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Trauma Recovery and Empowerment Model (TREM)

The Trauma Recovery and Empowerment Model (TREM) is a fully manualized group-based intervention designed to facilitate trauma recovery among women with histories of exposure to sexual and physical abuse. Drawing on cognitive restructuring, psychoeducational, and skills-training techniques, the gender-specific 24- to 29-session group emphasizes the development of coping skills and social support. It addresses both short-term and long-term consequences of violent victimization, including mental health symptoms, especially posttraumatic stress disorder (PTSD) and depression, and substance abuse. TREM has been successfully implemented in a wide range of service settings (mental health, substance abuse, criminal justice) and among diverse racial and ethnic populations.

Descriptive Information

Areas of Interest	Mental health treatment Substance abuse treatment Co-occurring disorders
Outcomes	Review Date: December 2006 1: Severity of problems related to substance use 2: Psychological problems/symptoms 3: Trauma symptoms
Outcome Categories	Alcohol Drugs Mental health Social functioning Trauma/injuries
Ages	18-25 (Young adult) 26-55 (Adult)
Genders	Female
Races/Ethnicities	American Indian or Alaska Native Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Residential Outpatient
Geographic Locations	Urban
Implementation History	Community Connections Trauma Education staff have provided training in TREM to more than 1,500 clinicians in nearly 30 States. Clinicians have come from a variety of disciplines and programs: approximately 40% have worked in mental health settings, 40% in substance abuse settings, and the remaining 20% in correctional settings, domestic violence programs, or homeless services programs. TREM groups have been implemented in a wide range of agencies, including residential and nonresidential substance abuse and mental health programs, correctional institutions, health clinics, and welfare-to-work programs, among others. TREM groups also have been successfully offered in programs located in urban, inner-city settings (e.g., in Philadelphia, Cleveland, Atlanta, Phoenix, and Denver) and rural settings (e.g., in Maine, South Carolina, Georgia, and Delaware). TREM group participants have typically been recipients of publicly funded mental health, substance abuse, and other human services and have been diverse in terms of overall life skills and functioning. They include the most disenfranchised clients who often are homeless and make heavy use of inpatient, crisis, and other high-cost services. Community Connections has been offering TREM continuously since 1997.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: No Evaluated in comparative effectiveness research studies: Yes
Adaptations	TREM was initially developed and implemented in Washington, DC, with a predominantly African American population. Caucasian and Latina women have participated successfully in TREM. A culture-specific adaptation for Latina women has been developed and published in a separate manual.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Review Date: December 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Amaro, H., Dai, J., Arevalo, S., Acevedo, A., Matsumoto, A., & Nieves, R. (n.d.). Effects of integrated trauma treatment on outcomes among Black, Hispanic, and White women in urban community-based substance abuse treatment. Manuscript submitted for publication.

Study 2

Toussaint, D. W., VanDeMark, N. R., Bornemann, A., & Graeber, C. J. (2007). Modifications to the Trauma Recovery and Empowerment Model (TREM) for substance-abusing women with histories of violence: Outcomes and lessons learned at a Colorado substance abuse treatment center. Journal of Community Psychology, 35(7), 879-894.

Study 3

Fallot, R. D., McHugo, G. J., & Harris, M. (2005). DC Trauma Collaboration Study: Background and preliminary report. Unpublished manuscript.

Supplementary Materials

Amaro, H., Fallot, R. D., & Harris, M. (n.d.). Group intervention study for drug abuse and trauma. Report submitted to the National Institute on Drug Abuse.

Cocozza, J. J., Jackson, E. W., Hennigan, K., Morrissey, J. P., Reed, B. G., Fallot, R., et al. (2005). Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse and Treatment, 28, 109-119.

Fallot, R. D., & Harris, M. (2001). Trauma Recovery and Empowerment Model (TREM) Group Intervention Fidelity Scale.

Fallot, R. D., & Harris, M. (2002). Trauma Recovery and Empowerment Model (TREM): Conceptual and practical issues in a group intervention for women. Community Mental Health Journal, 38(6), 475-485.

Finkelstein, N., VanDeMark, N., Fallot, R., Brown, V., Cadiz, S., & Heckman, J. (2004). Enhancing substance abuse recovery through integrated trauma treatment. Sarasota, FL: National Trauma Consortium. Report prepared for the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

McHugo, G. J., & Fallot, R. D. (n.d.). An RCT of the Trauma Recovery and Empowerment Model. A four-year (2004-2008) randomized controlled trial of TREM effectiveness funded by NIMH [National Institute for Mental Health]. Unpublished manuscript.

McHugo, G. J., Kammerer, N., Jackson, E. W., Markoff, L. S., Gatz, M., Larson, M. J., et al. (2005). Women, co-occurring disorders, and violence study: Evaluation design and study population. Journal of Substance Abuse Treatment, 28, 91-107.

Morrissey, J. P., Jackson, E. W., Ellis, A. R., Amaro, H., Brown, V. B., & Najavits, L. M. (2005). Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services, 56(10), 1213-1222.

National Trauma Consortium. (n.d.). Excerpt on TREM from Chapter 3: Overview of trauma-specific group treatment models, in Integrating trauma treatment into substance abuse services for women. Document prepared for the Substance Abuse and Mental Health Services Administration.

National Trauma Consortium. (n.d.). Excerpt on TREM from Chapter 5: Cultural adaptations of trauma specific models, in Integrating trauma treatment into substance abuse services for women. Document prepared for the Substance Abuse and Mental Health Services Administration.

Outcomes

Outcome 1: Severity of problems related to substance use
Description of Measures	Severity of problems related to substance use was assessed in interviews using the Addiction Severity Index drug composite score (ASI-D) and alcohol composite score (ASI-A), which measure problem severity during the past 30 days. Possible scores range from 0 to 1, with higher scores indicating greater problem severity of substance use.
Key Findings	One evaluation found that participants in the TREM condition showed significantly greater decreases in drug addiction severity, at both 6- and 12-month follow-ups, than those receiving usual care (p < .01). Further, participants who received 12 or more TREM sessions improved more than those who received none or fewer than 12 sessions (p = .018). In this evaluation, both intervention and comparison groups also improved in alcohol addiction severity with no significant advantage for the TREM condition. In another evaluation, TREM participants' mean alcohol and drug problem severity scores decreased from baseline to 1-year follow-up, relative to recipients of alternative care (p = .008 for alcohol problem scores and p = .0004 for drug problem scores). A third evaluation reported no statistically significant findings for this outcome.
Studies Measuring Outcome	Study 1, Study 2, Study 3
Study Designs	Quasi-experimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Outcome 2: Psychological problems/symptoms
Description of Measures	Psychological symptoms were assessed with (1) the Global Severity Index (GSI) of the Brief Symptom Inventory, a self-report scale that measures symptom dimensions; (2) self-rated health, a self-rating of one's overall physical health from excellent to poor; and (3) the Social Role Functioning index, consisting of nine questions assessing the difficulty respondents experience in daily living and role-functioning areas.
Key Findings	One evaluation found significantly reduced symptoms of psychological problems among TREM participants 1 year after the intervention (p = .008). Another evaluation found significantly lower scores on GSI 1 year after the intervention (p = .021). A third evaluation reported no significant findings for this outcome.
Studies Measuring Outcome	Study 1, Study 2, Study 3
Study Designs	Quasi-experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 3: Trauma symptoms
Description of Measures	Trauma symptoms were assessed with (1) the Posttraumatic Symptom Scale (PSS) of the Posttraumatic Diagnostic Scale, which asks respondents to indicate how often in the past month they experienced specific problems after a traumatic event; and (2) the Feeling-Dissociation Scale and Feeling-Trauma Coping Scale, which examine respondents' strategies for coping with the traumatic events in their lives.
Key Findings	All evaluations found that at 12-month follow-up, trauma symptoms were reduced among TREM participants compared with recipients of alternative care (p < .05). In one evaluation, at follow-up, TREM participants averaged 15.6 on a trauma symptom scale, while the comparison group averaged 20.8.
Studies Measuring Outcome	Study 1, Study 2, Study 3
Study Designs	Quasi-experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult)	100% Female	34.6% White 31.5% Hispanic or Latino 30.4% Black or African American 3.5% Race/ethnicity unspecified
Study 2	18-25 (Young adult) 26-55 (Adult)	100% Female	52% White 18% Black or African American 16% Hispanic or Latino 8% American Indian or Alaska Native 6% Race/ethnicity unspecified
Study 3	18-25 (Young adult) 26-55 (Adult)	100% Female	82.5% Black or African American 17.5% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Severity of problems related to substance use	4.0	3.5	1.9	2.5	1.9	3.5	2.9
2: Psychological problems/symptoms	3.6	3.4	1.9	2.3	1.9	3.5	2.7
3: Trauma symptoms	3.3	3.2	1.9	2.3	1.9	3.5	2.7

Study Strengths

For the most part, each study employed commonly used measures with sound psychometric properties. Several of the studies noted baseline differences in the treatment conditions and the possibility of there being other unmeasured baseline differences that could have affected the results. Statistical analyses were appropriate, and sample size and power were adequate. The fact that integrated trauma services in different forms could provide positive results across nine sites is a program strength. Overall, the studies had very little attrition and missing data or used sophisticated statistical methods to adjust for the levels of attrition/missing data.

Study Weaknesses

While each of the three studies addressed fidelity, the discussion of psychometrics in two of the studies was brief. One study did not address missing data/attrition. All studies were quasi-experimental, so confounds are possible. There was no one clearly defined model. Other weaknesses include the lack of a randomized study design, the unknown quality of the program contrasts, and the fact that the authors did not measure or report how long participants had been in the project before the study. No information was given on the subscales or scales created for the study.

Readiness for Dissemination

Review Date: December 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Clinician Rating Scale for Substance Use

Copeland, M., & Harris, M. (2000). Healing the trauma of abuse: A women's workbook. Oakland, CA: Authors.

Fallot, R., & Harris, M. (2001). Trauma Recovery and Empowerment Model (TREM) Group Intervention Fidelity Scale.

Harris, M. (1999). Trauma Recovery and Empowerment (Part I): Empowerment, Tape 1 [VHS]. Washington, DC: Community Connections.

Harris, M. (1999). Trauma Recovery and Empowerment (Part I): Empowerment, Tape 2 [VHS]. Washington, DC: Community Connections.

Harris, M. (1999). Trauma Recovery and Empowerment (Part II): Trauma recovery [VHS]. Washington, DC: Community Connections.

Harris, M. (1999). Trauma Recovery and Empowerment (Part III): Advanced trauma recovery issues and closing rituals, Tape 1 [VHS]. Washington, DC: Community Connections.

Harris, M. (1999). Trauma Recovery and Empowerment (Part III): Advanced trauma recovery issues and closing rituals, Tape 2 [VHS]. Washington, DC: Community Connections.

Harris, M., & Community Connections Trauma Work Group. (1998). Trauma Recovery and Empowerment: A clinician's guide for working with women in groups. New York: Community Connections, Inc.

Harris, M., & Fallot, R. (2001). Stages in Trauma Recovery Rating Scale. Washington, DC: Community Connections.

Harris, M., & Fallot, R. (2004). Trauma Recovery and Empowerment Profile (TREP) [Handout].

National Trauma Consortium. (n.d.) Overview of trauma-specific group treatment models. Excerpt from unpublished monograph.

TREM Training Outline and selected handouts

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.8	3.5	2.9	3.4

Dissemination Strengths

The implementation materials serve as a practical, hands-on guide to the intervention. Both the video and treatment manual offer a rationale for the sequencing of treatment components. The videos include information for clinicians and administrators and describe organizational requisites for effective implementation. The training workshop offers the opportunity to practice leading groups and to receive feedback on performance. Training emphasizes clinician leadership style as a key factor in effective service delivery. Both fidelity and clinical process measures are provided, with the fidelity measure utilizing data from a variety of sources.

Dissemination Weaknesses

The program videos rely on more didactic presentation rather than illustrative examples. There appears to be no training provided for clinical supervisors. No outcome measures or indicators are provided to support quality assurance.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Manual	$30 each	Yes
2-day, on-site training	$4,000-$9,000 depending on number of trainees, trainers, and travel costs	No
On-site or telephone consultation	$175-$200 per hour	No
TREM fidelity scale	Free	No
Outcome measures	Varies	No

Additional Information

The cost per participant varies depending on local mental health service costs. TREM is usually conducted as a 75-minute group with 29 weekly sessions. Groups typically include 8-10 members and 2 or 3 co-leaders (counselors, social workers, clinicians, or community support specialists).

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

* Morrissey, J. P., Jackson, E. W., Ellis, A. R., Amaro, H., Brown, V. B., & Najavits, L. M. (2005). Twelve-month outcomes of trauma informed interventions for women with co-occurring disorders. Psychiatric Services, 56(10), 1213-1222.

* Toussaint, D. W., VanDeMark, N. R., Bornemann, A., & Graeber, C. J. (2007). Modifications to the Trauma Recovery and Empowerment Model (TREM) for substance-abusing women with histories of violence: Outcomes and lessons learned at a Colorado substance abuse treatment center. Journal of Community Psychology, 35(7), 879-894.

Contact Information

To learn more about implementation, contact:
Rebecca W. Berley, M.S.W.
(202) 608-4735
rwolfson@ccdc1.org

To learn more about research, contact:
Roger D. Fallot, Ph.D.
(202) 608-4796
rfallot@ccdc1.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):

http://www.ccdc1.org