Trauma Recovery and Empowerment Model (TREM)

1. Introduction

Version followed: the women's TREM group manual (Harris & the Community Connections Trauma Work Group, 1998, Trauma Recovery and Empowerment: A Clinician's Guide for Working with Women in Groups, Free Press, xvi + 413 pp.), using the current 29-topic, three-part sequence published by the California Evidence-Based Clearinghouse (CEBC). The original layout of 33 weekly sessions (11 + 10 + 9 topics plus closing rituals) is noted where it differs. Men's (M-TREM, 3rd ed., 2016) and adolescent-girls' (G-TREM, 3rd ed., 2005) adaptations are summarised as variants. Sources: topic titles, part structure, session length, group size, the components of each topic chapter (rationale, goals, agenda, exercises, leader's notes) and the reconciliation of topic counts are based on CEBC, the ACF Clearinghouse, the Psychiatric Services review, Social Work Today (Community Connections staff) and library catalogue records. The manual's per-topic content is not publicly available, and Fallot & Harris (2002) and Toussaint et al. (2007) are drawn on through their abstracts and clearinghouse summaries [uncertain]. Each topic's own discussion questions and exercises are therefore not reproduced here, and no published step-by-step protocol for the topics exists outside the manual: steps in section 4 apply the published session frame and stay marked [synthesis], except the few exercise examples the clearinghouses publish. [source: ACF Prevention Services Clearinghouse; CEBC; Psychiatric Services review 1999; Social Work Today 2007; USI library catalogue]

TREM is a manualised, gender-specific, psychoeducational and skills-building group programme. Clinicians and service users at Community Connections, a non-profit mental-health agency in Washington, DC, developed it in the 1990s. Maxine Harris led the work, with Roger Fallot and the agency's Trauma Work Group. It was built for women survivors of sexual, physical and emotional abuse in the public mental-health system: women who are homeless, incarcerated, dually diagnosed or psychotic, for whom traditional trauma work had been unavailable or ineffective. [source: Social Work Today 2007; Psychiatric Services review; SCCMHA] The publisher describes the interventions as refined over almost five years by 27 clinicians with more than 500 participants, combining social-skills training, psychoeducational and psychodynamic techniques and peer support, with discussion questions, sample responses and experiential exercises for each topic. [source: Simon & Schuster book page]

How change happens, as the developers describe it.

• Abuse disrupts the development of ordinary life skills: self-identity, labelling emotions, boundaries and healthy relationships.
• Many current symptoms and "negative" behaviours (substance use, dissociation, self-harm) began as legitimate ways of coping and surviving.
• Many women do not link their present difficulties to past abuse.

Change therefore comes from three things: (1) psychoeducation and cognitive restructuring that connect present problems to trauma and reframe symptoms as coping; (2) building the recovery skills that abuse interrupted, plus less costly coping alternatives; (3) peer support and empowerment in a group of women with shared experience. It does not come from retelling, reliving or uncovering memories. [source: Social Work Today 2007; Fallot & Harris 2002 abstract; CEBC]

2. Framework

Format [source: ACF 580; CEBC; Psychiatric Services review]

• Closed group of about 8–10 members (CEBC allows 3–10), run by 2–3 co-leaders. For women's groups the leaders are female [source: DWC training page].
• One topic per weekly 75-minute session, delivered in the prescribed order [source: CEBC; ACF 580; Psychiatric Services review]. Session counts reconciled: the 1998 manual ran 33 weekly sessions [source: Social Work Today; ACF 580; GWU dissertation abstract ("33-topic model")]. Community Connections staff described the current women's version in 2007 as 29 leader-driven sessions in three core sections [source: Social Work Today]. CEBC and the NREPP-derived description give 24–29 sessions, and CEBC's topic list (9 + transition, 10, 9) totals 29 [source: CEBC; NREPP via Healthy Communities Promise Practice]. The lower bound of 24 is not explained [uncertain]. The IDB evidence platform's "18 to 29 sessions in five phases" counts the special-population modules as a fifth phase; its lower bound of 18 is not explained [uncertain; it may reflect the 18-session M-TREM, inference only].
• In the manual, each topic has a rationale (drawn from trauma's impact on self-development), goals, an agenda, exercises and leader's notes. The theory draws on models of women's development such as self-in-relation, and the organisation is phase-oriented [source: Psychiatric Services review]. Community Connections staff describe each session as one topic covered through structured conversations, questions and experiential exercises [source: Social Work Today 2007].
• A session is a guided conversation followed by an experiential exercise. The adaptations describe the same frame: G-TREM uses icebreaker, then discussion questions, then experiential activity; M-TREM adds a relaxation or meditation activity.
• There is no homework component (CEBC).
• Settings: outpatient clinics, hospitals, community agencies, residential care, jails and prisons, shelters, substance-use programmes, welfare-to-work programmes.

Phases (phase-oriented model of recovery) [source: CEBC topic list; ACF 580; Psychiatric Services review]

Criteria for moving between phases. The sources give a fixed sequence, not individual readiness criteria. Leaders cover topics in order, and members move through as a closed cohort. [source: ACF 580; CEBC] Part 1 is deliberately placed before the trauma content so that self-soothing, boundaries and group trust are in place first [source: Psychiatric Services review, which calls it phase-oriented]. [synthesis] Before starting Part 2, a leader can informally check that:

• most members attend reasonably regularly;
• members can name at least one self-soothing strategy;
• group rules about confidentiality and respectful listening are holding;
• no member is in acute crisis without an individual clinician.

If these are not in place, add a review or transition session rather than skipping ahead.

Variants [source: ACF 844; ACF 691; Social Work Today; CEBC]

• M-TREM (men): 18 weekly sessions of 75–90 minutes in the current 3rd edition, with at least one male leader [source: ACF 844]. Earlier versions ran 24 weeks [source: Social Work Today 2007]; SCCMHA describes 24 topics in three male-specific categories: "Male Myths, Emotions, and Relationships", "Trauma Recovery" and "Recovery Skills" [source: SCCMHA]. The first session addresses male myths and societal pressures, and early sessions build emotional vocabulary [source: Social Work Today]. Part 1 covers male gender myths, emotions such as anger and shame, coping, trust and intimacy. Part 2 links trauma to symptoms, substance use and relationships and builds interpersonal, problem-solving and life-planning skills [source: ACF 844]. Manual: Fallot et al., 2016, 3rd ed.
• G-TREM (girls aged 12–18): 16 sessions of 75–90 minutes, weekly or twice weekly, in narrow age bands. Topics include boundaries, self-care, peer pressure, trust, managing feelings and self-soothing.
• Other variants: modified sessions for women with serious mental illness, incarcerated women, women who have been abusive, and mothers. A four-session version for short-stay units. An open-group residential version (Toussaint et al., 2007). Spanish materials. A self-help workbook (Copeland & Harris) for women who cannot attend a group.

3. Guiding principles

[source: Social Work Today 2007 (Community Connections staff), unless tagged otherwise]

• Symptoms as coping. Treat substance use, dissociation and self-harm as survival strategies that once made sense. In practice: ask "what did this help you survive?" before addressing cost.
• Abuse interrupted skill development. In practice: teach skills such as identifying feelings, setting boundaries and self-soothing as things never learned, not as personal failings.
• Make the trauma–symptom link explicit. In practice: each trauma topic ends by connecting the abuse type to a present-day difficulty.
• Recognise the trauma, do not recount it. Members need to acknowledge they were traumatised, not recall details. TREM does not unearth "buried" memories. In practice: steer away from graphic detail and decline requests to retrieve memories.
• Present focus. In practice: return discussion to current symptoms, behaviour and desired functioning.
• Non-judgement and no self-blame. In practice: leaders say explicitly that members are not to blame for past survival behaviours.
• Offer alternatives; do not just forbid. In practice: never ask a member to give up a coping method without building a less costly substitute.
• Inclusion. Women with psychosis, cognitive deficits or irregular attendance are not excluded. In practice: keep a seat open after absences, hospitalisations or detox, and tolerate tuning out.
• Empowerment. In practice: members choose how much to share, and leaders invite rather than require participation [synthesis on the how].
• Peer support. In practice: route questions to the group ("who else has noticed that?") rather than answering everything as leader [synthesis on the how].
• Gender specificity. Gender shapes how women experience and cope with trauma, and men often struggle to see themselves as victims. [source: Fallot & Harris 2002 abstract; Social Work Today] In practice: run single-gender groups and use the gender-specific manual.
• Psychoeducational group, not process group. [source: BHTEN training objectives] In practice: keep to the agenda and the topic, and use "trauma educational statements" rather than open-ended processing.
• Consumer partnership. The model was co-developed with clients. In practice: invite members' feedback on pacing and exercises [synthesis on the how].
• Fidelity to sequence and manual. [source: CEBC] In practice: deliver topics in order and use the TREM Fidelity Scale and supervision where available.
• Not psychodynamic. It is cognitive restructuring, psychoeducation and skill building [source: Social Work Today]. In practice: do not interpret transference or unconscious material in group.

4. Intervention inventory

What this inventory is built from. TREM's interventions are its topic sessions, plus a small set of group procedures that run through every session. Titles, sequence, session format and the components of each topic (rationale, goals, agenda, exercises, leader's notes) come from the published sources (CEBC, ACF, the Psychiatric Services review and Social Work Today). The manual's own goals, questions and exercises for each topic are published only in the manual [uncertain]; the per-topic steps below are the writer's synthesis built on the published session frame [synthesis].

So, for each topic:

• Purpose is drawn from the title and the part-level goals.
• Steps apply the published session frame (opening, guided questions, experiential exercise, closing) to that topic and are [synthesis] unless tagged.
• Example language is mine and labelled (illustrative).

Use the manual for the actual agenda questions and exercises. The only exercise examples published outside the manual are: practising safety precautions after the physical-safety discussion (ACF 580), discussing a recent situation where one wished to have communicated more clearly (M-TREM, ACF 844), and the comfort booklet (G-TREM, ACF 691). [uncertain: all other per-topic manual content]

A. Group procedures used throughout

A1. Intake trauma inquiry and group selection

• Purpose: Identify women whose difficulties may be trauma-linked and offer TREM. Community Connections asks about trauma history at intake and considers whether trauma may explain symptoms. [source: Social Work Today]
• Steps:
  • Ask about physical, sexual and emotional abuse in plain language, without requiring detail.
  • Explain TREM as a skills-and-education group that does not ask anyone to retell her story.
  • Do not exclude women for psychosis, cognitive difficulties or patchy attendance [source: Social Work Today].
  • [synthesis] Do screen for:
    • current acute suicide risk, followed by a standard risk assessment and safety plan;
    • an ongoing abusive relationship, followed by safety planning before or alongside the group;
    • a current relationship with another member (as abuser, partner or relative), in which case allocate to different groups;
    • a need for an individual clinician alongside the group.
  • Confirm she can attend weekly at the set time.
• Example language (illustrative): "A lot of women we see have been hurt in the past, and it often connects to things like sleep, drinking or feeling on edge. This group helps with those links and with skills. You won't be asked to tell what happened."
• Watch for: Distress just from the question. Note it, slow down and offer grounding. Ambivalence is normal: offer a first-session trial.

A2. Setting up the group

• Purpose: Create a stable, safe frame for the group. [source: ACF 580; CEBC]
• Steps:
  • Closed group of 8–10 members (3–10 acceptable) with 2–3 co-leaders, the same room and the same time each week, and 75 minutes per session.
  • Have the manual open and the session agenda ready.
  • [synthesis] Agree with co-leaders beforehand who leads the discussion, who tracks distress and who will step out with a member if needed.
• Watch for: Leaders drifting into a process-group style. BHTEN training explicitly distinguishes TREM from a process group.

A3. Standard session structure

• Purpose: Deliver one topic per session in a predictable, contained way. [source: ACF 580 (guided conversation, then experiential exercise); ACF 691 (icebreaker, questions, activity); ACF 844 (relaxation or meditation); Psychiatric Services review (goals, agenda, exercises, leader's notes)]
• Steps:
  1. Welcome, then a brief check-in or icebreaker.
  2. Name the topic and its goals for the day.
  3. Work through the agenda of guided discussion questions, moving from general and educational to personal and present-day.
  4. Do the experiential exercise tied to the topic, for example practising safety precautions after discussing physical safety.
  5. [synthesis] Close with a summary, one take-away per member and a calming or grounding activity (the M-TREM frame includes relaxation or meditation).
  6. [synthesis] Leaders debrief together after the session, using the leader's notes.
• Example language (illustrative): "Today's topic is emotional boundaries. By the end we want everyone to have one way to say no, or ask for something, that feels doable this week."
• Watch for: Over-running the discussion so the exercise is lost. Members leaving the session still activated: budget closing time.

A4. Trauma educational statements and reframing symptoms as coping

• Purpose: Cognitive restructuring that links past abuse to present problems and removes blame. Writing useful "trauma educational statements" is a TREM training objective. [source: BHTEN; Social Work Today]
• Steps:
  • When a member describes a symptom (drinking, cutting, spacing out, not trusting), name its likely original survival function.
  • Acknowledge what it costs her now.
  • Invite the group to suggest less costly alternatives.
• Example language (illustrative): "Spacing out may have been the smartest thing your mind could do back then. The question now is when it still helps and when it gets in your way."
• Watch for: Statements that sound like excuses or lectures. A good reframe produces visible relief or nodding, and members starting to use the language themselves.

A5. Self-soothing and grounding toolkit (cross-cutting)

• Purpose: Give members ways to calm themselves during and between sessions. Self-soothing is a core TREM skill. [source: CEBC; DWC; BHTEN] G-TREM uses a "comfort booklet" of comforting images [source: ACF 691].
• Steps: [synthesis]
  • Start a personal list in Part 1 and add to it all the way through.
  • Practise one strategy in the session.
  • Use it at the end of any heavy session.
• Watch for: Strategies that are themselves costly, such as substances or isolation. Reshape these rather than forbid them.

A6. Handling disclosure in group

• Purpose: Keep acknowledgement of trauma safe for the speaker and for listeners. [source: Social Work Today (recognise, don't recall; no memory retrieval)]
• Steps: [synthesis]
  • Thank her and validate her.
  • Gently cap detail: ask her to give the headline, not the details.
  • Link what she said back to the topic and to present effects.
  • Check how the rest of the group is doing.
  • Offer individual follow-up for anything that needs more.
• Example language (illustrative): "Thank you for trusting us with that. You don't need to tell us more details for it to count. What do you notice it still affects today?"
• Watch for: Other members dissociating or leaving the room, and disclosures that trigger a duty to report (see section 5).

A7. Closing rituals (Part 4)

• Purpose: Mark the ending, consolidate change and plan ahead. [source: ACF 580; Social Work Today (self-assessment and planning sessions)]
• Steps: [synthesis]
  • Each member reviews which skills she now uses and what has changed.
  • Members give each other positive feedback.
  • Each member makes a written plan for continuing support.
  • End with a group ritual chosen with members.
• Watch for: Grief or abandonment reactions as the end approaches. Mention the ending several sessions ahead.

A8. Fidelity and outcome monitoring

• Purpose: Keep delivery faithful to the model and track members' gains. [source: CEBC]
• Steps:
  • Use the TREM Fidelity Scale, which covers group context, implementation and session-level delivery; it is available from Community Connections.
  • Consultation is available by audio-recording sessions with consent and sending them to Community Connections.
  • Outcome measure: the Trauma Recovery and Empowerment Profile (TREP). Not reproduced here.
• Watch for: Recording requires members' informed consent and secure storage [synthesis].

B. Part 1: Empowerment topics

[source for titles: CEBC (9 topics plus a transition section). Part goals, verified: helping women protect and comfort themselves, set physical and emotional boundaries and build self-esteem. Leaders link disempowerment and low self-esteem to trauma, address distorted views of womanhood and the body, reframe drug use, dissociation and self-harm as skills that helped them survive, then introduce "less costly strategies" for self-soothing [source: Social Work Today 2007, Community Connections staff]. A Community Connections supervisor describes telling members "We're glad you did all those things" [source: Social Work Today]. ACF summarises the original Part 1 as covering gender identity, sexuality, interpersonal boundaries and self-esteem [source: ACF 580]. Steps and example language for each topic: synthesis]

B1. What It Means to Be a Woman

• Purpose: Open the group by examining messages about womanhood and gender identity, and build cohesion.
• Steps:
  • Group rules and introductions.
  • Discuss the messages members received about being a woman and where those messages came from.
  • Exercise: each member names one message she wants to keep and one she wants to drop.
• Example language (illustrative): "What did you learn growing up about what a woman is supposed to be?"
• Watch for: Early over-disclosure. Contain it gently, since trust is still forming.

B2. What Do You Know and How Do You Feel About Your Body?

• Purpose: Basic body knowledge and feelings about the body, often disrupted by abuse.
• Steps:
  • Accurate, simple education about the body.
  • Discuss comfortable and uncomfortable feelings about the body.
  • Exercise: one kind thing the body does for her.
• Example language (illustrative): "Many women who've been hurt feel disconnected from their bodies. That makes sense. Today we just notice, without judging."
• Watch for: Shame, dissociation, and disclosure of eating-related or self-harm behaviour. Follow up individually.

B3. Physical Boundaries

• Purpose: Define personal space and the right to control touch.
• Steps:
  • Discuss what a physical boundary is and how hers were crossed (without detail).
  • Exercise: practise noticing and stating a comfortable distance, for example by moving chairs or stepping closer and further apart with consent [synthesis].
• Example language (illustrative): "You get to decide how close is close enough. Let's practise saying 'that's close enough.'"
• Watch for: Freezing or difficulty knowing her own limit. That is useful information, not failure.

B4. Emotional Boundaries: Setting Limits and Asking for What You Want

• Purpose: Saying no and making requests.
• Steps:
  • Discuss times members struggled to refuse or to ask.
  • Role-play a short, current scenario: refusing, then requesting.
• Example language (illustrative): "Try one sentence: 'No, I can't do that,' or 'I'd like…'. No explaining needed."
• Watch for: Apologising and over-explaining. Coach brevity.

B5. Self-Esteem

• Purpose: Counter abuse-shaped negative self-beliefs and build balanced self-worth.
• Steps:
  • Identify the critical self-statements members carry and where they came from.
  • Practise an alternative self-statement.
  • Peers name strengths they see in each other.
• Example language (illustrative): "Whose voice is that when you call yourself stupid? Is it yours?"
• Watch for: Rejecting compliments. Keep the feedback specific and small.

B6. Developing Ways to Feel Better: Self-Soothing

• Purpose: Build a personal set of safe comfort strategies. [source: ACF 691 comfort-booklet example for G-TREM]
• Steps:
  • List what members currently do to feel better, including costly strategies, without judgement.
  • Sort the list by cost.
  • Build a list of safer options across the senses, activities and people.
  • Try one in session.
• Example language (illustrative): "Everything on this list worked in some way. Let's add some that cost you less."
• Watch for: Shame about substance use. Reframe it as coping (A4).

B7. Intimacy and Trust

• Purpose: Understand how abuse affects trust, and how to judge trustworthiness gradually.
• Steps:
  • Discuss signs that someone is safe or unsafe to trust.
  • Discuss trust as something given in small steps.
  • Exercise: describe the steps by which trust could grow in one current relationship.
• Example language (illustrative): "Trust doesn't have to be all or nothing. What would a small first step look like?"
• Watch for: All-or-nothing trust that shows up in the group itself.

B8. Female Sexuality

• Purpose: Education about and reclaiming of sexuality as one's own.
• Steps:
  • Factual, non-graphic education.
  • Discuss messages members received about sexuality.
  • Explore what a sexuality defined by herself would mean.
• Example language (illustrative): "Your sexuality belongs to you, whatever happened in the past."
• Watch for: Triggering of sexual-abuse memories. Use grounding, and let members pass.

B9. Sex with a Partner

• Purpose: Consent, choice and communication in sexual relationships.
• Steps:
  • Discuss the right to say yes, no or not now.
  • Discuss the signs of pressure.
  • Practise how to raise safer-sex and comfort needs with a partner.
• Example language (illustrative): "What helps you know you really want to, not just that you're going along?"
• Watch for: Disclosure of current coercion. Start safety planning individually.

B10. Transition session (end of Part 1)

• Purpose: Consolidate Part 1 skills and prepare for the trauma-focused part. [source: CEBC lists a transition section]
• Steps:
  • Review self-soothing and boundary skills.
  • Preview Part 2, explaining that it names types of abuse without retelling stories.
  • Each member plans how she will look after herself after heavier sessions.
• Watch for: Anticipatory anxiety and drop-out risk. Contact absent members.

[uncertain] ACF counts 11 Part 1 topics in the original; CEBC lists 9 named topics plus a transition section (10). The published sources do not name the original's additional topic. "Self-monitoring" is not a Part 1 skill in any published source, so it is not listed in the framework table.

C. Part 2: Trauma recovery topics

[source for titles: CEBC ("at least ten topics"). Part goal, verified: link sexual, physical and emotional abuse to psychiatric symptoms, substance use and current relationships, and build tools to counter these effects, without retelling or uncovering memories; skill gaps addressed include how to label situations and feelings accurately [source: ACF 580; Social Work Today 2007]. The manual's Part 2 covers members' personal history and includes a session on abuse in mental-health settings such as seclusion and restraint [source: Psychiatric Services review]. Steps and example language: synthesis]

TREM is not a memory-processing or exposure therapy. Part 2 names categories of abuse and their effects. It does not invite trauma narratives. So the readiness and dosing rules for exposure methods do not apply. Containment does: cap detail (A6), end every session with grounding (A5), and give an individual follow-up route. [source: Social Work Today for no reliving or retrieval; containment steps: synthesis]

C1. Gaining an Understanding of Trauma

• Purpose: Introduce what trauma is and the idea that current problems can be understandable responses to it.
• Steps:
  • Give a plain definition of trauma.
  • Collect common after-effects on a board.
  • Each member ticks, privately, the effects she recognises.
  • Introduce the reframe "what happened to you" rather than "what's wrong with you".
• Example language (illustrative): "Many of the problems that brought you here may be ways you learned to survive."
• Watch for: Relief versus overwhelm. Some members are hearing the link for the first time.

C2. The Body Remembers What the Mind Forgets

• Purpose: Educate about bodily trauma responses: startle, pain, sleep problems and physical reactions to reminders.
• Steps:
  • Explain how the body can react to reminders without a clear memory.
  • Identify personal body signals.
  • Practise one body-based calming strategy.
• Example language (illustrative): "Your body can react before you know why. That's a signal to take care, not proof of anything specific."
• Watch for: Do not interpret body sensations as evidence of unremembered abuse. Treat memories and sensations as the client's experience, not as facts to be uncovered [synthesis; consistent with Social Work Today].

C3. What Is Physical Abuse?

• Purpose: Name and define physical abuse and dispel minimising beliefs.
• Steps:
  • Give a definition and examples, including ones commonly minimised as "discipline" or "normal fights".
  • Discuss how it was explained to members at the time.
  • Link it to present effects.
• Example language (illustrative): "Being hit was not your fault, whatever you were told about why."
• Watch for: Self-blame and anger. Steer away from graphic accounts.

C4. What Is Sexual Abuse?

• Purpose: Define sexual abuse broadly and counter self-blame.
• Steps:
  • Give a definition, covering non-contact abuse and abuse by known people.
  • Discuss the common messages abusers give.
  • Link it to current effects.
  • End with grounding.
• Example language (illustrative): "You can know this happened without going into the details here."
• Watch for: The highest risk of dissociation and drop-out. Check in with members individually after the session.

C5. Physical Safety

• Purpose: Assess current safety and build practical safety precautions. [source: ACF 580 gives this as the example: practising safety precautions after the discussion]
• Steps:
  • Discuss current risks at home, on the street and in relationships.
  • Each member identifies her warning signs.
  • Exercise: practise specific precautions and draft a personal safety plan.
• Example language (illustrative): "Let's make this practical: who could you call, where could you go, and what would you take?"
• Watch for: Disclosure of current danger. Do an individual risk assessment and refer to domestic-violence services.

C6. What Is Emotional Abuse?

• Purpose: Recognise emotional abuse as real abuse with real effects.
• Steps:
  • Give a definition and examples: humiliation, threats, isolation, control.
  • Discuss how it shaped self-talk.
  • Link it to self-esteem work (B5).
• Example language (illustrative): "Words that were used to control you can still echo in how you talk to yourself."
• Watch for: "It wasn't that bad" minimisation and comparing suffering between members.

C7. Institutional Abuse

• Purpose: Acknowledge abuse within institutions, including mental-health settings: seclusion, restraint, overmedication and sexual exploitation. [source: Psychiatric Services review]
• Steps:
  • Validate these experiences.
  • Discuss how they affect trust in services, including this one.
  • Plan how to self-advocate.
• Example language (illustrative): "Some of you were hurt in places that were supposed to help. It makes sense to be wary of us too."
• Watch for: Defensiveness in leaders. Allegations about current services may need to be escalated (see section 5).

C8. Abuse and Psychological or Emotional Symptoms

• Purpose: Link abuse to depression, anxiety, dissociation, voices and other symptoms.
• Steps:
  • Each member maps one symptom: when it started, what it protected against and what it costs now.
  • Apply the A4 reframe.
• Example language (illustrative): "What might that symptom have been protecting you from?"
• Watch for: Members with psychosis. Accept their experiences as they are and avoid debating them.

C9. Trauma and Addictive or Compulsive Behavior

• Purpose: Connect substance use and compulsive behaviours to trauma as coping, and introduce alternatives.
• Steps:
  • Each member identifies what the behaviour did for her: numbing, sleep, courage, connection.
  • Identify its costs.
  • Choose one less costly replacement from the self-soothing list.
• Example language (illustrative): "Before we talk about stopping, let's be honest about what it gives you."
• Watch for: Intoxication in session. Coordinate with addiction treatment.

C10. Abuse and Relationships

• Purpose: Recognise how abuse shapes current relationship patterns.
• Steps:
  • Discuss recurring patterns: choosing unsafe partners, isolation, caretaking.
  • Each member names one pattern she wants to change.
• Example language (illustrative): "What patterns do you notice in who you get close to?"
• Watch for: Self-blame. Keep the focus on patterns, not fault.

D. Part 3: Advanced trauma recovery and skills building

[source for titles: CEBC. Part goal (communication, decision-making, regulating overwhelming feelings, healthier relationships; blame, responsibility and forgiveness): CEBC; ACF 580. Steps and example language: synthesis]

D1. Family Myths and Distortions

• Purpose: Identify distorted family rules and messages that kept abuse hidden or blamed the child.
• Steps:
  • List family rules ("don't tell", "we're fine").
  • Test each rule against what members now know.
  • Rewrite one rule.
• Example language (illustrative): "What was the rule in your family about talking about problems? Is it still running your life?"
• Watch for: Loyalty conflicts and distress.

D2. Family Life: Current

• Purpose: Examine present-day family relationships and boundaries.
• Steps:
  • Map current contact with family.
  • Identify which contacts help and which harm.
  • Plan one boundary.
• Example language (illustrative): "What contact with family feels right for you now, not what you're supposed to do?"
• Watch for: Pressure to confront family. Leave the choice to the member.

D3. Decision-making: Trusting Your Judgment

• Purpose: Build confidence in her own judgement after abuse taught her to distrust it.
• Steps:
  • Walk through a structured process: options, pros and cons, gut check, choice, review.
  • Practise it on a current decision.
• Example language (illustrative): "What does your gut say, and what does your head say?"
• Watch for: Deferring to others, including the leaders.

D4. Communication: Making Yourself Understood

• Purpose: Clear, assertive communication. M-TREM uses the example exercise of discussing a recent situation where the member wished she had communicated more clearly. [source: ACF 844]
• Steps:
  • Contrast passive, aggressive and assertive styles.
  • Role-play a recent situation using an assertive script.
• Example language (illustrative): "Let's replay that conversation. What would you want to say if it went the way you'd like?"
• Watch for: Practise in a safe setting first.

D5. Self-Destructive Behaviors

• Purpose: Understand self-harm and risky behaviour as coping, and build alternatives and a safety plan.
• Steps:
  • Map triggers, the function of the behaviour and safer substitutes.
  • Each member writes or updates a personal safety plan.
  • Leaders check current risk individually.
• Example language (illustrative): "This kept you going at some point. What could do that job with less harm?"
• Watch for: Active suicidal ideation. Follow a standard risk assessment, collaborative safety plan and lethal-means counselling (safe storage and removal), and inform the member's individual clinician.

D6. Blame, Acceptance, and Forgiveness

• Purpose: Place responsibility with abusers, accept what happened, and treat forgiveness as optional. [source: ACF 580 ("role of forgiveness in recovery")]
• Steps:
  • Distinguish blame, responsibility, acceptance and forgiveness.
  • Each member identifies where she still blames herself.
  • Discuss acceptance and forgiveness as choices, not requirements.
• Example language (illustrative): "Forgiveness is your choice. Recovery doesn't depend on it."
• Watch for: Religious or family pressure to forgive.

D7. Feeling out of Control

• Purpose: Regulate overwhelming feelings.
• Steps:
  • Rate feelings on a 0–10 scale and identify early warning signs.
  • Pair a strategy with each level, drawing on self-soothing, grounding and reaching out.
  • Practise in session.
• Example language (illustrative): "At a 4 you might take a walk. At an 8, who do you call?"
• Watch for: Members becoming activated during the exercise. Use it as live practice.

D8. Relationships

• Purpose: Build healthier, safer relationships.
• Steps:
  • Group lists signs of healthy and unhealthy relationships.
  • Each member assesses one current relationship.
  • Each member plans one step toward mutuality.
• Example language (illustrative): "In a good relationship, what goes both ways?"
• Watch for: Identifying current abuse. Follow C5.

D9. Personal Healing

• Purpose: Self-assessment and planning for continued recovery. [source: Social Work Today (self-assessment and planning)]
• Steps:
  • Each member reviews changes since session 1, the skills she now uses and her next goals.
  • Identify her ongoing supports.
• Example language (illustrative): "What would you tell the woman who walked into the first session?"
• Watch for: Dismissing her own progress. Use peer feedback.

E. Adaptations as interventions

• M-TREM: Starts with male gender myths and emotions beyond anger, such as shame and fear, and with how hard it can be to see oneself as a victim. Each session includes a relaxation or meditation activity. At least one leader is male. [source: ACF 844; Social Work Today]
• G-TREM: Age-banded groups with an icebreaker, questions and a hands-on activity (for example the comfort booklet). Adds peer pressure and self-care topics. [source: ACF 691]
• Open-group residential version: TREM modified for an existing residential substance-abuse programme in Colorado, for substance-abusing women with histories of violence. The modifications shortened the intervention and moved from closed to open meetings; gains in trauma recovery skills were associated with gains in outcomes [source: CEBC and IDB summaries of Toussaint et al., 2007]. The specific session changes are not described in the published summaries [uncertain].
• Self-help workbook: For women who cannot attend a group. [source: Social Work Today] Copeland & Harris's workbook has four parts (Empowerment, Trauma Recovery, Creating Life Changes, Closing Rituals) and 33 topics meant to be worked through in order, since each builds on the ones before. Each topic opens with a rationale, gives activities interspersed with survivors' stories, and ends with "Things to Remember Every Day". Its opening guidance asks readers to pace themselves and set goals, make their surroundings safe, seek professional help if they are being abused, and stop any exercise that causes distress. [source: Psychiatric Services review of the workbook, 2003]

5. Handling problems

From the sources

• Irregular attendance, hospitalisation or detox. Do not remove a member for missed sessions. Keep her place and welcome her back. The model was designed to keep women engaged through admissions. [source: Social Work Today] [synthesis] Make a brief contact after any absence, and give a one-line recap of the missed topic at her return.
• Tuning out or dissociating in session. Accommodate it rather than treat it as non-compliance. [source: Social Work Today] [synthesis]
  • Use the member's name softly.
  • Invite a grounding action: feet on the floor, name objects in the room, hold something cold or textured.
  • Lower the intensity of the topic for everyone.
  • Check in after the session.
  • If dissociation is frequent, review with her individual clinician.
• Request to recover or explore memories. Decline, and refocus on current symptoms, behaviour and goals. [source: Social Work Today] [synthesis] Explain that she does not need to remember details to heal from what she knows happened. Refer for individual trauma-focused assessment if she wants more.
• Self-blame for past survival behaviour. Leaders explicitly remove judgement and reframe the behaviour as coping (A4). [source: Social Work Today]
• Men who reject the victim label or only express anger. Address gender myths early and build an emotional vocabulary. [source: Social Work Today; ACF 844]
• Harmful coping that a member is not ready to give up. Offer alternatives rather than demand that she stop. [source: Social Work Today]

Synthesis (not given in the published sources) [synthesis]

• Overwhelm from group content. Pause the agenda and lead a grounding activity for the whole group. Shrink the question to the present ("what is one thing that helps today?"). Offer a member the option to step out with a co-leader, who stays with her until she is regulated. Tell the group she is being looked after. Shorten the discussion and keep the closing intact.
• Graphic disclosure that floods others. Interrupt kindly ("I'm going to stop you there to look after you and the group"). Validate, then ground. Offer an individual follow-up within days.
• Stuck or silent group. Move from personal questions to general or educational ones ("what do women often feel?"). Use pairs before the full group, and move to the experiential exercise earlier. Silence in Part 2 may be self-protective, so do not push.
• One member dominating. Acknowledge her contribution, then go round the group. Agree a talking-time norm at the start.
• Conflict between members, or re-enactment (scapegoating, rescuing, sexualised or threatening behaviour). Stop it promptly and restate the safety rules. Name the pattern as an understandable trauma response without blaming anyone. Repair one-to-one if needed. Remove a member only for threats to others' safety, and offer her an individual alternative.
• Rupture with leaders (feeling judged, distrust of the service, institutional-abuse history). Acknowledge the specific failure, invite feedback, and adjust. Do not defend the institution. A non-defensive response models the boundary and mutuality skills TREM teaches.
• "Non-adherence". There is no homework to be non-adherent with (CEBC). Practice between sessions is invitational. Low use of skills is information for problem-solving: what got in the way?
• Acute suicidality or self-harm. Assess risk individually and the same day, following your service's standard procedure. Make a collaborative safety plan, do lethal-means counselling (safe storage and removal), and coordinate with the member's clinician or crisis services. Do not process this in the group.
• Current abuse or danger, or a child at risk. Disclosures of current child maltreatment, abuse of a vulnerable adult, or abuse by staff in an institution trigger local mandatory-reporting duties. Explain the limits of confidentiality at intake and again in session 1. Use domestic-violence safety planning (C5).
• Member who has abused others. Community Connections offers additional sessions for women survivors who have been abusive [source: ACF 580]. In a standard group, focus on her own victimisation and current skills. Discuss with supervision whether a specialised group is indicated, and whether other members are safe with her.
• Psychosis. Keep content concrete and short. Validate her feelings without debating her beliefs. Coordinate with her prescriber or case manager. Psychosis alone is not a reason to exclude [source: Social Work Today].
• Intoxication in session. Discreetly ask her to leave for that session. Arrange a check-in and welcome her back next week.
• Open-group or shortened delivery. [synthesis] Give new members a pre-group orientation to the rules and to self-soothing. Front-load Part 1 skills, and use topics that stand alone. [The shortened, open-group residential version is confirmed by the CEBC and IDB summaries of Toussaint et al., 2007; its implementation details are not published: uncertain]
• Leader vicarious trauma. Co-leader debriefs, regular supervision, and consultation through Community Connections where available.

Sources

Web pages

• Trauma Recovery and Empowerment Model – Title IV-E Prevention Services Clearinghouse (ACF)
• Men's Trauma Recovery and Empowerment Model – ACF Clearinghouse
• Trauma Recovery and Empowerment for Adolescent Girls and Young Women Ages 12–18 – ACF Clearinghouse
• TREM – California Evidence-Based Clearinghouse for Child Welfare
• Trauma Recovery and Empowerment: A Clinician's Guide for Working With Women in Groups (book review), Psychiatric Services 1999;50(4):572
• Healing the Trauma of Abuse: A Women's Workbook (book review), Psychiatric Services 2003;54(5):754
• Trauma Recovery and Empowerment (Maxine Harris), Simon & Schuster book page
• Social Work Today, Mar/Apr 2007, article on TREM at Community Connections
• Fallot & Harris (2002), The Trauma Recovery and Empowerment Model (TREM): conceptual and practical issues – abstract only (Ovid)
• Trauma Recovery and Empowerment Model (TREM) – IDB Plataforma de Evidencias
• TREM / M-TREM training, Detroit Wayne (DWC Training)
• W-TREM 5-day webinar – BHTEN
• SCCMHA: TREM (W-TREM and M-TREM) description
• Masin-Moyer (2017) dissertation record, ATREM vs TREM – UPenn (abstract only; not used for technique content)
• Trauma recovery and empowerment: a clinician's guide for working with women in groups – USI Library catalogue record (bibliographic details and page count; no contents note)
• The Trauma Recovery and Empowerment Model: A Trauma-Informed Treatment Program for Female Offenders in the Community – GWU ScholarSpace dissertation record (abstract only; source of "33-topic model")
• Trauma Recovery and Empowerment Model (TREM) – Healthy Communities Promise Practice (NREPP-derived description)

Books and papers cited

• Harris, M., & the Community Connections Trauma Work Group (1998). Trauma Recovery and Empowerment: A Clinician's Guide for Working with Women in Groups. New York: Free Press. xvi + 413 pp. (The primary manual.)
• Fallot, R. D., Beyer, L. L., DeHart, M., Wilson, C., Borges, J., & Hoefling, D. (2016). Men's Trauma Recovery and Empowerment Model (M-TREM): A Clinician's Guide to Working with Male Trauma Survivors in Groups (3rd ed.). Washington, DC: Community Connections.
• Berley, R. W., Guillory, K., Harris, M., Quezada, C. J., & Seagroves, K. (2005). Love and Life: Trauma Recovery and Empowerment for Adolescent Girls and Young Women Ages 12–18 (G-TREM) (3rd ed.). Washington, DC: Community Connections.
• Fallot, R. D., & Harris, M. (2002). The Trauma Recovery and Empowerment Model (TREM): Conceptual and practical issues in a group intervention for women. Community Mental Health Journal, 38(6), 475–485.
• Fallot, R. D., McHugo, G. J., Harris, M., & Xie, H. (2011). The Trauma Recovery and Empowerment Model: A quasi-experimental effectiveness study. Journal of Dual Diagnosis, 7, 74–89.
• Copeland, M. E., & Harris, M. Healing the Trauma of Abuse: A Woman's Workbook. New Harbinger. [uncertain: year not verified]
• Toussaint, D. W., et al. (2007). Modification of TREM for substance-abusing women with histories of violence at a Colorado residential substance-abuse treatment centre. (Summarised by CEBC and IDB.)

Overall [uncertain] flags

• The per-topic agenda questions, exercises and leader's notes of the 1998 manual are not publicly available. Steps in section 4 apply the verified session frame and stay labelled synthesis; only three published exercise examples are sourced (ACF 580, 844, 691).
• Topic counts reconciled: 33 weekly sessions in the 1998 original (ACF: 11 + 10 + 9 topics plus closing rituals; Social Work Today; GWU dissertation); 29 in the current women's version (Social Work Today 2007; CEBC list of 9 + transition, 10, 9); 24–29 is the CEBC/NREPP range; IDB's 18–29 in five phases is unexplained. Section 4 follows the CEBC list of 29. The size of the closing-ritual block, the original's eleventh Part 1 topic and the 24 and 18 lower bounds remain [uncertain].