Community Mental Health Journal, Vol. 38, No.

6, December 2002 ( 2002)

The Trauma Recovery and

Empowerment Model (TREM):
Conceptual and Practical Issues in a
Group Intervention for Women

Roger D. Fallot, Ph.D.

Maxine Harris, Ph.D.

ABSTRACT: This article describes the Trauma Recovery and Empowerment Model
(TREM), a manualized group intervention designed for women trauma survivors with
severe mental disorders, and discusses key issues in its conceptualization and implemen-
tation. TREM recognizes the complexity of long-term adaptation to trauma and ad-
dresses a range of difficulties common among survivors of sexual and physical abuse.
Focusing primarily on the development of specific recovery skills and current function-
ing, TREM utilizes techniques shown to be effective in trauma recovery services. The
groups content and structure are also informed by the role of gender in the ways women
experience and cope with trauma.

KEY WORDS: trauma; PTSD; womens services; skills training; and group therapy.

Over the past fifteen years, clinicians, researchers, and mental health
administrators have become more aware of the prevalence and impact
of physical and sexual violence in the lives of people served by the public
mental health system. Clinically, two kinds of interventions have been
developed to address the impact of trauma and facilitate trauma recov-

This work was supported in part by a grant from the Federal Substance Abuse and Mental Health
Services Administration (Grant No. 2UD 1 TI11400-03).
Roger D. Fallot, Ph.D., and Maxine Harris, Ph.D., are Co-Directors of Community Connections
in Washington, DC. Dr. Harris is Executive Director of the National Capital Center for Trauma
Recovery and Empowerment.
Address correspondence to Roger D. Fallot, Ph.D., Community Connections, 801 Pennsylvania
Avenue, S.E., Washington, DC 20003; e-mail: rfallot@communityconnectionsdc.org.

475 2002 Human Sciences Press, Inc.

476 Community Mental Health Journal

ery among people with severe mental disorders (who may also have
substance abuse problems). The first focuses directly on the goal of
PTSD symptom reduction. This cognitive-behavioral approach adapts
existing PTSD interventions to the specific needs of people with severe
mental disorders by, for example, minimizing or eliminating exposure
elements of treatment and expanding the role of cognitive restructuring
(Rosenberg et al., 2001). The second involves a broader view of trauma
sequelae and a more inclusive method for facilitating the development
of trauma recovery skills. The Trauma Recovery and Empowerment
Model or TREM (Harris, 1998) reflects this latter view. This article will
describe TREM, a manualized group intervention, and discuss several
key considerations in the development and implementation of this
model.

THE TRAUMA RECOVERY AND EMPOWERMENT MODEL

(TREM) GROUP INTERVENTION

We developed the Trauma Recovery and Empowerment Model (TREM)

as a group intervention to address the long-term cognitive, emotional
and interpersonal consequences of sexual and physical abuse. It specifi-
cally responds to the needs of women trauma survivors with severe
mental disorders, many of whom also have significant substance use
problems. The TREM approach uses a supportive, skill-building curricu-
lum that allows members to acknowledge the impact of abuse while
focusing their energies on developing techniques for mastery and en-
hancing their existing strengths for coping with current life events.
The TREM initiative was launched at Community Connections, a
provider of mental health and substance abuse services in Washington
D.C., in the early 1990s. Over 20 clinicians developed the model and
received feedback from consumers who participated in the first TREM
groups and whose advice and comments were incorporated into subse-
quent iterations of the model. The fully manualized intervention was
published in 1998 (Harris, 1998).
The TREM approach to trauma recovery is based on four core assump-
tions:

1. Some current dysfunctional behaviors and/or symptoms may have

originated as legitimate coping responses to trauma.
2. Women who experienced repeated trauma in childhood were de-
 Roger D. Fallot, Ph.D., and Maxine Harris, Ph.D. 477

prived of the opportunity to develop certain skills necessary for

adult coping.
3. Traumatic events, specifically sexual and physical abuse, sever
core connections to ones family, ones community, and ultimately
to ones self (including disrupted awareness of ones own feelings,
thoughts, and behaviors).
4. Women who have been abused repeatedly feel powerless and un-
able to advocate for themselves.

Using these assumptions as a guide, clinicians selected several topics

that addressed skill deficits and knowledge gaps and developed these
topics into sessions for the intervention. The topics divided into three
broad categories that eventually formed the three parts of the model:
empowerment, trauma education, and skill-building. The intervention,
which incorporates 33 recovery topics, extends over nine months with
women meeting weekly for 75 minutes. Although the groups are leader-
led and follow a specified format with discussion questions and experien-
tial exercises, women have the opportunity to share their personal expe-
riences and to participate as much as they feel comfortable doing. In
order to foster a sense of belonging and member safety the groups are
for women only with two or three female co-leaders.
TREM groups consist of 810 members. The co-leaders have all re-
ceived basic training and supervision in the TREM approach and are
generally masters or bachelors level clinicians. Group members are
women with histories of sexual and/or physical abuse in childhood or
adulthood who also have symptoms of mental illness and/or drug and
alcohol addiction. While TREM groups can be offered in a free-standing
outpatient setting, they are generally part of a comprehensive case
management or residential program of care.
TREM emphasizes the development of trauma recovery skills. We
have identified eleven areas of skill development that are essential to
recovery from the impact of prolonged trauma: Self-awareness (the abil-
ity to recognize bodily and motivational states and to articulate that
awareness to others in a clear manner); Self-protection (the ability to
recognize, avoid, and/or manage potentially harmful situations and to
establish safe and manageable interpersonal boundaries); Self-soothing
(the ability to mange and diminish feelings of distress, pain, and hurt);
Emotional modulation (strategies to control the intensity and expression
of affective states); Relational mutuality (the capacity to engage in a
reciprocal meeting of interpersonal needs); Accurate labeling of self and
others (the capacity to use accurate words to label ones own behavior
478 Community Mental Health Journal

and the behavior of others); Sense of agency and initiative-taking (the

ability to see oneself as the primary source of action and initiative in
ones life); Consistent problem-solving (the ability to combine cognitive,
affective and social skills in resolving personal and interpersonal situa-
tions); Reliable parenting (the ability to respond to the needs of depen-
dent children and grandchildren in a reliable and consistent way); Pos-
sessing a sense of purpose and meaning (the ability to actively seek and
meet ones needs in an appropriate manner and to view ones actions
in a larger context of meaning); Judgment and decision-making (the
ability to form reliable judgments based on thoughts, feelings, and per-
ceptions and to use those judgments to make beneficial decisions). A
variety of techniques in TREM facilitate the development of these
trauma recovery skills throughout the group intervention.

KEY CONSIDERATIONS IN THE DEVELOPMENT OF TREM

Conceptualization of the Impact of Trauma in TREM

Because trauma, especially prolonged or repeated childhood abuse, can

have such diverse and complex sequelae, we developed TREM to be
responsive to a comprehensive array of survivors difficulties and needs.
Trauma-related difficulties often appear in life domains not directly
and apparently connected to abuse: in relationship patterns; cognitions
about self and others; and affective responses not within the PTSD
clusters (e.g., depression). Clinical reports have drawn special attention
to the long-term, pervasive nature of trauma adaptation; prolonged
trauma exposure can have a significant impact in biological, psychologi-
cal, social, and spiritual spheres.
For all of these reasons, we developed an intervention that focuses
on a broad understanding of traumas impact. Trauma increases the
risk that survivors will experience many specific difficulties. TREM is
aimed at six of these major areas of risk:

1. Difficulties with emotional control (affective dysregulation). An

inability to modulate emotions is a commonly reported response
to prolonged and severe trauma (van der Kolk et al., 1994). Anxiety,
fear, hyperarousal, and problems with modulating anger are prev-
alent. In response to these painful and potentially overwhelming
feelings, trauma survivors often engage in a range of self-soothing
behaviors and activities. Though some self-soothing attempts may
 Roger D. Fallot, Ph.D., and Maxine Harris, Ph.D. 479

be adaptive and effective, many otherslike substance abuse,

indiscriminant relationship-seeking, and self-mutilationexacer-
bate and broaden the survivors problems in psychosocial function-
ing (van der Kolk et al., 1994).
2. Emotional numbness and dissociation. Emotional numbing is a
hallmark symptom of PTSD and dissociation is one of the most
clearly documented effects of trauma (van der Kolk et al., 1996).
Dissociation may serve as a mediator between traumatic events
on one hand and psychiatric symptoms and risk-taking behavior
on the other. In addition, ongoing or recurrent dissociation has a
direct impact on daily living activities; the effects range from the
relatively mild (e.g., occasional inattentiveness, lapses in concen-
tration) to moderate (e.g., memory blanks) to severe (e.g., dissoci-
ative identity disorders).
3. Difficulties maintaining safe, stable, and mutually satisfying inter-
personal relations. Numerous studies have demonstrated the in-
creased risk of revictimization that accompanies histories of child-
hood sexual and physical abuse. Children with histories of physical
abuse show lower levels of intimacy and higher levels of conflict
in activities with their peers (Parker & Herrera, 1996). A wide
range of interpersonal difficulties in adulthood has been reported
for individuals who were sexually or physically abused as children.
4. Depression. Other than increased PTSD risk, a heightened prob-
ability of developing depressive symptoms is perhaps the most
consistently found trauma sequela (Brady et al., 2000). Both pro-
spective and retrospective reports have confirmed this finding.
In surveys of dually diagnosed women, depression is among the
clearest symptomatic responses to trauma; it is related to the
frequency, type (combined sexual and physical abuse), and recency
of abuse (Goodman et al., 1997).
5. Difficulties in accurate appraisal of self and the world. Many re-
ports have documented the ways in which trauma may lead to a
reshaping of the survivors self-perceptions; decreased self-esteem,
shame, stigma, and guilt reflect the potentially negative effect of
trauma on ones sense of self. Assumptions about oneself as worthy
and about the world as benevolent and meaningful are disrupted
(Janoff-Bulman, 1992). In their place are experiences of the self
as fragile and vulnerable and the world as dangerous and unpre-
dictable. Responses of others that minimize or deny the reality of
abuse contribute to a lack of survivors trust in their own percep-
tions as well as their trust in others. An inability to read danger
480 Community Mental Health Journal

accurately and self-blame for abuse are common phenomena

among survivors.
6. Substance abuse. Across a variety of populations, histories of
trauma increase the risk of developing substance use disorders.
Women with histories of childhood sexual abuse are many times
more likely than women who have not been abused to have a
substance use disorder (Polusny & Follette, 1995). Childhood histo-
ries of abuse make a significant contribution to later alcohol use
problems even when other factors, like parental alcohol abuse, are
controlled (Miller et al., 1993). This same pattern holds for adults
with severe mental disorders: those who are childhood abuse survi-
vors are more likely than those with no abuse history to have
substance use problems (Darves-Bornoz et al., 1995).

Trauma Recovery and Empowerment Model Goals

Shalev (1997) has recommended that services for people with more
prolonged and complex PTSD, especially those with other complicating
concerns such as poverty, should appropriately shift from a narrow
focus on symptom reduction to a more broadly conceived rehabilitative
emphasis. TREM is designed to integrate skill development with symp-
tom reduction; self-soothing skills, for example, are effective mecha-
nisms for coping with emotional arousal and flooding. TREM also em-
phasizes the ways in which trauma affects current functioning in a
number of life domains and the role of recovery skills in planning for the
future. The intervention is based on the clinical observation that broad-
based recovery skills and symptom reduction/management are mutually
reinforcing. As skills develop, symptoms lessen and as symptoms de-
crease, skills develop further. Each of the six problem areas is addressed
via one or more skill-development approaches. For example, self-protec-
tion skills are fundamental to establishing safe, stable relationships.

Trauma Recovery and Empowerment Model Techniques

For people with multiple problems, multi-faceted service models are

common. In addressing trauma-related symptoms and recovery skills,
TREM incorporates several techniques that have been shown to be
effective in other interventions.

1. Cognitive restructuring. Trauma frequently results in pervasive

negative schemas about the self and about other people. Many
 Roger D. Fallot, Ph.D., and Maxine Harris, Ph.D. 481

cognitive-behavioral approaches recommend addressing such neg-

ative thought patterns and offering more adaptive alternatives.
Pilot studies reported by Rosenberg et al. (2001) suggest that, for
people with PTSD and a severe mental disorder, strengthening the
cognitive restructuring components of therapy may be especially
effective. TREM group leaders use cognitive reframing techniques
to challenge rigid and overgeneralized negative thinking about the
self (self as fully blameworthy, guilty, shameful, stigmatized by
victimization, powerless) and about the world (others seen as al-
ways dangerous, untrustworthy, exploitative, and controlling or
as invariably safe, trustworthy, and benign).
2. Skills training. While cognitive-behavioral techniques (e.g., expo-
sure) have been found effective in reducing arousal symptoms
following many types of single-incident trauma, common symp-
toms of avoidance and numbing may call for more direct ap-
proaches such as skill training. Especially for individuals whose
longstanding trauma adaptations have interfered with the exercise
of self-management and interpersonal skills, such domains as self-
soothing, assertiveness training, and emotional modulation are
important areas for therapeutic focus. TREM sessions provide op-
portunities to discuss and practice the full range of recovery skills.
3. Psychoeducation. Psychoeducation is a key component of many
approaches to trauma recovery services. Foa et al. (1995) incorpo-
rated a psychoeducational element in their successful brief preven-
tion program designed to decrease the risk of chronic PTSD among
recent assault victims. In psychiatric rehabilitation services, psy-
choeducation is also commonly used to provide information about
the symptoms of mental disorders and their management, about
the impact of drug and alcohol use, and about medication target
symptoms and side effects. TREM uses psychoeducational methods
to shape discussions of the definition and impact of abuse; of possi-
ble relations between trauma and psychological or emotional symp-
toms; and of possible relations between trauma and substance use;
among other topics.
4. Peer support. Recovery movements in substance abuse, mental
health, and dual diagnosis have long valued peer support as a
critical element in their success. For trauma survivors, mutual
support is often a powerful antidote to feelings of shame, alien-
ation, and loneliness. TREM groups involve significant peer sup-
port as members discover that they are not alone with often hidden
and secret experiences of abuse. Group members are also in a
482 Community Mental Health Journal

unique position to recognize and validate each others strengths

and adaptive coping skills.
5. Contained exposure. Exposure is one of the cognitive-behavioral
interventions shown to be effective in reducing PTSD symptoms
in a wide variety of studies. For women trauma survivors with
multiple additional vulnerabilities, though, extensive use of expo-
sure raises several questions. Exposure interventions, for example,
may carry the risk of higher attrition rates (McDonagh-Coyle et
al., 1999), especially among populations with more severe mental
health problems. Further, several recent studies have shown cogni-
tive restructuring to be as effective as exposure (e.g., Tarrier et
al., 1999). For these reasons, TREM does not emphasize the impor-
tance or value of detailed recall and retelling of trauma narratives.
Exposure in TREM occurs as group members recount specific as-
pects of their abuse histories, including traumatic events, the im-
pact of these events, and members responses and coping methods.
Such exposure, however, is brief, focused, and woven by the group
leaders into specific psychoeducational and recovery skill goals
designated for each session.

TREM and Gender-Specificity

TREM asserts that gender roles and expectations significantly affect

the kinds of violence to which individuals are likely to be exposed; the
impact of trauma; and the individuals ways of understanding and coping
with traumatic experiences. TREM was initially developed as a womens
intervention; feminist principles are central to its empowerment goals.
Surveys have found that women and men are likely to be exposed to
different kinds of violence. For example, sexual abuse among individuals
with severe mental illness is more common among girls and women
(Mueser et al., 1998). Women survivors of childhood sexual abuse report
greater trauma-related distress than men, with higher levels of de-
pression and anxiety as well as posttrauma symptoms (Sigmon et al.,
1996). Women are more likely to engage in nurturing and social network-
ing activities designed to enhance safety and reduce distress. Finally,
women have often expressed their preference for same-sex services.
The content of the TREM intervention is tailored to the unique needs
of women. The first part of TREM emphasizes empowerment and is
designed to help members develop the strengths and skills necessary for
more directly addressing trauma and its impact. Moreover, the gender-
specific membership of the group makes a significant contribution to
 Roger D. Fallot, Ph.D., and Maxine Harris, Ph.D. 483

group cohesiveness. In TREM, there are enhanced opportunities for

women to learn from other women. For most women the perpetrator of
abuse was a man even though a woman may have colluded by remaining
silent or uninvolved. Consequently women usually see men as more
threatening and may be more inclined to play traditional roles with
men in the group. Many trauma survivors experience feelings of isolation
and differentness from others. TREM groups develop a sense of com-
munity and fellowship among members that is built, at least in part,
on their identification as womens groups.

SUPPORTING MATERIALS AND NEXT STEPS

In several pilot studies among women trauma survivors with serious

mental disorders, results have pointed to the effectiveness of TREM in
increasing overall functioning, decreasing psychiatric symptoms, de-
creasing hospitalization and emergency room use, and decreasing HIV
risk behavior (Fallot & Harris, 2001). Group participants consistently
have rated the group as helpful, specifically in increasing the amount
of control they experience in their lives; in helping them to make better
decisions; and in leading to safer and more positive relationships.
TREM is currently being studied as part of the District of Colum-
bia Trauma Collaboration Study (DCTCS), a SAMHSA-funded quasi-
experimental project examining effective services for women abuse sur-
vivors with co-occurring mental health and substance use disorders.
TREM principles inform all service delivery in the project, including
trauma-informed case management services and other group services
that have been adapted to reflect the core assumptions of the TREM
approach.
In order to ensure the consistent implementation of the manualized
intervention, we have also developed a TREM fidelity measure. Part of
the DCTCS, this instrument is being used to provide feedback to group
leaders after selected sessions; instrument reliability is also being as-
sessed. Finally, we have developed two outcome measures closely related
to the TREM approach; both of these are being used in the DCTCS
and their psychometric properties are being evaluated. The first is the
Trauma Recovery and Empowerment Scale (TRES), a 25-item self-
report inventory that reflects key cognitive, emotional, and behavioral
changes related to the groups goals. The second is a clinician inventory
called the Trauma Recovery and Empowerment Profile (TREP). This
rating scale provides descriptive dimensions and anchor points for each
484 Community Mental Health Journal

of the eleven recovery skills. Clinicians may use the TREP as part of
ongoing clinical assessment and service planning as well as for evaluat-
ing outcomes.

SUMMARY

TREM is a manualized group intervention designed for women trauma

survivors with severe mental disorders. It draws on a broad conceptual-
ization of the impact of trauma; addresses primarily current functioning
and skill development, combining techniques shown to be effective in
trauma recovery work; and is informed by the role of gender in the ways
women experience and cope with trauma.

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(TREM): Conceptual and Practical Issues in a Group
Intervention for Women
SOURCE: Community Ment Health J 38 no6 D 20021001

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