of Marijuana, which had previously been illegal, has, in some places, been de-criminalized and made legal. New drugs are constantly being invented, tested, and processed on the global market. The development of the drug ‘‘Crocodile’’ in Russia, and its rapid and recent spread throughout the world is one such example (Shuster 2011). In many
& Kira B. Mauseth [email protected] 1
Department of Psychology, Seattle University, 901-12th Ave, Seattle, WA 98211, USA
2
Department of Psychology, Seattle Pacific University, 3307-3rd Ave W, Seattle, WA 98119, USA
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Muslim countries in much of North Africa, the Middle East, and parts of Asia, substances of all kinds have gone through a significant shift in both use and acceptance. Practitioners of Islam who make up the Muslim culture that is predominant in the aforementioned geographic areas have had a particularly unique and challenging relationship with substance use in recent generations. Although something like ‘‘Crocodile’’ may not (yet) be a scourge in this part of the world, other substances including alcohol, hashish, amphetamines, and addictive prescription medications certainly have a significant impact on the lives of those who use them and the larger communities of which they are part. The commandments set forth in the Quran and the sayings in the Hadith provide instruction about the use of intoxicants (specifically alcohol), which strongly influence the extent to which substances of all kinds are accepted and/or may therefore be made illegal in predominantly Muslim countries such as Jordan, Saudi Arabia, and Egypt (Michalak and Trocki 2007). However, recent and dramatic changes in both political control and social activism in many predominantly Muslim countries inherently impact other social and cultural norms, including substance use. Behaviors and schools of thought that were previously held as ‘‘taboo’’ have enjoyed different (new) levels of acceptance and tolerance in the last 5–10 years specifically. It can be argued that shifts in social norms around substance use in Muslim culture have changed perceptively despite little if any change in laws governing such practices in many predominately Muslim countries. In Jordan, there is an interesting mix of influences that illustrate the complexities behind substance use in Muslim culture. As part of a traditionally more moderate Muslim country compared with neighbors such as Saudi Arabia, many Jordanians have approached substance use (specifically alcohol and hashish) with more openness, if not with more tolerance. In recent years, this openness has contributed to a dramatic expansion in both the number of smoke shops and the use of hookahs or ‘‘hubbly bubblys’’ in restaurants. Although frequented by both men and women between the ages of 18 and 50, these smoke shops and cafes are becoming increasingly popular as social gathering places for young people under the age of 30 (AlMarri and Oei 2009; Amir 2001; Haddad et al. 2010). The reasons for this increase are complex, but the social change and shift in perception of substance use that they seem to represent are certainly significant. With the intention of contributing more to the understanding about the impacts of social and generational change on substance use, and the potential implications of that change on subsequent generations of Muslims, qualitative interviews were conducted with six Jordanians between the ages of 23 and 56. Narrative analysis was used to identify themes and explore similarities and differences between members of different generations in their perceptions about substance use in Jordan today. Findings suggest that although laws may be clear, social expectations and responses are decidedly less so, and the ambiguity around substance use in general differs by generation.
Background Previous Research on Substance Use in Muslim Culture Much of the data that exist on the topic of substance use and Muslim culture have focused on alcohol use and specific passages in the Quran and other Islamic teachings such as the Hadith (Michalak and Trocki 2007). While the Quran is synonymous with Islam as the Bible is to Christianity, the Hadith is less well known but is vital to the understanding and
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practice of Islam. The Hadith is a collection of the Prophet Muhammad’s words and actions. Traditionally, Muslims recognize the Quran as the ‘‘word-for-word message of God,’’ believed to supersede the Hadith; however, both are used interchangeably (Michalak and Trocki 2007). Interestingly, the Quran and Hadith are controversial in their regulation of alcohol consumption and do not provide a definitive guide on substance use for Muslims. Previous research has recognized the shift in perspectives concerning alcohol use in the Quran and Hadith. Michalak and Trocki (2007) outlined the progression of three stages in the Quran and Hadith that range from alcohol use being tolerated, to being prohibited during prayer, to the full prohibition of alcohol, including punishment in the form of physical abuse (Michalak and Trocki 2007). The confusion of the religious legality of alcohol has compounded the debate of what alcoholic beverages are prohibited. In the Quran, the word for the forbidden beverage, khamar, translates to meaning only specific alcoholic beverages, such as those derived from grapes, wheat or barley, or controversially, according to others, any substance that intoxicates (Michalak et al. 2009). The khamar, because of its historical context, may not include modern substances, such as hard liquor or illegal drugs, promoting confusion for contemporary followers of the Islamic faith (Michalak and Trocki 2007). The conflicting views of alcohol consumption within the Quran and Hadith have created unclear guidelines for Muslims. The ambiguity of the religious texts and the prohibition of alcohol have become a more acknowledged issue in the past decade. Fatwas, advice given from Islamic scholars, are often issued in response to queries of substance use, especially from the younger, less conservative generation of Muslims and Muslims living in predominantly non-Muslim countries (Michalak and Trocki 2007; Michalak et al. 2009). While the consensus of belief from most Muslims and fatwas is that the use of alcohol is prohibited, some take it as far as prohibiting indirect contact with alcohol, for example, working in a store that sells alcohol is discouraged (Michalak et al. 2009). However, Michalak et al. (2009) found that the most asked question of Muslims was that of why alcohol was prohibited. The fatwas that were issued in response dictated that the consumption of alcohol is a haram, a severe transgression, and that it has harmful effects on every aspect of the consumer’s life (Michalak et al. 2009). Haddad et al. (2010) contend that substance use violates the Islamic principle of not partaking in behaviors that are destructive to the body or soul. In agreement with Islamic laws, many predominately Muslim countries have forbidden the sale, possession, or consumption of alcohol by Muslims but not for non-Muslims (Almarri and Oei 2009). However, this has not prevented Muslims from using or abusing substances. While substance abuse in the Muslim culture is becoming more acknowledged, Muslims themselves are often not being educated on the subject. A study by Haddad et al. (2010) on substance abuse among adolescents in Jordan contends that while most Jordanian adolescents have a basic understanding of substance use, the information may primarily be coming from the mass media and peer groups. A lack of education about substance abuse has also lead many Jordanian adolescents to believe that addictions are constant and that quitting an addiction is not feasible (Haddad et al. 2010). The condemnation of substance use by the Islamic faith has created a social stigma in addressing substance use and treatment options. Tahboub-Schulte et al. (2009) detail how a Muslim family wanted to send a family member abroad for substance abuse treatment due to the ‘‘intensity of existing cultural stigma’’ (p. 73). Unfortunately, the collective shame of alcohol consumption as a haram may be furthering the denial of Muslims who abuse substances and not aiding in developing preventative measures. The social stigma of substance use within the Muslim culture has lead to the current misinformation and lack of literature on the subject (Haddad et al. 2010; AlMarri and Oei 2009). However, despite the
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religious restrictions and shame associated with substance use, the amount of literature on the subject is increasing as there has been a documented rise in substance abuse cases (Tahboub-Schulte et al. 2009). Substance abuse has moved from the cities to rural areas, with the majority of substance abusers being male and between the ages of 20 and 35 years (AlMarri and Oei 2009; Amir 2001; Haddad et al. 2010). The rate of female substance users is very low, a possible result of underreported cases and social stigma (AlMarri and Oei 2009). Alcohol, heroin, and cannabis are reported as the most abused substances; nevertheless, there are not adequate data about the frequency or quantity of use (AlMarri and Oei 2009). These measurable shifts in demographic changes associated with use may simply be a result of more access as global influences increase, but it is also likely that recent social and political changes in the Middle East and North Africa have contributed to the rise in substance use within Muslim populations in these areas.
Social and Political Change in the Arab World and its Impact on Substance Use In the last 5 years, the Arab world specifically has experienced dramatic and consequential political and social change as part of a multinational series of revolutions, riots, and protests that have taken place across the entire region. The beginning of this time period has been referred to in the media as the Arab Spring. The governments of Egypt, Tunisia, Lybia, and Yemen have been completely overthrown since 2010, while Syria remains embroiled in a civil war that has killed tens of thousands of people (Ruorden 2013). In Morocco and Jordan, known social and political ‘‘moderates’’ in the region, constitutional reforms have been implemented in response to large-scale public protest (Tawil 2013). The potential implications of this large-scale social and cultural change relative to substance use in these countries are significant and varied. In some places, the return to a more conservative Islamist political approach might result in a crackdown on access to substances and those who use them. In other places, where social upheaval has resulted in the lessening of restrictions toward the people on the part of the government, an increase in substance access, use, openness, and tolerance may occur as never before. Certainly, the impact of drastic social and political change has found its way into the everyday lives of the populations affected by the change. Conclusive research establishing a link between substance use with the Arab Spring is yet to be conducted. However, studies addressing social change and the conditions that contributed to the revolts and revolutions of the Arab Spring are available, specifically in terms of generational and technological parallels. Exploring a potential link is worthwhile given a rise in substance use and the similar climates that exist in Jordan as in other nations that did experience uprisings as a part of the Arab Spring. Generationally, the Middle East and North Africa are experiencing a massive bulge in the young adult populous, and Jordan is no exception (Hoffman and Jamal 2012). In exploring political and social differences between age cohorts of this region, Hoffman and Jamal (2012) note that with this burgeoning youth demographic, there is a trend of lower individual religiosity, which might indicate greater tolerance/acceptance of alcohol use. However, contradictory evidence was also found. The study showed the youngest age cohort (between age 18 and 24) was more supportive of political Islam and Shari’a law (Islamic law based on the Quran but written by scholars and interpreters) than the oldest cohort of respondents who were ages 55 and above (Hoffman and Jamal 2012). Importantly, the level of education in the younger cohort mitigates that finding where higher levels of education relate inversely to support of political Islam (Hoffman and Jamal 2012).
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The increase in technology and social media use among young adults is another social change parallel linking Jordan to the nations of the Arab Spring (Al-Oqily et al. 2013). AlOqily et al. (2013) stressed the importance social networking and social media in the free expression of ideas while researching social network use among Jordanian university students. Like in Egypt, Tunisia, and Lybia, social media and social networking are allowing young people to share ideas with anonymity, organize, and express political agendas. Social media and technology also allow for greater access to Western (typically non-Muslim) culture and media, including normalized images of substance use. As mentioned, a relationship has not yet been established between the Arab Spring and substance use, but the potential for such a link to exist is present. Looking at recent studies that examine substance use in Jordan shows that increases in substance use over the same period of time the Arab Spring have embroiled the region. Al-Omari et al. (2014) list a nearly 29 % increase in cases of reported drug use from 2011 to October 2013. Also important is the average age of participants in their study, conducted at two drug and alcohol rehabilitation centers in Jordan, which was below 30. Among even younger demographics, substance use is increasing in Jordan with the rise of water pipe smoking in middle and high school students (Alzyoud et al. 2013; Mzayek et al. 2012). Especially interesting is Alzyoud’s (2013) finding that girls were more likely to be water pipe users than boys among 993 participants ages 11–17. Finally, although slightly predating the Arab Spring, a study on substance use among Jordanian university students found alcohol to be the most prevalent substance used among the students surveyed (Hamaideh et al. 2010). The study goes on to postulate that the high numbers of alcohol use observed could be related to increasing western cultural influences from TV and Internet media. Independent of the social and political upheaval in many Muslim countries following the Arab Spring, the increase in the use of technology and the access to a ‘‘global culture’’ and economy are also having an impact on substance use (Al-Oqily et al. 2013). Muslims from different generations, with different access to and familiarity with other cultures and lifestyles may, have drastically different notions about substance use and its consequences. Exposure to both medical and recreational substance use through the internet and social media could strongly influence norms about what is acceptable and what is not. The current study sought to understand personal explanations for and understanding behind substance use in Jordan specifically, through in depth interviews with Jordanian Muslims.
Methods In this study, narrative inquiry qualitative analysis was used to assess observations, experiences, and beliefs about substance use in Jordanian culture.
Participants The researchers in this study were in Jordan in September 2013, participating in relief work with refugees residing in Jordan. Participants in this study were recruited through word-ofmouth from among Jordanian nationals who interacted with our research team during that time. Participants included six Jordanian citizens ranging in age from 23 to 56 who worked in a service or volunteer position where they had direct interaction with the attitudes and
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beliefs of others. Two men and four women were interviewed. Demographic data for each participant are shown in Table 1. In qualitative literature as a whole, no set standard exists regarding the number of participants required for an appropriate sample size. Rather, the quality of the data is the ultimate measure of an appropriate sample size in its ability to meet the goals of the individual study and reflect universal concepts (Richie et al. 2003). Data saturation is met when there is redundancy that begins to emerge in information that is presented across interviews. In conducting this type of research, there are limitations in the generalizability of the results; however, this type of study allows an exploration of common experience, which can further examined in future research.
Procedure for Interviews The procedure for the data collection in this study included interviewing each participant in a location convenient to them in the cities of Amman and Jarash. Interviews were conducted by a research team member in September 2013. Creswell et al. (2007) suggest that when conducting narrative interviews, researchers should use broad, topic-specific questions that are open-ended, followed by clarifying questions to draw out depth and richness in participant response. Interviews were, therefore, organized and conducted in a nondirective, thematically oriented manner. Examples of questions in this study include ‘‘When you think about drug or alcohol use in your culture, what ideas come to mind?’’, ‘‘Do you see any differences between gender and age when it comes to substance use?’’, and ‘‘How do families here deal (or not) with substance use issues and/or addiction?’’. Translators were not used, as all of the participants in this study spoke fluent English. Interviews were conducted over a 1-week period of time, and typically took between 30 and 60 min to complete.
Procedure for Analysis The qualitative nature of this study allows for research that is exploratory and subjective. This type of research is appropriate for small sample sizes, yet is not confined to the scope of individual experience (Reissman 1993; Ponterotto 2005). A qualitative approach was employed in this study because of the unique ability of qualitative research to allow participants to attribute meaning to their experience and provide rich information about cultural themes and practices (Gilgun 2009). Additionally, narrative inquiry allowed our research team to access detailed data that may have been difficult to interpret through the use of questionnaires or quantitative research, particularly give the stigmatized nature of the topics examined (Creswell et al. 2007).
Table 1 Participant demographic data
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Participant #
Sex
Age
Marital status
1
F
56
Married
2
M
45
Married
3
M
26
Single
4
F
25
Single
5
F
23
Single
6
F
25
Single
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Following the guidelines of narrative inquiry analysis, each of the interviews was listened to, transcribed, and then checked to confirm the accuracy of the transcription (Ponterotto 2005). After transcription was complete, each member of the research team read the interviews multiple times to gain familiarity with the content. Research members paid careful attention to the overall narrative thread and the emotional content represented in each narrative. Researchers then broke each interview down into fragments that represented complete thoughts and organized them into themes, categories, and concepts. Examining narratives in this manner allows researchers to employ detailed content analysis while gaining a holistic view of the elements of each interview. Excerpts from passages that support and represent broader concepts were identified to be quoted in the results section. Through this approach, a thorough understanding was reached regarding the observations and beliefs about substance use in Jordan through the eyes of our participants.
Results Islamic Understanding of Substance Use Every participant began their interview by emphatically stating that alcohol and drug usage is strictly prohibited or forbidden. Alcohol in particular is both religiously and legally forbidden because it is mentioned in the Koran and made illegal through Shariah, law which is interpreted from parts of what is written in the from the Quran. One older participant (P1, lines 154–160) said, ‘‘I don’t put too much stock in (Shariah), because that’s people’s interpretation.’’ She described how many of the substances which are currently in use in Jordan are not explicitly mentioned in the Koran and therefore not outlawed. However, she went on to state that she relies on morality to guide her interpretation of what she thinks about any type of substance use, ‘‘That’s like, like fire… when you consider the major rules, it hurts, its harmful to yourself, it wastes money.’’ When she thinks about substance use in her culture, she relies on the spirit of the law, instead of the law itself. Some participants spoke of the difference between attending the mosque, and having respect for the moral traditions of Islam (P1, P2 and P3). Participant 2 described this contrast, ‘‘I think, uh, some people respect the religion in the villages, they are still holding the religion to the morals. Despite of, we are not conservative people, we are normal people, and we are very free, but we still have the old fashion’’ (lines 64–74). While alcohol and drug use is considered to be illegal (perceptually or actually) for most Muslims, it is not illegal for those living within Jordan who profess a different faith. Several participants spoke of the influence of foreigners bringing drugs and alcohol into Jordan. It is illegal in Jordan for anyone who is Muslim to own a liquor store, but liquor stores do exist within Jordan, owned and managed by people of different faiths. Despite the acknowledgement that substance use is forbidden, as the interviews progressed, participants revealed that each of them knew of friends or family members who used substances, or had heard about it in their communities.
Prevalence of Substance Use Participant reports of prevalence rates varied widely from interview to interview. Some of the variability in what was reported seemed to be due to a lack of awareness, but some significant differences emerged between those living in big cities, as opposed to those in
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more rural areas. Additionally, the drug or substances of choice changed dependent on geographical location, age, and gender. When talking about substance use, a theme that seemed to be an undertone in many of the interviews was although use is a problem, it it’s not in my home, not in my family, not in my community. In a way, this reflects the hidden nature of substance use within Jordan. Participant 1 described the presence of substance abuse problems stating, ‘‘And our segment and people I deal with, my family the people we deal with, we know it’s not widespread. We are not the people that go out to clubs. There are places for people who do that but not in my immediate family’’ (P1, lines 20–22) Yet this same participant went on to describe a sister who is addicted to morphine. Similarly, Participant 3, who said that alcohol use is rare and not a problem, went on to admit that he has in fact done binge drinking with his friends.
Alcohol Usage Reports of alcohol usage were the most varied of any substance, perhaps due in part to the experience of usage being hidden from the public eye, more legally regulated, and therefore difficult to identify. Some said that it was rare and not an issue (P3), while others reported that there is widespread access (P4 and P5) and that it is very common (P1). When asked to estimate how many people use alcohol, participants reported rates varying from 10 % (P2) all the way up to 70 % (P5), with one participant estimating that while 25 % may use alcohol, perhaps only 5 % abuse alcohol. Participants reported greater availability in the cities, where lower prices and a feeling of anonymity may lead to higher rates of usage. Even participants who lived in the city, however, seemed to have little awareness of how much consumption was actually taking place. One participant described avoiding establishments which might serve alcohol, ‘‘I just hear about it and sometimes I see people buying alcohol but I don’t go to restaurants that sell alcohol, I don’t go there for food. So that’s why I can’t tell a percent.’’ (P4, lines 37–39). Participant 2, who lives in a small town, estimated usage rates around 10 %, stating that his town is very conservative. One opinion that all participants had consensus on is that alcohol is a man’s substance in Jordan. Though there are some women who use alcohol, it is far more common among men, and they have easier access to it. One participant described binge drinking being typical when drinking because it is only done on special occasions and is not typical, ‘‘When he get the chance to drink alcohol, he will drink more and more to get drunk because maybe tomorrow he will never get the chance’’ (P3, lines 183–187). In Jordan, he says, if you drink alcohol, you drink to get drunk. Although some said that rates of drinking vary greatly even between people groups within Jordan, one participant said it is common among the wealthy who can afford to not work. ‘‘Uneducated people, uh, who use the alcohol, most of them uneducated people and they have no works, they have uh, are a lot of money, maybe their families is uh, their families are rich or wealthy, and they have no responsibility’’ (P3, lines 198–202). One participant (P3) said that in Muslim gulf countries, alcohol usage is much more prevalent because there is more money in those countries. Participants mentioned tourism and foreigners bringing alcohol into the urban areas in Jordan, with a trickle down effect into the towns.
Tobacco and Marijuana Usage A newly popularized drug, which has become widespread with in Jordan is tobacco smoked with a hookah, or as it is nicknamed, ‘‘hubbly bubbly,’’ or shisha. Hookahs are used to smoke a tobacco or tobacco-like product that is common in restaurants and cafes in
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Jordan. The drug is particularly popular with young people, and some participants reported it being more common among women than among men. Although Jordanian law prohibits ‘‘smoking in public places,’’ there are currently no federal regulations for its dispersion of the tobacco or tobacco-like products smoked in Hookahs, and many restaurants make their own house blend (Whitman 2014). Participant 1 spoke of the dangers of an unregulated substance being so widely used, saying that the sweet flavors are marketed toward young people with no information about the harmful chemicals hidden within an innocuous ‘‘apple’’ flavor. Participant 2 said that women are starting to smoke more now, both cigarettes and hookah, because they see it on television and want to be cool. A brief mention was made of marijuana from a few participants, one stating that in her town, it was more common, whereas in the city, she sees people using alcohol more often (P5).
Pills and Inhalants Usage Participants 2 and 4 spoke of pills and inhalants growing in popularity within schools, with drug dealers distributing to young children. Participant 2 mentioned that police have been brought into schools in his town to try to manage the drug distribution. Participant 1 spoke of her sister’s addiction to morphine pills, but did not seem to think it was a problem.
Reasons People Use Substances The reasons people gave for choosing to use substances are similar to those we would expect in Western culture. Some said that it was for a mental escape (P1) or to forget one’s problems (P2 and P3), whereas other drank to have fun or to be cool. One participant described refugees in the country as needing to drink stating, ‘‘you know, they leave an identity…they live in emergency…And they need the drugs and alcohol to forget their pains, they say, ‘we drink alcohol to forget our pains, to forget our, uh, forget what we lost’’’ (P3, lines 22–25). Participants 2 and 4 spoke of private usage with friends for social occasions.
Response to Substance Users Perception of Users Participants indicated that drinking greatly changes your reputation. Individuals who consume alcohol were described as weak, despised, selfish, and untrustworthy. One participant who manages a business said that when she found out an employee had consumed alcohol, she immediately let him go (P1). Men who drink seem to be tolerated within society as long as they are able to maintain functioning in daily life, and do not publicly exhibit their drinking. Participant 1 described her response to those who drink the following way, ‘‘we don’t interfere, that’s how they are and you don’t talk about it’’ (P1, line 335).
Feelings Toward Family Members of Users People often look at family members of users with pity. Especially when the person using alcohol is the head of the household, the wife is regarded with pity, ‘‘The wife usually is
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just the victim. She’s trying to live. To shield herself from the effects of (alcohol use). Just leave him alone so she doesn’t get abused’’ (P1, lines 355–357).
Public Responses All participants spoke of public substance use as being very inappropriate and elicited strong reactions. In the towns, substance use, particularly alcohol use, is met with confrontation, anger, social shaming, and sometimes violence (P2 and P3). If people in your town find out that you are someone who drinks, you bring shame on yourself and your family, ‘‘it’s like shame. Yeah, I saw your son drunk. You know what does it mean if they say to my father, I saw your son drunk. It is like catastrophe’’ (P2, lines 236–239). If anyone is seen drinking in public, people respond by trying to eliminate the problem, through confrontation or through force. ‘‘Nobody will allow this man to walk the street while he is drunk or even he, if they saw even a bottle, thrown on the side of the road. ‘Oh my god, it’s a bottle, oh my god.’. It’s a strange thing, yeah it’s very strange’’ (P2, lines 48–54). Other people within a small town will respond with anger toward individuals who are using alcohol, and this response can lead to removal of the individual from community life. ‘‘Even if you go in the street, you know, eh, the rumors, if the people hear about somebody that this man is the drink alcoholic, they trying to avoid him, yeah, so he become, uh, like isolation’’ (P2, lines 166–174). At times, the response within the community can lead to physical violence, often from other men who see someone in public who is drunk, perhaps due to the strong negative reaction which is elicited when individuals consume alcohol, if individuals do partake in the consumption of alcohol they do so in private, hidden behind closed doors. In the cities, there is still a strong negative response to substance use, but it is less personal. Participants said that if someone is drinking in public, they will just call the police (P3, P4, and P5). Individuals who drink in cities are less likely to experience physical violence, but they can be shunned socially (P4), and they risk going to prison (P3 and P5).
Family Response Toward Substance Users While the public response toward alcohol users is strongly negative, family members sometimes respond differently. Substance use is seen as negative and extremely harmful, but if someone knows that a family member is drinking, they often try to hide or cover up the behavior (P1, P2 and P3). There also seems to be a level of denial that is used to respond to substance use within the family. For example, participant 1 stated that within her family substance use is not widespread; however, she went on to describe two family members as alcoholics and another family member who is addicted to morphine. She said that often people know about problems with drinking, but they re-label it as a different problem, ‘‘It’s not a secret everybody that knows him knows he’s been drinking… but people just, you know kind of dance around it… They don’t talk about it—he’s not at the wedding because he’s not feeling so good’’ (P1, lines 55–67). Participants 2 and 3 also reported that individuals who are using alcohol will lie to their family members about it, and if family members become aware of the problem, they will try to avoid talking about it. Some participants reported that if the problem does not remain hidden, family members will at times respond to young people by kicking them out of the house, or fighting with them (P2 and P3). However, if the family member who is drinking is the head of the household, divorce was also suggested as a response (P2). Only two participants mentioned
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any type of treatment for substance use, and both suggested rehabilitation, but suggested that family members might call the police and take them to a rehab center.
Responses to Users Vary Based on Gender It seems that the response toward the substance user varies greatly by gender. For men, especially young men, some alcohol use is tolerated if he (the male user) is still able to function, ‘‘The man here, he can do anything he wants, you can forgive him, because he’s a teenager, he can do whatever he wants’’ (P4, lines 52–54). However, for women, the response is often not as forgiving. ‘‘If a woman does it (drinks), that’s her life. She’s finished’’ (P4, line 55). Participants reported that more stigma and discrimination is associated with female substance users. Young female substance users receive harsher punishment than men and are socially branded, whereas young men who use are able to salvage their reputation when they stop using. ‘‘Women are judged by much harsher standards than are men… It depends, uh, the society, uh what segment of society she is from, she will either get killed (laughing) to uh, being punished, to being hidden, you know’’ (P1, lines 231–238).
Recovery Resources for Family Members From the information gathered through our interviews, the primary method of dealing with substance use seems to be to try to work out a solution within the family— by trying to convince users that what they are doing is harmful, seeking help from extended family, or resorting to violence. When asked how family members deal with substance use, one participant said, ‘‘I believe prevention is the best medicine’’ (P1, lines 379–380). It seems that after prevention, families often cover up substance use and hope that it resolves itself, and only when family situations get desperate do they seek intervention. Participant 1 mentioned that extended family members will sometimes step into help a woman whose husband is an alcoholic, ‘‘if they notice he is abusive, or he’s not supporting her enough, or he’s sick because of it’’ (lines 377–378). It is very difficult to go outside of the family to get help, and it seems that chance of stigma is only risked if the situation is indeed desperate. The only resources for a woman whose husband is an alcoholic are through her family, and she would only use that option if she felt there was no other choice. ‘‘If she notices abuse for the children then she will get more help from his brothers. His family is more effective than her family’’ (P1, lines 373–375). While the family seems to be the preferred method of dealing with substance use, it appears the options are still very limited.
Rehabilitation Centers The only real resource that was mentioned for helping individuals who were struggling with substance use outside of the family was rehabilitation centers. Four participants spoke of the existence of rehab centers, yet the descriptions varied widely regarding its utility and access. Two participants (P3 and P5) spoke relatively positively about rehab, saying that the centers had good doctors and good medicine and that people could go without the fear of being arrested. Participant 3 even claimed that these centers offered free services. However, participants agreed that going to rehab is rare, associated with stigma, and some
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participants were skeptical about whether or not it was effective. When asked whether rehab is helpful, Participant 5 responded, ‘‘Yes, when they are in the rehab. After they come out, I think that society judges them or blames them. When the environment around them… it is difficult situation. It is not a supportive environment around them (when they return to society) so somehow maybe they can get back to drink again or to take some substance’’ (P5, lines 73–76). It seems that participants are unsure whether the option of going to a rehabilitation center would be worth the social shame that is associated with it.
Discussion It seems clear from the responses of these participants that substance use is clearly understood to be a negative thing, but it is also handled inconsistently depending on the type of substance used and the gender of the user. Despite being asked about all substances, none of the participants here seemed to be overly concerned with anything outside of alcohol, even though mention is made of cigarettes, hookah, ‘‘pills,’’ and inhalants. Many of these pose similarly serious health risks, and yet because there is relatively less stigma, there is less urgency around or attention given to those problems. Alcohol is notable for its extremely negative reputation, even relative to many other substances, and users of alcohol are treated very differently than are users of other substances, particularly ‘‘hubbly bubbly’s.’’ One very surprising finding was that many of the participants noted the significant increase in use in Jordan of these ‘‘hubbly bubbly’s’’ but that little to no social and political attention was being paid to this issue. In fact, the increase in use of hookahs in restaurants and cafes particularly among younger generation, and groups of young women specifically, was noted as a trend. Another surprising finding was both the availability of and access to rehab and treatment centers in Jordan. Despite the negative stigma associated with going to treatment of any kind, it was interesting that such treatment was available and widely known in urban areas. It is unclear whether or not the social and political change associated with the Arab Spring has had a direct impact on substance use in Jordan, but the participants here all acknowledged that there has been a dichotomous social shift in recent years among younger generations both toward and away from substance use. These shifts could support the social and political trends that have been noted of a bimodal distribution among young people toward of both more Western liberal thinking on one end and conservative political and social Islamist thinking on the other.
Conclusion In Jordan, where political, social, and generational changes have been significant, but notably less dramatic than other Muslim countries in recent years, substance use has reflected this. There has been an increase in use of many substances, particularly alcohol, among young people in the Arab world (Al-Omari et al. 2014), and Jordan is no exception to that trend. Alcohol was consistently seen as the most dangerous and highly stigmatized substance among the respondents in this study, but it was noted that other substances such as tobacco and hash are being used more frequently, more openly, and more popularly among both young men and women in urban centers. Future research on the social changes in substance use and addiction should endeavor to learn more about how substance use education may be better incorporated into Jordanian schools and other programing in a
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culturally appropriate way. Given the influx of refugees to Jordan in the last several decades, substance use education and access to treatment may be an even more important concern for social, medical, and political groups. Refugee populations, and in fact any peoples who are exposed to multiple traumatic events, are even more likely to use and abuse substances (Ruorden 2013). It is important that Muslim youth be exposed not only to the cultural and religious expectations about substance use, but to the health issues around use and addiction as well. As social and political change continues to occur in the Arab world within the context of a smaller and smaller global community, conversations with Muslim youth about the complexities and stigmas around substance use should be included in the discussion. Accurate educational information about addiction and recovery provided in a culturally relative and appropriate way may be essential for Muslim youth in Jordan to help them both define and manage what seems to be a growing trend toward use. Because of the sensitive nature of this issue, substance use may (if it has not already) become representative of social change. A backlash against use and users as representing a shift toward liberalism in this political context may be imminent. Developing increased awareness about substance use and its consequences for youth in this context is therefore even more significant.
References AlMarri, T. S. K., & Oei, T. P. S. (2009). Alcohol and substance use in the Arabian gulf region: A review. International Journal of Psychology, 44, 222–233. doi:10.1080/00207590801888752. Al-Omari, H., Hamed, R., & Tariah, H. A. (2014). The role of religion in the recovery from alcohol and substance abuse among Jordanian adults. Journal of Religion and Health, 1–10. doi:10.1007/s10943014-9868-5. Al-Oqily, I., Alkhatib, G., Al-Khasawneh, A., & Alian, M. (2013). Social networks impact: The case of Jordan youth. International Journal of Continuing Engineering Education and Life Long Learning, 23(1), 100–114. doi:10.1504/ijceell.2013.051953. Alzyoud, S., Weglicki, L. S., Kheirallah, K. A., Haddad, L., & Alhawamdeh, K. A. (2013). Waterpipe smoking among middle and high school Jordanian students: Patterns and predictors. International Journal of Environmental Research and Public Health, 10(12), 7068–7082. doi:10.3390/ ijerph10127068. Amir, T. (2001). Comparison of patterns of substance abuse in Saudi Arabia and the United Arab Emirates. Social Behavior and Personality, 29, 519–530. Creswell, J. W., Hanson, W. E., Plano, V. L., & Morales, A. (2007). Qualitative research designs: Selection and implementation. The Counseling Psychologist, 35(2), 236–264. Gilgun, J. F. (2009). Qualitative research and family psychology. In J. H. Bray & M. Stanton (Eds.), The Wily-Blackwell handbook of family psychology (pp. 85–99). Malden, MA: Wiley-Blackwell. Haddad, L., Shotar, A., Umlauf, M., & Al-Zyoud, S. (2010). Knowledge of substance abuse among high school students in Jordan. Journal of Transcultural Nursing, 21, 143–150. doi:10.1177/ 1043659609357632. Hamaideh, S., Mudallal, R., Al-Mudallal, H., & Abu Hammoudeh, M. (2010). Prevalence, types and predictors of illicit substance use among the Hashemite University students in Jordan. Jordan Medical Journal, 44(2), 125–132. Hoffman, M., & Jamal, A. (2012). The youth and the Arab spring: Cohort differences and similarities. Middle East Law and Governance, 4(1), 168–188. doi:10.1163/187633712x62399. Michalak, L., & Trocki, K. (2007). Alcohol and Islam: an overview. Contemporary Drug Problems, 33, 523–562. Michalak, L., Trocki, K., & Katz, K. (2009). ‘‘I am a Muslim and my dad is an alcoholic—What should I do?’’ internet-based advice for Muslims about alcohol. Journal of Muslim Mental Health, 4, 47–66. doi:10.1080/15564900902771325.
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Substance Use in Muslim Culture: Social and Generational Changes in Acceptance and Practice in Jordan Kira B. Mauseth1 • Jordan Skalisky1 • Noe¨l E. Clark2 Ray Kaffer1
•
Springer Science+Business Media New York 2015
Abstract Through narrative analysis, this paper explores the changes in acceptance of and response to substance use in Muslim culture by evaluating data collected in qualitative interviews in Jordan in 2013. What is known and unknown about substance use in Muslim culture throughout the Arab world from previous research findings provides a foundation from which to explore new perspectives and compare themes between younger and older generations in Jordan. Trends of social change and behavioral expression influenced by dramatic political and social upheaval in the Arab world in the last 5 years will also be evaluated for the way in which they may be influencing both substance use and its acceptance among young adults in this population. Recommendations for future research and work in this area are also provided based on these findings. Keywords
Substance use Muslim culture Islam Jordan Social change
Introduction Substance use, including both alcohol and drugs, has changed dramatically in terms of both acceptance and response throughout the international community over the last several decades. In the USA, the use of Marijuana, which had previously been illegal, has, in some places, been de-criminalized and made legal. New drugs are constantly being invented, tested, and processed on the global market. The development of the drug ‘‘Crocodile’’ in Russia, and its rapid and recent spread throughout the world is one such example (Shuster 2011). In many
& Kira B. Mauseth [email protected] 1
Department of Psychology, Seattle University, 901-12th Ave, Seattle, WA 98211, USA
2
Department of Psychology, Seattle Pacific University, 3307-3rd Ave W, Seattle, WA 98119, USA
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Muslim countries in much of North Africa, the Middle East, and parts of Asia, substances of all kinds have gone through a significant shift in both use and acceptance. Practitioners of Islam who make up the Muslim culture that is predominant in the aforementioned geographic areas have had a particularly unique and challenging relationship with substance use in recent generations. Although something like ‘‘Crocodile’’ may not (yet) be a scourge in this part of the world, other substances including alcohol, hashish, amphetamines, and addictive prescription medications certainly have a significant impact on the lives of those who use them and the larger communities of which they are part. The commandments set forth in the Quran and the sayings in the Hadith provide instruction about the use of intoxicants (specifically alcohol), which strongly influence the extent to which substances of all kinds are accepted and/or may therefore be made illegal in predominantly Muslim countries such as Jordan, Saudi Arabia, and Egypt (Michalak and Trocki 2007). However, recent and dramatic changes in both political control and social activism in many predominantly Muslim countries inherently impact other social and cultural norms, including substance use. Behaviors and schools of thought that were previously held as ‘‘taboo’’ have enjoyed different (new) levels of acceptance and tolerance in the last 5–10 years specifically. It can be argued that shifts in social norms around substance use in Muslim culture have changed perceptively despite little if any change in laws governing such practices in many predominately Muslim countries. In Jordan, there is an interesting mix of influences that illustrate the complexities behind substance use in Muslim culture. As part of a traditionally more moderate Muslim country compared with neighbors such as Saudi Arabia, many Jordanians have approached substance use (specifically alcohol and hashish) with more openness, if not with more tolerance. In recent years, this openness has contributed to a dramatic expansion in both the number of smoke shops and the use of hookahs or ‘‘hubbly bubblys’’ in restaurants. Although frequented by both men and women between the ages of 18 and 50, these smoke shops and cafes are becoming increasingly popular as social gathering places for young people under the age of 30 (AlMarri and Oei 2009; Amir 2001; Haddad et al. 2010). The reasons for this increase are complex, but the social change and shift in perception of substance use that they seem to represent are certainly significant. With the intention of contributing more to the understanding about the impacts of social and generational change on substance use, and the potential implications of that change on subsequent generations of Muslims, qualitative interviews were conducted with six Jordanians between the ages of 23 and 56. Narrative analysis was used to identify themes and explore similarities and differences between members of different generations in their perceptions about substance use in Jordan today. Findings suggest that although laws may be clear, social expectations and responses are decidedly less so, and the ambiguity around substance use in general differs by generation.
Background Previous Research on Substance Use in Muslim Culture Much of the data that exist on the topic of substance use and Muslim culture have focused on alcohol use and specific passages in the Quran and other Islamic teachings such as the Hadith (Michalak and Trocki 2007). While the Quran is synonymous with Islam as the Bible is to Christianity, the Hadith is less well known but is vital to the understanding and
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practice of Islam. The Hadith is a collection of the Prophet Muhammad’s words and actions. Traditionally, Muslims recognize the Quran as the ‘‘word-for-word message of God,’’ believed to supersede the Hadith; however, both are used interchangeably (Michalak and Trocki 2007). Interestingly, the Quran and Hadith are controversial in their regulation of alcohol consumption and do not provide a definitive guide on substance use for Muslims. Previous research has recognized the shift in perspectives concerning alcohol use in the Quran and Hadith. Michalak and Trocki (2007) outlined the progression of three stages in the Quran and Hadith that range from alcohol use being tolerated, to being prohibited during prayer, to the full prohibition of alcohol, including punishment in the form of physical abuse (Michalak and Trocki 2007). The confusion of the religious legality of alcohol has compounded the debate of what alcoholic beverages are prohibited. In the Quran, the word for the forbidden beverage, khamar, translates to meaning only specific alcoholic beverages, such as those derived from grapes, wheat or barley, or controversially, according to others, any substance that intoxicates (Michalak et al. 2009). The khamar, because of its historical context, may not include modern substances, such as hard liquor or illegal drugs, promoting confusion for contemporary followers of the Islamic faith (Michalak and Trocki 2007). The conflicting views of alcohol consumption within the Quran and Hadith have created unclear guidelines for Muslims. The ambiguity of the religious texts and the prohibition of alcohol have become a more acknowledged issue in the past decade. Fatwas, advice given from Islamic scholars, are often issued in response to queries of substance use, especially from the younger, less conservative generation of Muslims and Muslims living in predominantly non-Muslim countries (Michalak and Trocki 2007; Michalak et al. 2009). While the consensus of belief from most Muslims and fatwas is that the use of alcohol is prohibited, some take it as far as prohibiting indirect contact with alcohol, for example, working in a store that sells alcohol is discouraged (Michalak et al. 2009). However, Michalak et al. (2009) found that the most asked question of Muslims was that of why alcohol was prohibited. The fatwas that were issued in response dictated that the consumption of alcohol is a haram, a severe transgression, and that it has harmful effects on every aspect of the consumer’s life (Michalak et al. 2009). Haddad et al. (2010) contend that substance use violates the Islamic principle of not partaking in behaviors that are destructive to the body or soul. In agreement with Islamic laws, many predominately Muslim countries have forbidden the sale, possession, or consumption of alcohol by Muslims but not for non-Muslims (Almarri and Oei 2009). However, this has not prevented Muslims from using or abusing substances. While substance abuse in the Muslim culture is becoming more acknowledged, Muslims themselves are often not being educated on the subject. A study by Haddad et al. (2010) on substance abuse among adolescents in Jordan contends that while most Jordanian adolescents have a basic understanding of substance use, the information may primarily be coming from the mass media and peer groups. A lack of education about substance abuse has also lead many Jordanian adolescents to believe that addictions are constant and that quitting an addiction is not feasible (Haddad et al. 2010). The condemnation of substance use by the Islamic faith has created a social stigma in addressing substance use and treatment options. Tahboub-Schulte et al. (2009) detail how a Muslim family wanted to send a family member abroad for substance abuse treatment due to the ‘‘intensity of existing cultural stigma’’ (p. 73). Unfortunately, the collective shame of alcohol consumption as a haram may be furthering the denial of Muslims who abuse substances and not aiding in developing preventative measures. The social stigma of substance use within the Muslim culture has lead to the current misinformation and lack of literature on the subject (Haddad et al. 2010; AlMarri and Oei 2009). However, despite the
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religious restrictions and shame associated with substance use, the amount of literature on the subject is increasing as there has been a documented rise in substance abuse cases (Tahboub-Schulte et al. 2009). Substance abuse has moved from the cities to rural areas, with the majority of substance abusers being male and between the ages of 20 and 35 years (AlMarri and Oei 2009; Amir 2001; Haddad et al. 2010). The rate of female substance users is very low, a possible result of underreported cases and social stigma (AlMarri and Oei 2009). Alcohol, heroin, and cannabis are reported as the most abused substances; nevertheless, there are not adequate data about the frequency or quantity of use (AlMarri and Oei 2009). These measurable shifts in demographic changes associated with use may simply be a result of more access as global influences increase, but it is also likely that recent social and political changes in the Middle East and North Africa have contributed to the rise in substance use within Muslim populations in these areas.
Social and Political Change in the Arab World and its Impact on Substance Use In the last 5 years, the Arab world specifically has experienced dramatic and consequential political and social change as part of a multinational series of revolutions, riots, and protests that have taken place across the entire region. The beginning of this time period has been referred to in the media as the Arab Spring. The governments of Egypt, Tunisia, Lybia, and Yemen have been completely overthrown since 2010, while Syria remains embroiled in a civil war that has killed tens of thousands of people (Ruorden 2013). In Morocco and Jordan, known social and political ‘‘moderates’’ in the region, constitutional reforms have been implemented in response to large-scale public protest (Tawil 2013). The potential implications of this large-scale social and cultural change relative to substance use in these countries are significant and varied. In some places, the return to a more conservative Islamist political approach might result in a crackdown on access to substances and those who use them. In other places, where social upheaval has resulted in the lessening of restrictions toward the people on the part of the government, an increase in substance access, use, openness, and tolerance may occur as never before. Certainly, the impact of drastic social and political change has found its way into the everyday lives of the populations affected by the change. Conclusive research establishing a link between substance use with the Arab Spring is yet to be conducted. However, studies addressing social change and the conditions that contributed to the revolts and revolutions of the Arab Spring are available, specifically in terms of generational and technological parallels. Exploring a potential link is worthwhile given a rise in substance use and the similar climates that exist in Jordan as in other nations that did experience uprisings as a part of the Arab Spring. Generationally, the Middle East and North Africa are experiencing a massive bulge in the young adult populous, and Jordan is no exception (Hoffman and Jamal 2012). In exploring political and social differences between age cohorts of this region, Hoffman and Jamal (2012) note that with this burgeoning youth demographic, there is a trend of lower individual religiosity, which might indicate greater tolerance/acceptance of alcohol use. However, contradictory evidence was also found. The study showed the youngest age cohort (between age 18 and 24) was more supportive of political Islam and Shari’a law (Islamic law based on the Quran but written by scholars and interpreters) than the oldest cohort of respondents who were ages 55 and above (Hoffman and Jamal 2012). Importantly, the level of education in the younger cohort mitigates that finding where higher levels of education relate inversely to support of political Islam (Hoffman and Jamal 2012).
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The increase in technology and social media use among young adults is another social change parallel linking Jordan to the nations of the Arab Spring (Al-Oqily et al. 2013). AlOqily et al. (2013) stressed the importance social networking and social media in the free expression of ideas while researching social network use among Jordanian university students. Like in Egypt, Tunisia, and Lybia, social media and social networking are allowing young people to share ideas with anonymity, organize, and express political agendas. Social media and technology also allow for greater access to Western (typically non-Muslim) culture and media, including normalized images of substance use. As mentioned, a relationship has not yet been established between the Arab Spring and substance use, but the potential for such a link to exist is present. Looking at recent studies that examine substance use in Jordan shows that increases in substance use over the same period of time the Arab Spring have embroiled the region. Al-Omari et al. (2014) list a nearly 29 % increase in cases of reported drug use from 2011 to October 2013. Also important is the average age of participants in their study, conducted at two drug and alcohol rehabilitation centers in Jordan, which was below 30. Among even younger demographics, substance use is increasing in Jordan with the rise of water pipe smoking in middle and high school students (Alzyoud et al. 2013; Mzayek et al. 2012). Especially interesting is Alzyoud’s (2013) finding that girls were more likely to be water pipe users than boys among 993 participants ages 11–17. Finally, although slightly predating the Arab Spring, a study on substance use among Jordanian university students found alcohol to be the most prevalent substance used among the students surveyed (Hamaideh et al. 2010). The study goes on to postulate that the high numbers of alcohol use observed could be related to increasing western cultural influences from TV and Internet media. Independent of the social and political upheaval in many Muslim countries following the Arab Spring, the increase in the use of technology and the access to a ‘‘global culture’’ and economy are also having an impact on substance use (Al-Oqily et al. 2013). Muslims from different generations, with different access to and familiarity with other cultures and lifestyles may, have drastically different notions about substance use and its consequences. Exposure to both medical and recreational substance use through the internet and social media could strongly influence norms about what is acceptable and what is not. The current study sought to understand personal explanations for and understanding behind substance use in Jordan specifically, through in depth interviews with Jordanian Muslims.
Methods In this study, narrative inquiry qualitative analysis was used to assess observations, experiences, and beliefs about substance use in Jordanian culture.
Participants The researchers in this study were in Jordan in September 2013, participating in relief work with refugees residing in Jordan. Participants in this study were recruited through word-ofmouth from among Jordanian nationals who interacted with our research team during that time. Participants included six Jordanian citizens ranging in age from 23 to 56 who worked in a service or volunteer position where they had direct interaction with the attitudes and
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beliefs of others. Two men and four women were interviewed. Demographic data for each participant are shown in Table 1. In qualitative literature as a whole, no set standard exists regarding the number of participants required for an appropriate sample size. Rather, the quality of the data is the ultimate measure of an appropriate sample size in its ability to meet the goals of the individual study and reflect universal concepts (Richie et al. 2003). Data saturation is met when there is redundancy that begins to emerge in information that is presented across interviews. In conducting this type of research, there are limitations in the generalizability of the results; however, this type of study allows an exploration of common experience, which can further examined in future research.
Procedure for Interviews The procedure for the data collection in this study included interviewing each participant in a location convenient to them in the cities of Amman and Jarash. Interviews were conducted by a research team member in September 2013. Creswell et al. (2007) suggest that when conducting narrative interviews, researchers should use broad, topic-specific questions that are open-ended, followed by clarifying questions to draw out depth and richness in participant response. Interviews were, therefore, organized and conducted in a nondirective, thematically oriented manner. Examples of questions in this study include ‘‘When you think about drug or alcohol use in your culture, what ideas come to mind?’’, ‘‘Do you see any differences between gender and age when it comes to substance use?’’, and ‘‘How do families here deal (or not) with substance use issues and/or addiction?’’. Translators were not used, as all of the participants in this study spoke fluent English. Interviews were conducted over a 1-week period of time, and typically took between 30 and 60 min to complete.
Procedure for Analysis The qualitative nature of this study allows for research that is exploratory and subjective. This type of research is appropriate for small sample sizes, yet is not confined to the scope of individual experience (Reissman 1993; Ponterotto 2005). A qualitative approach was employed in this study because of the unique ability of qualitative research to allow participants to attribute meaning to their experience and provide rich information about cultural themes and practices (Gilgun 2009). Additionally, narrative inquiry allowed our research team to access detailed data that may have been difficult to interpret through the use of questionnaires or quantitative research, particularly give the stigmatized nature of the topics examined (Creswell et al. 2007).
Table 1 Participant demographic data
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Participant #
Sex
Age
Marital status
1
F
56
Married
2
M
45
Married
3
M
26
Single
4
F
25
Single
5
F
23
Single
6
F
25
Single
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Following the guidelines of narrative inquiry analysis, each of the interviews was listened to, transcribed, and then checked to confirm the accuracy of the transcription (Ponterotto 2005). After transcription was complete, each member of the research team read the interviews multiple times to gain familiarity with the content. Research members paid careful attention to the overall narrative thread and the emotional content represented in each narrative. Researchers then broke each interview down into fragments that represented complete thoughts and organized them into themes, categories, and concepts. Examining narratives in this manner allows researchers to employ detailed content analysis while gaining a holistic view of the elements of each interview. Excerpts from passages that support and represent broader concepts were identified to be quoted in the results section. Through this approach, a thorough understanding was reached regarding the observations and beliefs about substance use in Jordan through the eyes of our participants.
Results Islamic Understanding of Substance Use Every participant began their interview by emphatically stating that alcohol and drug usage is strictly prohibited or forbidden. Alcohol in particular is both religiously and legally forbidden because it is mentioned in the Koran and made illegal through Shariah, law which is interpreted from parts of what is written in the from the Quran. One older participant (P1, lines 154–160) said, ‘‘I don’t put too much stock in (Shariah), because that’s people’s interpretation.’’ She described how many of the substances which are currently in use in Jordan are not explicitly mentioned in the Koran and therefore not outlawed. However, she went on to state that she relies on morality to guide her interpretation of what she thinks about any type of substance use, ‘‘That’s like, like fire… when you consider the major rules, it hurts, its harmful to yourself, it wastes money.’’ When she thinks about substance use in her culture, she relies on the spirit of the law, instead of the law itself. Some participants spoke of the difference between attending the mosque, and having respect for the moral traditions of Islam (P1, P2 and P3). Participant 2 described this contrast, ‘‘I think, uh, some people respect the religion in the villages, they are still holding the religion to the morals. Despite of, we are not conservative people, we are normal people, and we are very free, but we still have the old fashion’’ (lines 64–74). While alcohol and drug use is considered to be illegal (perceptually or actually) for most Muslims, it is not illegal for those living within Jordan who profess a different faith. Several participants spoke of the influence of foreigners bringing drugs and alcohol into Jordan. It is illegal in Jordan for anyone who is Muslim to own a liquor store, but liquor stores do exist within Jordan, owned and managed by people of different faiths. Despite the acknowledgement that substance use is forbidden, as the interviews progressed, participants revealed that each of them knew of friends or family members who used substances, or had heard about it in their communities.
Prevalence of Substance Use Participant reports of prevalence rates varied widely from interview to interview. Some of the variability in what was reported seemed to be due to a lack of awareness, but some significant differences emerged between those living in big cities, as opposed to those in
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more rural areas. Additionally, the drug or substances of choice changed dependent on geographical location, age, and gender. When talking about substance use, a theme that seemed to be an undertone in many of the interviews was although use is a problem, it it’s not in my home, not in my family, not in my community. In a way, this reflects the hidden nature of substance use within Jordan. Participant 1 described the presence of substance abuse problems stating, ‘‘And our segment and people I deal with, my family the people we deal with, we know it’s not widespread. We are not the people that go out to clubs. There are places for people who do that but not in my immediate family’’ (P1, lines 20–22) Yet this same participant went on to describe a sister who is addicted to morphine. Similarly, Participant 3, who said that alcohol use is rare and not a problem, went on to admit that he has in fact done binge drinking with his friends.
Alcohol Usage Reports of alcohol usage were the most varied of any substance, perhaps due in part to the experience of usage being hidden from the public eye, more legally regulated, and therefore difficult to identify. Some said that it was rare and not an issue (P3), while others reported that there is widespread access (P4 and P5) and that it is very common (P1). When asked to estimate how many people use alcohol, participants reported rates varying from 10 % (P2) all the way up to 70 % (P5), with one participant estimating that while 25 % may use alcohol, perhaps only 5 % abuse alcohol. Participants reported greater availability in the cities, where lower prices and a feeling of anonymity may lead to higher rates of usage. Even participants who lived in the city, however, seemed to have little awareness of how much consumption was actually taking place. One participant described avoiding establishments which might serve alcohol, ‘‘I just hear about it and sometimes I see people buying alcohol but I don’t go to restaurants that sell alcohol, I don’t go there for food. So that’s why I can’t tell a percent.’’ (P4, lines 37–39). Participant 2, who lives in a small town, estimated usage rates around 10 %, stating that his town is very conservative. One opinion that all participants had consensus on is that alcohol is a man’s substance in Jordan. Though there are some women who use alcohol, it is far more common among men, and they have easier access to it. One participant described binge drinking being typical when drinking because it is only done on special occasions and is not typical, ‘‘When he get the chance to drink alcohol, he will drink more and more to get drunk because maybe tomorrow he will never get the chance’’ (P3, lines 183–187). In Jordan, he says, if you drink alcohol, you drink to get drunk. Although some said that rates of drinking vary greatly even between people groups within Jordan, one participant said it is common among the wealthy who can afford to not work. ‘‘Uneducated people, uh, who use the alcohol, most of them uneducated people and they have no works, they have uh, are a lot of money, maybe their families is uh, their families are rich or wealthy, and they have no responsibility’’ (P3, lines 198–202). One participant (P3) said that in Muslim gulf countries, alcohol usage is much more prevalent because there is more money in those countries. Participants mentioned tourism and foreigners bringing alcohol into the urban areas in Jordan, with a trickle down effect into the towns.
Tobacco and Marijuana Usage A newly popularized drug, which has become widespread with in Jordan is tobacco smoked with a hookah, or as it is nicknamed, ‘‘hubbly bubbly,’’ or shisha. Hookahs are used to smoke a tobacco or tobacco-like product that is common in restaurants and cafes in
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Jordan. The drug is particularly popular with young people, and some participants reported it being more common among women than among men. Although Jordanian law prohibits ‘‘smoking in public places,’’ there are currently no federal regulations for its dispersion of the tobacco or tobacco-like products smoked in Hookahs, and many restaurants make their own house blend (Whitman 2014). Participant 1 spoke of the dangers of an unregulated substance being so widely used, saying that the sweet flavors are marketed toward young people with no information about the harmful chemicals hidden within an innocuous ‘‘apple’’ flavor. Participant 2 said that women are starting to smoke more now, both cigarettes and hookah, because they see it on television and want to be cool. A brief mention was made of marijuana from a few participants, one stating that in her town, it was more common, whereas in the city, she sees people using alcohol more often (P5).
Pills and Inhalants Usage Participants 2 and 4 spoke of pills and inhalants growing in popularity within schools, with drug dealers distributing to young children. Participant 2 mentioned that police have been brought into schools in his town to try to manage the drug distribution. Participant 1 spoke of her sister’s addiction to morphine pills, but did not seem to think it was a problem.
Reasons People Use Substances The reasons people gave for choosing to use substances are similar to those we would expect in Western culture. Some said that it was for a mental escape (P1) or to forget one’s problems (P2 and P3), whereas other drank to have fun or to be cool. One participant described refugees in the country as needing to drink stating, ‘‘you know, they leave an identity…they live in emergency…And they need the drugs and alcohol to forget their pains, they say, ‘we drink alcohol to forget our pains, to forget our, uh, forget what we lost’’’ (P3, lines 22–25). Participants 2 and 4 spoke of private usage with friends for social occasions.
Response to Substance Users Perception of Users Participants indicated that drinking greatly changes your reputation. Individuals who consume alcohol were described as weak, despised, selfish, and untrustworthy. One participant who manages a business said that when she found out an employee had consumed alcohol, she immediately let him go (P1). Men who drink seem to be tolerated within society as long as they are able to maintain functioning in daily life, and do not publicly exhibit their drinking. Participant 1 described her response to those who drink the following way, ‘‘we don’t interfere, that’s how they are and you don’t talk about it’’ (P1, line 335).
Feelings Toward Family Members of Users People often look at family members of users with pity. Especially when the person using alcohol is the head of the household, the wife is regarded with pity, ‘‘The wife usually is
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just the victim. She’s trying to live. To shield herself from the effects of (alcohol use). Just leave him alone so she doesn’t get abused’’ (P1, lines 355–357).
Public Responses All participants spoke of public substance use as being very inappropriate and elicited strong reactions. In the towns, substance use, particularly alcohol use, is met with confrontation, anger, social shaming, and sometimes violence (P2 and P3). If people in your town find out that you are someone who drinks, you bring shame on yourself and your family, ‘‘it’s like shame. Yeah, I saw your son drunk. You know what does it mean if they say to my father, I saw your son drunk. It is like catastrophe’’ (P2, lines 236–239). If anyone is seen drinking in public, people respond by trying to eliminate the problem, through confrontation or through force. ‘‘Nobody will allow this man to walk the street while he is drunk or even he, if they saw even a bottle, thrown on the side of the road. ‘Oh my god, it’s a bottle, oh my god.’. It’s a strange thing, yeah it’s very strange’’ (P2, lines 48–54). Other people within a small town will respond with anger toward individuals who are using alcohol, and this response can lead to removal of the individual from community life. ‘‘Even if you go in the street, you know, eh, the rumors, if the people hear about somebody that this man is the drink alcoholic, they trying to avoid him, yeah, so he become, uh, like isolation’’ (P2, lines 166–174). At times, the response within the community can lead to physical violence, often from other men who see someone in public who is drunk, perhaps due to the strong negative reaction which is elicited when individuals consume alcohol, if individuals do partake in the consumption of alcohol they do so in private, hidden behind closed doors. In the cities, there is still a strong negative response to substance use, but it is less personal. Participants said that if someone is drinking in public, they will just call the police (P3, P4, and P5). Individuals who drink in cities are less likely to experience physical violence, but they can be shunned socially (P4), and they risk going to prison (P3 and P5).
Family Response Toward Substance Users While the public response toward alcohol users is strongly negative, family members sometimes respond differently. Substance use is seen as negative and extremely harmful, but if someone knows that a family member is drinking, they often try to hide or cover up the behavior (P1, P2 and P3). There also seems to be a level of denial that is used to respond to substance use within the family. For example, participant 1 stated that within her family substance use is not widespread; however, she went on to describe two family members as alcoholics and another family member who is addicted to morphine. She said that often people know about problems with drinking, but they re-label it as a different problem, ‘‘It’s not a secret everybody that knows him knows he’s been drinking… but people just, you know kind of dance around it… They don’t talk about it—he’s not at the wedding because he’s not feeling so good’’ (P1, lines 55–67). Participants 2 and 3 also reported that individuals who are using alcohol will lie to their family members about it, and if family members become aware of the problem, they will try to avoid talking about it. Some participants reported that if the problem does not remain hidden, family members will at times respond to young people by kicking them out of the house, or fighting with them (P2 and P3). However, if the family member who is drinking is the head of the household, divorce was also suggested as a response (P2). Only two participants mentioned
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any type of treatment for substance use, and both suggested rehabilitation, but suggested that family members might call the police and take them to a rehab center.
Responses to Users Vary Based on Gender It seems that the response toward the substance user varies greatly by gender. For men, especially young men, some alcohol use is tolerated if he (the male user) is still able to function, ‘‘The man here, he can do anything he wants, you can forgive him, because he’s a teenager, he can do whatever he wants’’ (P4, lines 52–54). However, for women, the response is often not as forgiving. ‘‘If a woman does it (drinks), that’s her life. She’s finished’’ (P4, line 55). Participants reported that more stigma and discrimination is associated with female substance users. Young female substance users receive harsher punishment than men and are socially branded, whereas young men who use are able to salvage their reputation when they stop using. ‘‘Women are judged by much harsher standards than are men… It depends, uh, the society, uh what segment of society she is from, she will either get killed (laughing) to uh, being punished, to being hidden, you know’’ (P1, lines 231–238).
Recovery Resources for Family Members From the information gathered through our interviews, the primary method of dealing with substance use seems to be to try to work out a solution within the family— by trying to convince users that what they are doing is harmful, seeking help from extended family, or resorting to violence. When asked how family members deal with substance use, one participant said, ‘‘I believe prevention is the best medicine’’ (P1, lines 379–380). It seems that after prevention, families often cover up substance use and hope that it resolves itself, and only when family situations get desperate do they seek intervention. Participant 1 mentioned that extended family members will sometimes step into help a woman whose husband is an alcoholic, ‘‘if they notice he is abusive, or he’s not supporting her enough, or he’s sick because of it’’ (lines 377–378). It is very difficult to go outside of the family to get help, and it seems that chance of stigma is only risked if the situation is indeed desperate. The only resources for a woman whose husband is an alcoholic are through her family, and she would only use that option if she felt there was no other choice. ‘‘If she notices abuse for the children then she will get more help from his brothers. His family is more effective than her family’’ (P1, lines 373–375). While the family seems to be the preferred method of dealing with substance use, it appears the options are still very limited.
Rehabilitation Centers The only real resource that was mentioned for helping individuals who were struggling with substance use outside of the family was rehabilitation centers. Four participants spoke of the existence of rehab centers, yet the descriptions varied widely regarding its utility and access. Two participants (P3 and P5) spoke relatively positively about rehab, saying that the centers had good doctors and good medicine and that people could go without the fear of being arrested. Participant 3 even claimed that these centers offered free services. However, participants agreed that going to rehab is rare, associated with stigma, and some
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participants were skeptical about whether or not it was effective. When asked whether rehab is helpful, Participant 5 responded, ‘‘Yes, when they are in the rehab. After they come out, I think that society judges them or blames them. When the environment around them… it is difficult situation. It is not a supportive environment around them (when they return to society) so somehow maybe they can get back to drink again or to take some substance’’ (P5, lines 73–76). It seems that participants are unsure whether the option of going to a rehabilitation center would be worth the social shame that is associated with it.
Discussion It seems clear from the responses of these participants that substance use is clearly understood to be a negative thing, but it is also handled inconsistently depending on the type of substance used and the gender of the user. Despite being asked about all substances, none of the participants here seemed to be overly concerned with anything outside of alcohol, even though mention is made of cigarettes, hookah, ‘‘pills,’’ and inhalants. Many of these pose similarly serious health risks, and yet because there is relatively less stigma, there is less urgency around or attention given to those problems. Alcohol is notable for its extremely negative reputation, even relative to many other substances, and users of alcohol are treated very differently than are users of other substances, particularly ‘‘hubbly bubbly’s.’’ One very surprising finding was that many of the participants noted the significant increase in use in Jordan of these ‘‘hubbly bubbly’s’’ but that little to no social and political attention was being paid to this issue. In fact, the increase in use of hookahs in restaurants and cafes particularly among younger generation, and groups of young women specifically, was noted as a trend. Another surprising finding was both the availability of and access to rehab and treatment centers in Jordan. Despite the negative stigma associated with going to treatment of any kind, it was interesting that such treatment was available and widely known in urban areas. It is unclear whether or not the social and political change associated with the Arab Spring has had a direct impact on substance use in Jordan, but the participants here all acknowledged that there has been a dichotomous social shift in recent years among younger generations both toward and away from substance use. These shifts could support the social and political trends that have been noted of a bimodal distribution among young people toward of both more Western liberal thinking on one end and conservative political and social Islamist thinking on the other.
Conclusion In Jordan, where political, social, and generational changes have been significant, but notably less dramatic than other Muslim countries in recent years, substance use has reflected this. There has been an increase in use of many substances, particularly alcohol, among young people in the Arab world (Al-Omari et al. 2014), and Jordan is no exception to that trend. Alcohol was consistently seen as the most dangerous and highly stigmatized substance among the respondents in this study, but it was noted that other substances such as tobacco and hash are being used more frequently, more openly, and more popularly among both young men and women in urban centers. Future research on the social changes in substance use and addiction should endeavor to learn more about how substance use education may be better incorporated into Jordanian schools and other programing in a
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culturally appropriate way. Given the influx of refugees to Jordan in the last several decades, substance use education and access to treatment may be an even more important concern for social, medical, and political groups. Refugee populations, and in fact any peoples who are exposed to multiple traumatic events, are even more likely to use and abuse substances (Ruorden 2013). It is important that Muslim youth be exposed not only to the cultural and religious expectations about substance use, but to the health issues around use and addiction as well. As social and political change continues to occur in the Arab world within the context of a smaller and smaller global community, conversations with Muslim youth about the complexities and stigmas around substance use should be included in the discussion. Accurate educational information about addiction and recovery provided in a culturally relative and appropriate way may be essential for Muslim youth in Jordan to help them both define and manage what seems to be a growing trend toward use. Because of the sensitive nature of this issue, substance use may (if it has not already) become representative of social change. A backlash against use and users as representing a shift toward liberalism in this political context may be imminent. Developing increased awareness about substance use and its consequences for youth in this context is therefore even more significant.
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