Leveraging the power of groups for forced migrant populations impacted by war and torture: Strengthening family and social resources among Syrian refugees in Jordan

Abstract

Objective:

Although there is emerging evidence for the effectiveness of group interventions for the mental health of war and torture-affected populations, there has been limited investigation into the social and interpersonal benefits that may be particular to group therapies.

Method:

Informed by interpersonal group theory and the concept of social resources, we conducted 31 interviews with Syrian men and women exposed to torture and exiled as refugees in Jordan to examine perceived changes in social resources and underlying mechanisms following participation in a 10-week group psychotherapy and group physiotherapy intervention.

Results:

The analysis revealed a two-stage process of change. First, participants identified changes in intrapersonal processes related to motivation, skills and readiness for social relationships. Next, participants drew upon these improved capacities to expand their available social networks and connections through new friendships with group members and strengthened family relationships. Several different mechanisms were identified that contributed to these distinct gains in social resources.

Conclusions:

The findings highlight community and family-level benefits rarely assessed in group-based interventions and enable understanding of how groups may strengthen social resources for refugee communities displaced from family, home, community, and country. The findings have implications for conceptualization and measurement of social resource outcomes in future research and cultivating social resources in group-based intervention design.

Background

The number of individuals and families forced to leave their homes has steadily risen over the last several decades. The United Nations High Commissioner for Refugees (UNHCR) estimated that global forced displacement reached 117 million in 2023, of which approximately 33 million are refugees. Refugees are individuals who have fled their countries and homes due to war, violence, conflict or persecution and have crossed an international border to find safety in another country (UNHCR, 2023). The war in Syria has resulted in almost 13.5 million individuals displaced (UNHCR, 2022). Although the greatest proportion of refugees from Syria are living in Turkey, over 650,000 live in Jordan which is the setting of this study. Approximately 83% live in the capital city of Amman, with smaller groups living in the refugee camps of Za’atari and Azraq (UNHCR, 2021).

Social Resources and War and Forced Displacement

Experiences of war, terror, and forced migration contribute to devastating losses and threaten the well-being of individuals, families, and communities. In addition to the well-documented impacts on mental health (Turrini et al., 2017), forcibly displaced persons contend with losses such as separation from their homeland, family, friends, neighbors, and embedded social networks (Bunn et al., 2023). These relational losses are particularly salient among forcibly displaced persons from collectivistic cultures, in which interpersonal relationships shape all aspects of life (Kirmayer, 2007). Erosion of social networks has been observed among Syrian refugees in Jordan, disrupting cultural norms of interdependence and contributing to emotional and financial strain (Tobin et al., 2022).

The loss of social resources among forcibly displaced persons is largely driven by physical separation from communities in which individuals were previously embedded (Ali-Naqvi et al., 2023; Wachter & Gulbas, 2018). Yet, trauma resulting from war and terror can also impact social resources even after forcibly displaced persons are resettled into new communities. Prolonged experiences of living in conditions that foment fear and mistrust erode capacities to attach securely and share emotional intimacy in relationships, precluding the formation of new bonds that can serve as sources of social support (De Haene et al., 2010; Morina et al., 2013). These experiences can negatively impact one’s personal agency and the social agency of the broader community (Kira et al., 2012). Moreover, ongoing experiences of uprooting and the conditions of displacement including material deprivation and limited access to resources challenge the establishment of a reliable context for daily life, connection to place and the formation and sustainment of new relationships and connections (Akesson & Basso, 2022; Albers et al., 2021; Bunn et al., 2023).

There is also a growing body of research that highlights the vital role of social resources and rebuilding the social-relational experience of “home” for the health and wellbeing of displaced communities (Hall et al., 2014a; Magan & Padgett, 2021; Sim et al., 2019). Social resources refer to the material and symbolic resources that are embedded in one’s social connections and which are accessed through social interactions and relationships (Lin, 1982). Social resources encompass available social connections and networks, social support and social integration (Hall et al., 2014b). Social support refers to support available through one’s social environment and interpersonal connections such as emotional support, practical assistance, information, and resources from one’s existing social relationships such as friends, families, neighbors, and other proximal community members (Wachter et al., 2022). Social integration involves a sense of belonging and being a part of a larger community (Weiss, 1974).

There is significant evidence related to the positive health and mental health benefits of diverse social resources for refugee communities (Chen et al., 2017; Hawkin et al., 2021). A systematic review found that social capital interventions (e.g., interventions which facilitated various social connections) contributed to healthier habits, improved coping skills, familiarity with one’s new home environment and reductions in mental health symptoms among refugee communities (Villalonga-Olives et al., 2022). Specific to Syrian refugees, familial networks, social group membership and belonging were important coping resources for managing the stress of displacement and linked with improved mental health and empowerment (Eggerman et al., 2023; Smeekes et al., 2017).

Despite the importance of social resources to the health and well-being of forcibly displaced communities, they are rarely the focus of intervention studies with such populations. Social resources and social support, specifically, are often conceptualized as independent variables, mediators, or moderators (Wachter et al., 2022). Individual and group interventions for forcibly displaced persons typically target changes in mental health problems, particularly symptoms of depression, anxiety, and trauma (Bunn et al., 2016). While individual-level symptom reduction is important, services for communities impacted by interpersonal and collective trauma must go beyond the focus on individual psychopathology and integrate attention to social and communal healing as a critical component of overall wellness (Hobfoll et al., 2007; Kira et al., 2010; Kira et al., 2012; Wu et al., 2021).

Group Theory and Social Resources

Group mental health interventions are potentially well-suited to restore social resources that were disrupted by experiences of war and forced displacement (Akinsulure-Smith & Smith, 2019; Bunn et al., 2016). Group theory identifies group relationships and related interpersonal learning opportunities as important therapeutic ingredients for positive change (Bunn et al., 2021; Yalom, 2020). Groups provide a setting for participants to interact and where they can form relationships and exchange support and connection (Ibrahim et al., 2019). Further, these relationships may continue outside of the group and the social benefits they provide may extend beyond the duration of the intervention. Even if relationships in the group are not sustained beyond the intervention, the experience of forming these relationships may yield social benefits. For instance, relationships formed in a group may restore trust in others and or the sense of belonging in a community, reinforcing the perception that if support was needed, it could be accessed (Zinfandel & Svensson, 2024). These renewed relational capacities may translate to relationships outside of the group, such as with friends, family, neighbors, and others in the community.

Despite the potential of group interventions to promote the social wellbeing of forcibly displaced individuals, research in this area remains very limited. A review of 36 group models for communities impacted by torture, political violence and forced displacement found that while groups were selected for their perceived social benefits, few studies measured changes in social and interpersonal wellbeing as part of their evaluation methodology (Bunn et al., 2016). Though not specific to refugees, a study of a group-based cognitive processing therapy for Congolese women with trauma histories found a greater increase in group membership activities and emotional support seeking compared to those in the control condition (Hall et al., 2014c). In Uganda, participants identified perceived long-term improvements in community cohesion and reductions in family conflict resulting from participation in a group interpersonal psychotherapy program (Lewandowski et al., 2016).

These studies provide important empirical support related to the positive and potentially unique social benefits of group mental health interventions, yet they are rare and are not specific to refugee and displaced communities who face unique challenges and disruptions to preexisting social resources. Moreover, we lack research that examines the process by which changes in social resources occur in ways that could inform theory, measurement and group intervention design.

Study Objective

Our study examined the experiences of Syrian men and women in an interdisciplinary group intervention in Jordan. We examined perceived changes in social resources, the nature and type of social resource change and underlying mechanisms that facilitated change. This examination was part of a broader study examining the social-relational consequences of war and forced migration and the role of social-relational resources in healing (Bunn et al., 2021, 2023).

Methods

This study received Institutional Review Board approval from the University of Chicago (protocol IRB17–0951) prior to implementation. The study protocol was also reviewed by the Ministry of Health in Amman, Jordan, and determined not to need formal approval; it was also reviewed and approved by an internal research advisory committee at the Center for Victims of Torture. (CVT). The study was conducted in partnership with CVT, who assisted with the implementation of the study.

Study location and group intervention

The study was conducted in Jordan and all data collection occurred at the Center for Victims of Torture offices in the cities of Amman and Zarqa. As described in detail previously (Bunn et al., 2021, 2023), CVT utilized a manualized 10-week interdisciplinary group treatment model consisting of group counseling and group physiotherapy intervention. The groups are delivered separately but occur concurrently over a period of approximately three months, as the content and approach of the groups are designed to complement one another. The group counseling intervention includes psychoeducation on trauma, emotion regulation skills, narration and sharing of traumatic experiences, goal setting and accessing social support (Kastrup, 2016). The physiotherapy group focused on developing skills to manage physical issues and chronic pain. This is accomplished with a focus on increasing mind-body awareness and movement and mobility exercises that can alleviate discomfort (de Ruiter et al., 2018). In delivering the interventions, trained facilitators focus on the importance of exchanging support with others in the group and are encouraged to continue to support each other outside the group.

The groups are intended for refugee and other displaced individuals struggling with functional challenges related to symptoms of psychological distress or reactions to trauma and who are willing to engage in treatment. Each group included eight to twelve individuals and, due to gender and social norms, were stratified by gender. Participants also received supportive individual social work services and if needed, referrals to external services such as for medical, legal, or housing.

Recruitment Procedures

To protect client confidentiality and maximize client self-determination, eligibility was limited to participants who expressed interest in participating in research during routine clinical assessment and follow-up interviews conducted by the partner organization. After an initial screening call to confirm interest in this research, potential study participants were identified by the partner organization, and their contact information was shared with the research team. To capture culturally specific experiences and meanings among adult group participants, eligibility was restricted to Syrian adults aged 21 years and older, who had already participated in group services and had completed a three-month follow-up assessment. Participants were excluded if they were determined to be high risk meaning they had present or past serious mental health issues such as suicidal thoughts and intentions. After potential participants indicated willingness, the research team applied a maximum variation sampling approach to identify a demographically varied sample according to gender, age, and clinic location (Patton, 2015). Participants were contacted by the research assistant and invited to participate in an interview.

Study Participants

The study sample included 13 Syrian men (42%) and 18 women (58%). Average age of participants was between 34 and 57 years. Participants were married (74%), widowed (13%), single or separated (13%) and displaced in Jordan with family members an average of 57 months (4.8 years) at the time of study. Most were parents and had children with them in Jordan (n=30). Approximately half of the sample received services in Zarqa (n=16) and half in Amman (n=15). Most (n=23) participated in multinational groups that included group members from Syria, Iraq, Yemen, and Sudan and fewer (n=8) participated in Syrian-only groups. Interviews were retrospective. Study participants completed the groups 7 to 11 months prior to data collection.

Data Collection

Study participants provided written consent. Interviews were conducted in Arabic at the Center for Victims of Torture in Jordan between November and December 2017 and lasted approximately 90 minutes. Research assistants were fluent Arabic speakers, had previous experience working with refugee and forcibly displaced communities and conducting interviews and received 20 hours of training on study-specific protocols and qualitative interviewing prior to initiating the study. Research participants received a transportation allowance and a supermarket voucher equal to $15 USD for their participation. All interviews were audio-recorded, transcribed into Arabic and translated into English. During this process, interviews were de-identified, and participants were assigned culturally relevant pseudonyms to protect their confidentiality while humanizing their voices (Heaton, 2022). Transcripts were reviewed for accuracy and consensus (Colina et al., 2017).

During interviews, participants were asked to reflect on their experiences in the interdisciplinary group therapy intervention, including if and how participation influenced their social resources, such as current relationships or access to support. For example, participants were asked, have you noticed any changes in your relationships since participating in the group. Additional probes inquired about perceived changes in family relationships or with members of the community. Participants were also asked if and how the group intervention contributed to these changes.

Data Analysis

We drew on inductive and interpretive thematic analysis methods to examine and interpret perceived changes in social resources following participation in the group intervention and mechanisms contributing to such changes (Braun & Clark, 2021). In the first stage of analysis, we used open coding to produce an initial set of codes that were applied to the data. In the next phase of analysis, we drew on these initial codes to develop categories that reflected larger patterns and meanings in the data. The research team was led by a female American researcher and Arabic-English speaking research assistants with diverse lived experiences, including an Arab American, individuals from the Middle East, and individuals with lived experience of immigration and forced displacement. The team worked in a collaborative fashion to refine these categories and facilitate a broader level of abstraction of themes and findings. In later stages of analysis, we also drew on grounded theory methods of analysis (Charmaz, 2008) and employed data visualization techniques to organize the categories into a model to explore interrelationships between categories and elaborate an overall process as derived from the data. In-depth discussions among the research team facilitated our examination of the categories and overall process and assessment of thematic saturation. The team coded the data using Dedoose, a web application that facilitates qualitative data analysis among multiple coders (Dedoose, 2021).

Rigor

The research team adhered to procedures to increase the rigor of this qualitative study. The first author traveled to the study site multiple times to conduct preliminary interviews, develop relationships with the partner and other relevant organizations, enhance understanding of the study context, and build a research team. The second author was based in Amman, Jordan for the duration of the study and worked closely with the PI at all stages of research. The third author was embedded within the partner organization and collaborated on study design, data collection methodology, development of tools, sampling, and ethical review. During data collection, weekly team meetings were used to discuss the data, explore emerging themes, address ongoing questions, and refine understandings. The inclusion of diverse insider and outsider perspectives with positionalities and varying areas of expertise relevant to the study contributed to a nuanced and diverse interpretations of the data in ways that enriched the analysis and interpretation process. Following guidelines for conducting cross-cultural research, all research materials were pilot tested for comprehension (Liamputtong, 2010).

Findings

In figure 1, we offer a model to describe changes in social resources that participants perceived resulted from participation in the interdisciplinary group intervention (group counseling and group physiotherapy) and the underlying mechanisms contributing to the change processes. As described in detail below, Syrian men and women described that they were able to rebuild and recapture important aspects of their social lives following participation in the group. These changes came about through a two-stage process. First, participants identified changes in intrapersonal processes related to increased readiness, motivation and skills for social relationships, which provided a foundation for subsequent improvements in other social resources. These improvements came about through improved emotion regulation capacities, growth in self-confidence for women and developing a more present-focused orientation to their lives. Next, men and women drew upon these changes and pivoted to expand their available social networks and connections, through the formation of new friendships with group members and strengthened family relationships. Participants maintained connections with group members in diverse ways long after the intervention ended and exchanged diverse forms of social support which reduced isolation and improved wellbeing. Improvement in family relationships resulted from enhanced communication capacities and sharing skills from the group. These improved relationships further solidified access to meaningful forms of family support and connection and enabled a greater sense of integration and belonging in their new lives in Jordan.

Figure 1:

Two-stage process of social resource changes and mechanisms

Increased Readiness, Motivation, and Skills for Social Relationships

Participants were clear about the negative impacts of war, forced displacement, and daily stressors on their social lives. Many participants described limited social interactions, isolation, and fear of navigating their new social environment in Jordan. Many found themselves with limited energy and motivation to rebuild their lives in displacement. As one Syrian woman said, “I used to be strong, but I became very tired. We lost the ability to do anything.”

After the group, participants identified perceived changes in their capacity and desire to engage socially. Increased readiness, motivation, and skills for social relationships captured changes in intrapersonal processes and overall orientation towards social relationships, specifically the value and meaning that participants attributed to their social relationships and their capacity to invest in new and existing relationships. Generally, participants described this as an increased willingness to engage socially and get along with others despite the stress in their lives and challenges in their relationships. As one participant, Ahmad, stated of his relationships at home and out in the community: “We forgive others for doing annoying things. This is one of the advantages. Because we used to take the smallest things seriously in the past, and that would cause us stress. However, we gave up on that.” Reflecting on changes following the group, Iman said that she “felt a change in my life.” She elaborated: “I changed for the best, for sure. I learned how to control my anger, and now life is easy. We have friends from the group, and we spend a great time too.” Ahmad and Iman’s comments demonstrated a willingness to invest effort in improving how they approach relationships as they learned to work more skillfully with difficult emotions. Changes in participants’ readiness, motivation, and skills for social relationships were enabled by three primary mechanisms: learning to manage difficult thoughts, emotions, and sensations; gaining confidence; and a broadening of perspective beyond past and ongoing challenges.

Learning to Manage Difficult Thoughts, Emotions, and Sensations

Participants emphasized the importance of learning to manage difficult thoughts, emotions, and sensations toward improving their relationships. Increased awareness of one’s internal state and emotions and the use of coping skills learned in the group helped improve relationships within participants’ families and with their friends and peers.

In the groups, participants learned to practice daily habits that improved their mood and affected how they interacted with others. For instance, one participant described how his wife, who had also participated in the groups, began to do activities “for herself, not for anybody else,” such as embroidery and exercise. Learning to manage worries and remain calm was another important skill for improving well-being and relationships. Another participant described how she used to “go crazy” and “cry all day” when her mother in Syria did not answer the phone, because she “always thought that something bad happened to them, like they got killed or ISIS reached them.” In the group, she learned to “think differently” and consider other possibilities for family members in Syria not responding to calls, such as electricity outages or phones being out of service. Not automatically assuming the worst outcome lessened her distress when faced with uncertainty, helping her to maintain a stable mood.

By learning to manage anger and stress in the group, participants also became less reactive with others. These positive benefits were important for family relationships as some participants reported that they had been hitting and yelling at their spouses and children. Iman, a widowed 40-year-old mother, described how she used emotion regulation exercises learned in group counseling to “breathe slowly and count to ten,” which helped defuse her anger and prevented her from hitting her children. Similarly, Lufti, a 40-year-old father, described how he learned to leave the house and walk outside if he experienced overwhelming emotion while fighting with his wife rather than hitting her.

Gaining Confidence and Autonomy

Many participants felt socially isolated before the group because of traumatic experiences during the war and the stress of forced displacement. Participants became more socially confident and less shy after participating in the groups, facilitating connection with group members, family and others in their communities. This was particularly the case for women, who identified the acts of committing to the group, coordinating their transportation to the center, and leaving their homes regularly to participate as exposures that increased their confidence and sense of autonomy. Sajeda, a 44-year-old mother, described how she spent most of her time at her apartment, caring for her sick husband. In the group, she felt comfortable with the other women from Syria and Iraq and these relationships inspired a sense of confidence that generalized to other social domains.

I used to stay at home. I was shy. I didn’t even go to my parents’ house. I only was visiting them once a month. I was always at my house. But when I was with them in the group, I felt very comfortable. I was afraid of going out or talking to anyone, but now I am different. I feel comfortable. I am not afraid. I can go anywhere.

Like Sajeda, women in the study indicated that independently participating in the group and the support from group members helped them gain social confidence. Azhar, a 36-year-old mother living with her husband and young children, described this in her interview. “The first thing for me was the transportation,” she said, “I couldn’t ride the bus alone, but this Center encouraged me. The second thing is that when they talk, they emphasize self-confidence.” The intervention integrates a strengths orientation, and throughout the group process, providers encourage participants to connect with their innate strengths.

Broadening Perspective Beyond Past and Present Difficulties

Lastly, participants described changing their outlook as important toward facilitating their engagement in relationships. In the group, participants learned to live with grief and ongoing uncertainty and stress in their lives. They worked to come to terms with painful past and present circumstances by sharing their life experiences with group members during and outside of the group. Through this acceptance, they began to focus on things that they valued and were within their control. This included creating a safe and comfortable life for their children and creating a sense of community and belonging through friendships. As Rahaf, a 36-year-old mother living in Zarqa described, “Participating with the center took me out of what I’ve been in. They’ve drawn my attention to the beautiful future, and that we should leave the past. I mean this Center motivated us to make new relationships and welcome the better future.” Rahaf had been separated from her parents and siblings for years at the time of the interview. Her experiences of separation from close family members mirrored those of many other participants. Often, participants were overwhelmed by the grief of all they had lost and the pain of being separated from their families, their homes and land. Through participation in the group and the experience of sharing with others struggling with similar losses and challenges, participants learned to hold their grief alongside hope for the future. They learned to interrupt cycles of rumination about the past, allowing them to act toward building a more meaningful and hopeful future within their current circumstances, which included investing in relationships.

Ahmad, a 52-year-old father, had been living in Jordan for five years with his wife and two daughters. He also spoke about the shift in his perspective following participation in the group.

We all had limited thinking; all we were thinking about the situation of… (pause). Now, we think about things around us, our kids, our friends. When I was in Aleppo, I used to get mad easily. Now I’m calmer, my interactions with my kids are smoother, especially with kids because you know they are so demanding. The only thing that we were thinking about was when will this end. When will we end? However, now, we’re thinking about how to live, how to raise our kids and how to continue living. This is the benefit I got. It was our place to breathe out.”

The change that Ahmad speaks of came from being able to imagine a future for himself and his children. He connects his shift in perspective with this experience in the group—“it was our place to breathe out.” Ahmad highlighted how coping with stress in interpersonal relationships, regulating his emotions, and disrupting rumination helped him orient his attention and efforts toward “continuing to live” despite all that he had lost.

New Friendships with Group Members

Increased skills and readiness for social relationships set the stage for additional gains in other social resources that resulted from participation in the group. New friendships with group members referred to the expansion of participants’ social networks through new connections with one another. New friendships provided meaningful forms of daily support, reduced isolation, and enhanced well-being. In some cases, participants developed close friendships with all the group members and continued to stay in touch regularly. In other cases, participants were particularly close with one or two group members and would continue to gather with them, talk on the phone, or message them through applications such as WhatsApp, an online messaging platform.

One woman, Farah, described friendship and positive feelings that were generated from her new friendships. She described an ongoing exchange of support from group members:

[Before] I didn’t have a group to go to a restaurant with or walk as a group in the street. For a year and a half, I have been going out to buy household supplies and go back to call my family in Syria. Now, I have friends that I can go out with and share information about resources. I mean now you have someone who supports you and tells you about things. I might know something she doesn’t know, and I’d call her and let her know. Isn’t this a good feeling? Of course it is.

Whereas before she felt alone, new friendships with group members provided opportunities for socializing and reliable sources of symbolic and material support. These friendships and the resources they generated gave a “good feeling.” Several mechanisms enabled these friendships to be sustained after the group ended, including looking out for one another, integrating into each other’s lives, and remembering each other.

Looking Out for One Another

Looking out for one another referred to the process whereby group members remained in frequent contact with each other after the group, inquired into each other’s lives, helped each other with problems, and shared resources. Huda, a 55-year-old woman living in Jordan, remained particularly close to one group member: “I call her and visit her. Whenever she tells me to come over, I go. You know, sometimes we have a lot on our mind, and a lot to think about. No matter how busy we are, we don’t forget each other.” Huda highlighted how she views this friendship as a valued source of support, to the extent that she and her friend make time to check in on each other amid their busy lives. Abedulla, a 63-year-old man, described calling the members of his group “constantly.” As he explained, “Sometimes your brother needs you to wipe his tears, whether he is young or old, tears are not just for the young.” By checking in with each other and being available when someone is going through a difficult time, Abedulla and other participants rally around friends who could benefit from a kind word or additional support. This process strengthened and sustained friendships after the group ended.

Many participants used technology to check in on each other. Group members often created a group text to communicate and stay in touch. Rahaf, a 36-year-old mother, described this:

We arrange a time in the evening to talk in the group. Whoever is free participates in the conversation, How are you? How’s life with you? I mean we talk to each other about food, visits, places that offer support for Syrians. We talk about all of these things.

Later in the interview, Rahaf indicated that such exchanges occurred daily among her friends. Participants benefitted from these group exchanges even when they were not actively participating. “As I mentioned, we’re ten in the group. We’re not necessarily talking at the same time. I might get the notifications indicating that two of them are chatting. When I have time, I read their whole conversation, and I might laugh even if I wasn’t there.” Rahaf’s comments demonstrated how being a part of the test messaging group generated positive feelings and a sense of closeness, even when they are not in real time.

Participants also communicated about practical resources, signing each other up for services or classes and providing tangible support like food or supplies. One man, Malek, had a child with a hearing disability. He remembered when group members informed him of services available for his son through a non-governmental organization. This information helped participants address their basic needs and these exchanges of support and care strengthened friendships and connections.

Integrating into Each Other’s Lives

Friendships with other group members were also maintained through efforts to integrate into each other’s lives including daily visits to drink tea or coffee, and share momentous occasions, such as weddings or funerals. Duha said, “In a few days, the son of one of our friends will be married so we visited her. Another one of them, her aunt passed away, so we visited her. Also, one of her relatives passed away, so we visited her and our friend as well. When her grandmother passed away, we visited her. I’m telling you, any occasion that happens, we see each other.” Group members circled around each other for these life milestones as a sign of support and friendship.

Many participants considered their new friends as surrogate family members, particularly given their separation from family members who back home or in other countries. Ramiz, for example, described ongoing close friendships with other men from his group, and maintained closeness by staying connected daily. He explained, “My brothers are in Tripoli, when I see one of the Iraqi men, I feel like they are one of my brothers, of course all of them are Iraqi. Now, I talk to them daily. We talk for an hour. They are very close to me.” This act of daily connection engendered a feeling of familial closeness between Ramiz and his friends in the group, despite differences in nationality and background.

Remembering Each Other

Remembering each other captured the extent to which participants kept each other in mind and viewed their friendships as important even when they were not able to see each other or stay in touch. For some participants, interactions became less frequent after the group intervention ended. They identified barriers to maintaining relationships including transportation difficulties, stressors of daily life, lack of a group gathering space, and inconsistent access to technology and WIFI. While all participants spoke of these barriers to some extent, they were more frequently identified by men.

Yet, even when unable to connect in person, participants remembered each other and called to mind their experiences in the groups and the friendships formed. These remembrances engendered feelings of happiness of the good times together and a feeling of ongoing closeness. Azhar, a 26-year-old woman said, “Two days ago, one of my friends called me after a long time. I asked her, ‘I wonder how I came to your mind.’ She said, ‘You’re always in my mind, I’m just a little bit busy.’” Participants retained a sense of closeness, even when physical presence and direct contact was not possible. This perceived sense of support led to a feeling that if they needed anything, there would be someone that could assist.

Strengthened Family Relationships

Building upon increased readiness and skills for social relationships, participants experienced important changes in the nature and quality of their family relationships, referred to as strengthened family relationships. Changes in family relationships after the interdisciplinary group intervention included feeling closer to family members and increased value placed on family relationships. Amna, a 36-year-old mother originally from Daraa and living in Jordan with her husband and five children, described these changes: “The benefit of the group for me would be the way I treat my children. They are the most valued people in my life now and forever. My children and my parents are very important to me.” The strengthening of family relationships came about through improving communication practices within families and sharing skills from the group with those around them.

Improving Family Communication

Participants described different communication practices that they perceived as strengthening their family relationships, including greater ability to express affection verbally and non-verbally, improved listening skills, and more open discussion of needs and wants. Parents expressed affection toward their children more often after the group by sharing loving words, hugs, and kisses. Relationships with children took on greater emotional depth as parents asked questions about their children’s lives and engaged them in conversation, mirroring methods that had been used with them in the group intervention. Parents benefited from increased closeness in their relationships with their children, which they, too, experienced as a source of social support and friendship. Mazen, a 61-year-old father, described, “[My son] became my friend, I love him now more. I guide him to the right path now. I don’t get angry anymore now, and he in return takes care of me.” Razan noted a change in patience and listening skills with her son because of participating in the group. She said, “I give him all my attention, I listen to everything he talks about, and then we discuss it.” In both cases, participants indicated a shift in communication with their children, which involved increased listening, providing needed guidance, and communicating affection.

Participants also improved their marital relationships due to learning to communicate directly and listen to each other. As described earlier, managing one’s stress and learning to cope with difficult emotions was a central focus of the group counseling intervention and a foundational step for improving family relationships. Men and women noted decreased irritability and aggression toward their spouses, which they perceived as reducing discord and opening space for more skillful communication. Some women increased confidence in their own communication skills when engaging their husbands in discussion, facilitating increased self-advocacy and open expression of wants, needs, and concerns. One participant described being better able to defend her thoughts and opinions when talking with her husband and drew a connection between these new skills and content in the group related to empowerment and setting goals. Meanwhile, men became more willing to listen to their wives and children. When increased communication and mutual understanding between spouses was not achieved, participants learned to cope with frustrating aspects of their relationships through acceptance.

Sharing Skills Learned in the Group

Participants learned skills in the interdisciplinary group intervention to manage stress, emotions and physical pain. In the physiotherapy group, for example, they practiced exercises to alleviate and manage neck and back pain which were commonly experienced. In group counseling, participants learned breathing and relaxation techniques, and were encouraged to take walks and engage in daily exercise to manage the mind-body effects of torture, war and forced displacement. Along with practicing these skills themselves, participants shared these skills with family, friends, and neighbors. As Ahmad explained, “we are trying to share the knowledge that we got.” Parents often taught skills to their children, which helped children learn to manage their emotions and take care of their minds and bodies, but also served as an opportunity for increased quality time between parent and child. Ibstisam, a 45-year-old widow laughed during her interview when remembering how sharing the skills she learned in the group led to playful interactions and sharing joy with her children. She said, “They [referring to her children] laugh at me sometimes because I tell them to do this and that [referring to different physical movement exercises]. I have fun with them.”

Participants were enthusiastic about teaching skills to others: “When I get the benefit from the lecture, I’m supposed to be the ambassador of the organization outside the groups. I learn from them and pass them to my daughter, to my son, to my neighbor, to my neighborhood. Everyone should do this as well” (Ali, 61 years old). Sharing diverse skills thus was a mechanism for improving existing relationships, as this provided an opportunity for quality time together, expressed care and concern for each other, contributed to reducing stress among the individuals in one’s environment, and improved the quality of one’s social support system.

Discussion

Research investigating mental health interventions for communities impacted by war, torture, and forced displacement has overwhelmingly focused on changes in individual mental health. Given the devastating impact of such experiences on social networks, connections, and access to support and the interrelationship of these losses with mental health, it is also important to evaluate if and how interventions may enable positive changes in social resources. In this study, we sought to understand if and how participation in an interdisciplinary group intervention impacted the social resources of Syrian adults displaced in Jordan. Here, we examine these findings, situate them in the extant literature and consider implications for intervention development, research, and practice.

First, the findings brought to light diverse improvements in social resources that resulted from participation in the group. This included changes in participants’ ability and motivation to engage in social relationships along with expansion of social networks and improvements in the quality of existing social connections. Further, participants experienced an increased sense of perceived social support and a growing sense of belonging and integration in their new communities in Jordan. These findings add to the small body of research investigating changes in diverse social resources resulting from group-based mental health and psychosocial interventions with survivors of war and forced displacement (Hall et al., 2014; Im and Rosenberg, 2016; Goodkind et al., 2014; Wachter et al. 2020; Wollersheim, 2013). They align with major theories underlying psychotherapy groups, group work and mutual aid (Garvin et al., 2017; Yalom & Leszcz, 2020) in that they underscore the power, value, and activeness of relationships in group interventions, and the extent to which relational processes can continue to exert their influence long after the intervention has ended (Marmarosh et al., 2022).

The improvements in family relationships were unexpected, particularly given that the intervention is intended for individual adults and did not include content specific to improving family relationships or family processes. Nonetheless, the improvements are understandable and highlight the interplay between an individual’s well-being and their functioning within the family system (Fazel & Betancourt, 2018; Slobodin & de Jong, 2015). As participants learned new skills and made improvements in their ability to cope with ongoing stress and regulate challenging emotions, this had a beneficial impact on others in the family system. These findings highlight the potential spillover benefits of mental health interventions beyond their intended targets. Future interventions can actively encourage participants to share useful lessons with their families and others in their social network and develop tools and outlets for diffusing knowledge and practical skills.

The findings related to improvements in social resources can inform the selection of relevant measures for future research to explore the range and depth of changes in social resources resulting from group interventions. Based on this study, measures of attachment, motivation and readiness for social relationships, social network characteristics, social support, nature and quality of family and community relationships and social integration are all potentially relevant (Boateng et al., 2024; Ramaswami et al., 2022)

We identified a process whereby changes in social resources unfolded in a two-stage process. Intrapersonal changes related to readiness, skills and motivation for social relationships set the stage for other positive gains in social resources. These findings resemble the transtheoretical stages of change model (Prochaska & Norcross, 2001) where behavior change is conceptualized as a process that unfolds over time and involves progressing through different, discrete stages and associated tasks for movement to a new stage to occur. In this study, skills and experiences at the individual level functioned as preconditions for growth in social and interpersonal resources. This study represents a first, useful step in conceptualizing the process by which social connections may be strengthened in the context of group interventions for communities impacted by war and interpersonal losses.

Mechanisms that increase social resources among communities impacted by war, torture, and forced displacement have rarely been investigated (Bosqui & Marshoud, 2018; Hall et al., 2014c). We identified several mechanisms that contributed to gains in social resources. They included increased emotion regulation skills, gains in confidence and empowerment and communication skills. These findings highlight salient intervention components that functioned as levers of change and enabled positive gains in social networks, social support and the quality of social connections, insights that can inform future intervention development.

Finally, the study sheds light on the role that digital tools can play in facilitating access to and sustainment of social resources. New relationships with group members were sustained through continuous efforts to stay in touch and demonstrate care and support. WhatsApp groups spontaneously created by participants played an important role in this process and enabled consistent contact and a virtual group “space” where interactions and connections could be maintained. These findings speak to the importance of sharing interactional settings and routine activities with others as part of forming new social attachments (Soller et al., 2018). This study suggests that virtual settings can function as an important daily setting, offering needed opportunities for developing social connection and attachments in the context of displacement.

Limitations

The qualitative methods used in this study are uniquely suited to identify novel constructs and outcomes and uncover underlying mechanisms. In this study, we identified several social resource outcomes and mechanisms that operated in the group. It is not the intention of qualitative research, nor this study to establish causal order but those are important questions that should be taken up in future quantitative research. Though we were not able to do so in this study, in future studies it will be important to measure characteristics of participants’ family and social resources pre-intervention and consider evolving conditions in Syria to better understand and characterize changes post-intervention. We only included participants who had expressed interest in participating in research. Unmeasured participant characteristics (e.g., mental health, self-efficacy) may have affected their willingness to participants in ways that bear on the results. For this analysis, the data was collapsed across both group-based modalities (group counseling and group physiotherapy) and no between group differences were explored which is a limitation.

Conclusion

Despite these limitations, our study contributes to the literature on group interventions for refugee communities and how group interventions may facilitate change in social resources for individuals impacted by war and forced displacement. We derived a two-stage process, with individual-level intrapersonal processes laying an important foundation for positive changes and expansion to social networks and connections. We hope that future research will build upon this study to further refine the process model developed and investigate the role that group interventions can play in building and repairing social relationships for communities displaced from home and community.

Clinical Impact Statement.

This study reveals how group interventions may help torture-affected refugees rebuild social connections after forced displacement. Participants first experienced internal changes—renewed motivation and improved skills for relationships—before expanding their social networks through new friendships and stronger family bonds. The findings suggest these interventions may be particularly valuable when working with populations who have lost community ties through trauma and migration.