A Scoping Review of the Trauma Recovery and Empowerment Model (TREM)

Abstract

The link between interpersonal trauma and negative biopsychosocial outcomes has been well-documented. Integrated treatments that address trauma, mental health, and substance use among women with trauma histories have been found to be more effective than treatments that focus separately on these concerns. Since the early 2000s, the Trauma Recovery and Empowerment Model (TREM) has been described as a “promising” integrated trauma group therapy for women. Despite widespread recognition and implementation of TREM, its effectiveness has not been clearly established. The present scoping review is the first systematic effort to describe the extant literature on TREM and aims to provide an understanding of TREM’s effectiveness by organizing and synthesizing the available empirical data. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, a systematic search was conducted using PubMed, PsycINFO, SW Abstracts, Scopus, Embase, and Web of Science. Quantitative dissertation findings not published elsewhere and peer-reviewed journal articles published in English that reported outcomes from TREM intervention research with adult women were included. Twelve of the initial 385 publications identified met the inclusion criteria and reported data from nine studies. TREM demonstrated statistically significant effects on posttraumatic stress disorder, anxiety, psychological/psychosomatic distress, and substance use. A more limited set of findings suggests that TREM may also be associated with additional gains, including self-esteem, relationship power, social support, attachment, and spiritual well-being. Future research should replicate findings, use random assignment to groups, involve larger sample sizes and more representative samples, examine optimal duration, and identify components that facilitate change.

Keywords

TREM integrated treatment trauma group therapy mental health substance use

The link between interpersonal trauma and negative biopsychosocial outcomes has been well-documented (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). Trauma may impact physical health, education, employment, criminal justice system involvement, emotion regulation, self-esteem, self-injury, relationships, and revictimization (Craig et al., 2019; Felitti, 1998; Lotzin et al., 2018; McHugo, Kammerer, et al., 2005). Additionally, mental health and substance use conditions frequently co-occur among women with trauma histories (Fallot et al., 2011; Giordano et al., 2016; McKee & Hilton, 2019; Zinzow et al., 2011). Integrated trauma treatments that address women’s co-occurring concerns have been found to be more effective than treatments that focus separately on trauma, substance use, or mental health (Kelly & Daley, 2013). SAMHSA promotes several integrated trauma interventions for women, including the Trauma Recovery and Empowerment Model (TREM). TREM is frequently recommended as a treatment option for interpersonal trauma and is widely implemented across a variety of settings (Dodd & Littleton, 2017; Fallot et al., 2011; Giordano et al., 2016; Kaczkurkin et al., 2016; Kirst et al., 2017). TREM has been described as a “promising” intervention since the early 2000s (Lundgren & Krull, 2018) and currently retains this status (California Evidence-Based Clearinghouse [CEBC], 2016). The present article reports on a scoping review of TREM, which aimed to systematically identify TREM research trials and their outcomes.

TREM

TREM is a manualized group therapy approach developed for women to concurrently address interpersonal trauma, mental health, and substance use disorders (Harris & Anglin, 1998). The curriculum was developed by over 20 clinicians from Community Connections, a provider of behavioral health services in Washington, DC, with feedback from participating women (Fallot & Harris, 2002). TREM is rooted in feminist and relational theories with four core assumptions about trauma sequelae and recovery: Current behavioral concerns may reflect survival coping responses, development of adult coping skills may be hindered, disconnection can occur from self and others, and powerlessness can impede self-advocacy (Fallot & Harris, 2002). TREM facilitates recovery through psychoeducation, cognitive restructuring, skill building, and peer support (Harris & Anglin, 1998). Treatment is organized into three phases to focus on empowerment, trauma recovery, and advanced trauma recovery. TREM maintains a present-oriented emphasis and limits trauma exposure by deemphasizing detailed retelling of trauma narratives. Participants share their trauma experiences as they relate to current struggles and the designated topic of the week, such as self-esteem, self-soothing, emotional boundaries, and decision making. Each week has specific goals, guiding questions, and relevant exercises to further awareness and skill building. TREM is typically 24–33 weeks long with 75-minute sessions, two to three female cofacilitators, and 8–10 members. Modifications to TREM have included shortened length of treatment, the inclusion of attachment strategies, and development of a spiritual variation (Bowland et al., 2012; Masin-Moyer et al., 2020; Toussaint et al., 2007).

Rationale and Objectives

Despite widespread recognition and implementation of TREM, its effectiveness has not been clearly established (Lundgren & Krull, 2018). Early examination of TREM was conducted in the United States by the Women, Co-occurring Disorders and Violence Study (WCDVS), a multisite, longitudinal study of integrated services for women with histories of trauma, substance use, and mental health concerns (Noether et al., 2005). Positive outcomes were associated with integrated care across WCDVS sites (Cusack et al., 2008). However, the data for TREM were typically aggregated with other integrated trauma interventions (e.g., Cocozza et al., 2005; Morrissey et al., 2005), hindering identification of the specific contributions of TREM in a majority of studies (Clark & Power, 2005). More recent TREM-specific investigations demonstrate favorable, though somewhat inconsistent, outcomes (Cihlar, 2014; Fallot et al., 2011; Masin-Moyer et al., 2020). To date, no meta-analyses or systematic reviews have been conducted for TREM (Lundgren & Krull, 2018). Given the level of recognition and widespread implementation of TREM, it is critical to clarify its impact by systematically gathering, organizing, and synthesizing the intervention outcomes. Toward this end, this scoping review sought to systematically examine TREM’s effectiveness in reducing psychological distress and substance use and enhancing indicators of well-being for women who have experienced interpersonal trauma.

Method

Protocol and Eligibility Criteria

The present study used a protocol developed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (Tricco et al., 2018). The checklist included in this protocol, which contains 20 essential reporting items and two optional items, was established by a 24-member expert panel following guidance from the Enhancing the Quality and Transparency Of Health Research Network. Unlike a systematic review that conducts quality assessment, a scoping review seeks to identify the extent of existing literature about a given nascent topic.

The following inclusion criteria were used to determine eligibility: (1) quantitative studies reporting outcomes from TREM intervention research, (2) studies with only adult women, and (3) dissertation findings not published elsewhere/peer-reviewed journal articles published in English. Articles were excluded if they aggregated TREM group data with other group therapy modules in reported outcomes. Unpublished manuscripts were also excluded.

Information Sources and Search

The search strategy was determined by a research team member (MMM) who also conducted the literature search. This strategy was peer-reviewed independently by two librarians at the University of Pennsylvania. Selected key words included (1) trauma recovery and empowerment model; (2) WCDVS; (3) women, co-occurring disorders, and violence study; (4) TREM AND mental health; (5) TREM AND substance use; (6) TREM AND group therapy; (7) co-occurring disorders AND trauma intervention; and (8) group psychotherapy AND interpersonal trauma. The following six electronic databases were searched: PubMed, PsycINFO, SW Abstracts, Scopus, Embase, and Web of Science. The search strategy was not limited by year given the nascent scope of the topic. The final search results were exported into Excel and the duplicates were removed by a research team member (JCK).

Selection of Sources of Evidence and Data Charting Process

Selected publications were included in an Excel spreadsheet with the following columns: title, authors, journal, year of publication, duplicate, include, exclusion reason, level of review, empirical, gender, adult, study location, database, search term, and doi. Two independent reviewers (JK and MMM) then screened the titles, abstracts, and full texts until each study was included or excluded from this review. Initially, a total of 385 publications were identified. After 264 duplicates were removed, 121 articles were screened, resulting in 26 full-text publications assessed for eligibility. After data extraction in the first round of screening, two additional reviewers (ME and PS) screened the included subsample of publications that did not reach consensus during the first round. This follow-up review was executed independently in order to ensure interrater reliability. The research team resolved disagreements on study selection by consensus and discussion with other members, particularly as it related to the utility of aggregated data outcomes. Fourteen publications were excluded in the second round of screening due to aggregated group modules, unpublished findings, or emphasis on implementation rather than outcomes. A total of 12 publications ultimately met all inclusion criteria for this review. These 12 publications report findings from nine different studies (Online Appendix A).

Data Items and Synthesis of Results

Data were abstracted on study design and procedures (e.g., data set, methods), setting, sample size, participant demographics (e.g., race/ethnicity, age), measures (e.g., posttraumatic stress, substance use), key findings (e.g., clinical characteristics, intervention effects), and limitations (e.g., geographic location, design). Outcomes were assessed across mental health symptoms associated with depression, anxiety, posttraumatic stress disorder, and substance use by clinician-rated and self-reported items. Related well-being outcomes included factors such as somatic symptoms (e.g., nausea, dizziness, chest pains), spiritual well-being, attachment patterns, and self-esteem. Findings associated with participant attendance and posttreatment benefits were also noted.

Results

Table 1 lists the 12 included publications with detailed descriptions of the study design and procedures, setting, sample size, participant characteristics, measures, key findings, and limitations. Psychological distress, substance use, and other indicators of well-being were operationalized by questionnaires and are identified for each study in the “Outcome Measures” column of the table. If a study reported findings in more than one publication, this information was collated in the same cell in Table 1. The narrative below provides an overview of the findings.

Table 1.
TREM Studies of Effectiveness.

Reference Design and Methods Setting N Sociodemographics Outcome Measures Key Findings Limitations and Strengths

Amaro, Dai, et al. (2007) and Amaro, Larson, et al. (2007) Subsample of WCDVS.
Quasi-experimental.
Intervention group: 25-session modified TREM.
Comparison group: Treatment as usual.
Examined effectiveness of an integrated trauma group therapy.
Data collection at baseline, 6 and 12 months.
Examined effectiveness of trauma-enhanced substance use treatment combined with HIV/AIDS prevention on reducing sexual risk behaviors.
Intervention group: 25-session modified version of TREM with HIV/AIDS prevention sessions included.
Comparison group: Treatment as usual. Residential outpatient or methadone program.
Baseline: N = 342 (TREM = 181; Comparison = 161).
6 Months = 139.
12 Months = 138.
6 Months:
N = 232 (TREM = 122; Comparison = 110).
12 Months:
N = 191 (TREM = 81; comparison = 110). Age: TREM $\bar{x}$ = 35.9, SD = 7.5; treatment as usual $\bar{x}$ = 39.0, SD = 8.3.
Race/ethnicity: TREM = Black/African American: 37.6%; White: 26.5%; Latina/Hispanic: 31.5%; Other: 4.4%.
Race/ethnicity: Treatment as usual = Black/African American: 13.7%; White: 43.5%; Latina/Hispanic: 37.9%; Other: 5.0%.
Education < high school: TREM = 56.9%; treatment as usual = 51.5%.
Unemployed: TREM = 93.9%; treatment as usual = 90.1%. Addiction Severity Index (ASI; McLellan et al., 1980)
Global Severity Index (GSI) from the Brief Symptom Inventory (BSI; Derogatis & Spencer, 1993)
Posttraumatic Stress Scale (PSS; Foa et al., 1993)
Attendance
Relationship Power Scale (Pulerwitz et al., 2000)
Lifetime Symptom Checklist–Revised (LSC-R; Wolfe et al., 1997); revised by WCDVS (McHugo, Caspi et al., 2005).
Frequency of Child Abuse and Current Exposure to Interpersonal Abuse (CEIA; McHugo, Caspi et al., 2005) Alcohol and drug addiction severity significantly decreased in both TREM and comparison but no significant change between groups.
Higher drug abstinence rates found in TREM past 30 days at both 6- and 12-month follow-up.
Mental health symptomatology severity significantly improved for TREM at 12-month follow-up.
PTSD symptoms significantly improved for TREM group at 12-month follow-up.
Attendance averaged 10 TREM sessions; Completion rate (>12 of 25 sessions) = 44%.
Integrated trauma and substance use services may lead to reduced drug use and increased relationship power.
Treatment as usual group was three times as likely at 6-month follow-up and five times more likely at 12-month follow-up to engage in unprotected sex than TREM group.
Relationship power was significantly associated with unprotected sex.
Attendance averaged 9.7 TREM sessions.
Small sample size to detect differences by racial/ethnic group.
Lack of randomization and baseline differences in conditions.
No biological measure of drug use may result in underidentification.
Lacked end of treatment measure.
Most but not all participants completed TREM within first 6 months.
First study to examine changes in sexual HIV risk-related behaviors through integration of trauma-related services into treatment for substance use disorders.
Independent associations among HIV sessions, other TREM sessions, and other skill-building groups with study outcomes are unclear.
Confounding of baseline differences with TREM group status.
Unobserved differences could account for association of TREM group status and unprotected sex outcome.

Bowland et al. (2012, 2013) Randomized controlled trial.
Evaluated effectiveness of 11-session spiritually focused adaptation of TREM with older women in reducing trauma-related depressive, posttraumatic stress, somatic symptoms, and anxiety.
TREM modified to include feminist theological perspectives.
Examined whether spiritually adapted TREM would increase spiritual well-being and whether religious/spiritual coping was a mediator of the relationship between the intervention and the outcomes of depression, posttraumatic stress, anxiety, somatic symptoms, and spiritual well-being. Washington University in St. Louis, MO. Baseline: N = 43 (TREM = 21; Control = 22).
11-Week posttest: N = 36. Age: $\bar{x}$ = 61.3 years with a range of 55–83.
Race/ethnicity: White: 84%; African American/Black: 14%.
Income <US$50–US$65,000.
Associate’s or bachelor’s degree: 27.
Partnered: 23.
Catholic: 30%; Protestant: 37%; nondenominational Christian: 14%; Other: 19%.
Approximately 70% experienced sexual or physical abuse or neglect by parent; 42 of the 43 women reported being exposed to multiple types of violence and abuse. Geriatric Depression Scale (Yesavage et al., 1982)
Posttraumatic Stress Diagnostic Scale (Foà, 1995)
Beck Anxiety Inventory (Beck et al., 1988)
Patient Health Questionnaire (Kroenke et al., 2002)
A spiritual distress measure combined questions from Spiritual Assessment Inventory (Hall & Edwards, 1996).
A measure of religious coping (RCOPE; Pargament et al., 2000)
An Unnamed Forgiveness Scale (Idler, 1999)
Spiritual Well-Being Scale (Ellison, 1983)
Brief RCOPE (Pargament et al., 1998) Spiritual TREM (treatment group) had lower depressive symptoms, anxiety, and physical symptoms at posttest compared with control group.
Treatment exhibited largest effect on depressive symptoms.
Effect sizes were medium to large.
posttraumatic stress symptoms dropped in treatment group.
Gains maintained at 3-month follow-up.
Spiritual well-being increased in treatment group but not in control group.
Intervention had effect on religious/spiritual coping scores primarily through reducing negative coping.
Positive coping subscale changes were not significant.
Religious/spiritual coping mediated depressive and anxiety symptoms, but somatic symptoms and spiritual well-being scores were not significantly affected. Social desirability bias possible as investigator delivered intervention.
Small sample.
No interrater reliability for fidelity to intervention.
No measure of social support to examine whether it is mechanism of change.

Cihlar (2014) Quasi-experimental.
Intervention group: 25-week version of TREM.
Comparison group: Treatment as usual.
Examined whether TREM was associated with reduced PTSD symptoms, general mental health symptoms, substance use, increased social role functioning and increased relation to self and others as well as increased trauma-related coping skills.
Measurements taken at baseline, posttreatment, and 3-month follow-up.
Qualitative analysis to explore whether participants support use of TREM. Community setting; Green Door Agency in Northwest Washington, DC. Baseline: N = 20
(TREM = 15; treatment as usual = 5).
Posttreatment: N = 11 (TREM = 6; treatment as usual = 5).
3-month follow-up
N = 9 (TREM = 5; treatment as usual = 4).
Analyses based on N = 11. Formerly incarcerated women.
$Age : =$ 48.5, SD = 6.04.
Race/ethnicity: 91% African American/Black.
Employed: 9%.
Never married: 50%; Divorced: 36%.
Mental health diagnosis: 73%.
Education: approximately 11 years. ASI.
Brief Symptom Inventory-18 (BSI-18; Derogatis & Derogatis, 2001)
Behavior and Symptom Identification Scale (BASIS-32, Eisen et al., 1999)
Trauma Recovery and Empowerment Profile (TREP; Harris & Fallot, 2001). Modified Posttraumatic Symptom Scale (MPSS; Falsetti et al., 1993)
Attendance
Qualitative data revealed participant support for TREM.
Results somewhat support effectiveness of TREM.
60% completion rate.
Attendance averaged 16.25 of the 25 TREM sessions.
Despite no significance, medium to large effect sizes found in all but two outcome measures (BSI-18 and TREP’s trauma coping at posttreatment but medium/large at follow-up).
Statistically significant correlations were found between number of TREM sessions attended and outcome measures at 3-month follow-up. Very small convenience sample.
Participants were voluntary.
Participants received other services besides TREM.
Limited attendance with only 6 of the 10 participants completing 60% or more of intervention.
Potential gains that were not measured included knowledge gained through psychoeducation.
Self-report data (lack of understanding, bias, or social desirability).
For qualitative findings—group interviews (not individual).

Fallot et al. (2011) Quasi-experimental.
Intervention group: 33-week TREM, 75-minute sessions.
14 TREM groups were conducted with 6–12 participants per group.
Comparison group: Treatment as usual.
Examined the effectiveness of TREM beyond usual services.
In-person interview at baseline, 6 and 12 months. Urban community mental health agencies. Baseline: N = 251 (TREM = 153; treatment as usual = 98).
6-month and/or 12-month follow-up
N = 207 (TREM = 131; treatment as usual = 76). Age: TREM $\bar{x}$ = 42, SD = 8.6; treatment as usual $\bar{x}$ = 42, SD = 8.5.
Race/ethnicity for TREM: African American/Black: 86.9%; White: 9.8%; and Other: 3.3%.
Race/ethnicity for treatment as usual: African American/Black: 74.5%; White: 22.4%; Other: 3.1%.
Education: TREM = 11.3 years; treatment as usual: 11.4 years.
Relationship status TREM: Married/partnered: 20.3%; Widowed/separated/divorced: 42.5%; Never married: 37.3%.
Relationship status treatment as usual: Married/partnered: 33.7%; Widowed/separated/divorced: 37.8%; Never married: 28.6%.
Employment TREM: Currently employed = 17.1%.
Employment treatment as usual: Currently employed = 18.4%. ASI
GSI/BSI
PSS
LSC-R
TREP
SF-12 Health Survey (Salyers et al., 2000)
Substance Use Scale—combination of Alcohol Use Scale and Drug Use Scale (SUS; Drake et al., 1990)
Attendance
Attendance averaged 21.4 TREM sessions.
Significant improvement for alcohol and drug problem severity in TREM.
Both groups improved on most variables (not SF-12 scales or current trauma exposure variables).
TREM had significantly better outcomes for anxiety, personal safety, and current stressors.
Significant improvement over time within TREM for clinician ratings on the TREP (trauma recovery skills) and the SUS.
TREM group attendance was correlated with greater changes in TREP scores. Nonrandomized design.
Nonequivalence of TREM and treatment as usual at baseline; impact of this variation is unknown.
Propensity scores to control for differences.
Self-report data may have biased findings; bias minimized by focusing on differences over time.
Self-report and clinician-report data.

Karatzias et al. (2016) Pretest–posttest design.
Pilot data on effectiveness and acceptability of group manualized therapy for women who are survivors of interpersonal trauma.
Abbreviated 18-session version of standard 29-session TREM; 90-minute sessions offered weekly or biweekly. Outpatient clinics in five National Health Service (NHS) Boards in Scotland. Pretest (started treatment): N = 71.
Posttest (completed treatment): N = 42. Age: $\bar{x}$ = 40.4, SD = 10.6.
Attended higher education: 56.3%.
Unemployed or retired: 70.4%.
Divorced or single: 71.8%.
Race/ethnicity not reported. Clinical Outcomes in Routine Evaluation (CORE; Evans et al., 2000)
PTSD Checklist (PCL-C; Blanchard et al., 1996).
Symptom Checklist (SCL-90-R; Derogatis, 1979)
Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986).
Rosenberg Self-Esteem Scale (RSES; Rosenberg, 2015).
Attendance. Significant improvements over time for CORE well-being and total, SCL-90 somatization, anxiety, phobic anxiety, GSI, PCL-C avoidance, hyperarousal, and total DES and RSES.
Treatment effect sizes were small to medium.
Posttreatment: 9.9%–54.9% achieved clinical significance across measures compared to 9.9%–62% at follow-up.
DES: 54.9% of participants achieved clinical significance. RSES: 40.8% achieved clinical significance.
At follow-up, a higher percentage of participants achieved clinical significance for CORE total (25.4%), SCL-90 GSI (29.6%), RES (44%), and DES (60.6%) compared to ratings at posttreatment.
TREM may be useful for general distress and anxiety, including traumatic symptomatology, dissociation, and self-esteem symptoms.
Attendance averaged 10.5 TREM sessions; 41% noncompletion. High attrition (40%).
Small sample size.
Self-report measures.
No control group.
Limits generalizability to people with severe mental illness.
Longitudinal design would yield more robust causal inferences.

Masin-Moyer et al. (2020) Dissertation/published article.
Quasi-experimental.
Experimental group: ATREM (attachment-informed variation of TREM). Comparison group: TREM.
16-week duration with intervention group using more explicit attention to relationship, informed by attachment theory, among adult women with substance use disorder and/or mental health diagnosis as well as a history of trauma. Rural/suburban setting.
Three agencies: outpatient mental health treatment, residential substance use treatment, outpatient victim services. Preintervention: N = 129.
Postintervention (>10 sessions): N = 69 (ATREM = 37; TREM = 32).
Age: $\bar{x}$ = 42.4%, SD = 12.2.
Race/ethnicity: White: 92.8%; Other race/ethnicities: 7.2%.
Education < High school: 55.1%; > High school: 44.9%.
Presently working: 21.7%; not presently working: 78.3%.
Married/significant other: 36.2%; not in a relationship: 63.8%. ASI
BSI-18
PSS
LSC-R
Difficulties in Emotional Regulation Scale (DERS; Gratz & Roemer, 2004).
Relationship Scale Questionnaire (Griffin & Bartholomew, 1994)
Social Group Attachment Scale (Smith et al., 1999)
Social Provisions Scale (Cutrona & Russell, 1987).
Attendance TREM associated with significant pretest–posttest improvement on all clinical measures except substance use and attachment avoidance.
ATREM was associated with significant pre-test–posttest improvement on all measures except for substance use.
No significant differences between ATREM and TREM on clinical measures.
Attendance requirement of 60% (>9 of 16) of TREM sessions was met by all participants.
Unmeasured baseline differences.
Small sample size.
Relational nature of both ATREM and TREM makes detecting differential treatment effects challenging.
Fidelity checklist monitored delivery of content but not experiential processing.
Primary researcher facilitated ATREM groups which could contribute to social desirability bias in responses.

Paquin (2010) and Paquin et al. (2013) Dissertation.
Archival data.
Pretest–posttest time-series design; 22 sessions, twice weekly for 11 weeks.
Examined group fit and effectiveness of TREM for PTSD symptom reduction. Midwestern women’s state correctional facility. Pretest: N = 73 (6 groups).
Posttest: N = 51. Age: $\bar{x}$ = 38.26, SD = 8.17.
Race/ethnicity: African American/Black: 34.2%; White: 61.6%; Latina/Hispanic: .04%. PSS
Attendance
TREM effectiveness: PTSD symptoms decreased significantly between pre- and posttest.
Attendance averaged 18.68 TREM sessions.
Fit with group for avoidance decreased (diverged) and the conflict increased (converged) across sessions.
Increasing fit with the group on perceptions of group conflict was associated with attending more group sessions (commitment). Increasing fit with the group on perceptions of group avoidance was associated with PTSD symptom change (goal accomplishment).
Time-series design analyzed data points after each of 22 sessions for six groups over course of treatment (11 weeks).
Reliance on archival data; limited to existing parameters established of measuring PTSD during first and last sessions of treatment.
30% of final sample did not complete both pre- and posttest PTSD outcome measures.
Self-report of symptoms and social desirability.
Pretreatment variables such as personality characteristics, race/ethnicity, age, extra-group relationships, or perceptions of the group leader could possibly account for more of the variance than P-G fit on perceptions of group climate in terms of attendance and PTSD symptom change.
Findings could be limited to the experiences of incarcerated women.

Swope (2009) Dissertation.
The DC Trauma Collaboration Study.
Quasi-experimental.
Intervention group: 33-week version of TREM.
Comparison group: Services as usual.
Examined how participants’ pretreatment clinical severity related to engagement and outcomes.
In-person assessments conducted at baseline, 3, 6, 9, and 12 months.
Mental health agencies in two urban areas. Baseline: N = 246 (TREM = 150; Services as usual = 96).
12 months
N = 170 (TREM = 108; Services as usual = 62).
Age: $\bar{x}$ = 42.
Race/ethnicity for TREM: African American/Black: 87.6%; White: 9.8%; Latina/Hispanic, American Indian, Asian, or Other: 2.6%.
Race/ethnicity for services as usual: African American/Black: 74.5%; White: 22.4%; Latina/Hispanic, American Indian, Asian, or Other: 3.1%.
Relationship status of the sample: Married or significant other = 25.5%; Divorced or separated = 33.8%; Never married = 33.9%; Widowed = 6.8%.
ASI
GSI/BSI
PSS
LSC-R
Attendance
WCDVS Trauma Coping Measure
WCDVS Perceptions of Integration
Clinician-Rated Participation and Engagement
TREP
Greater pretreatment clinical severity on measures of trauma symptoms, general psychiatric functioning, and drug and alcohol use were associated with greater posttreatment reduction in general mental health and trauma symptoms and greater gains on the TREP.
More frequent attendance was associated with a greater reduction in drug use and PTSD symptoms from baseline to 12 months, and greater gains in coping and life skills.
Higher clinician-rated participation was associated with improvements with drug use severity, coping, and life skills.
Perceived integrated counseling rating at 3-month and 6-month assessments was significant predictor of posttreatment symptom reduction on PSS, GSI, and ASI-D, but only among TREM. Post hoc analyses.
Limited generalizability (only outpatient women).

Toussaint et al. (2007) Subsample of WCDVS.
Quasi-experimental.
Intervention group: TREM adapted to 24 sessions.
Comparison group: Treatment as usual.
Examined effectiveness of trauma-specific treatment for women with co-occurring trauma and substance use disorders.
Data collection at baseline, 6 and 12 months. Residential substance use treatment program for women with co-occurring mental health and substance use disorders and their dependent children. Baseline: N = 170 (TREM = 64; treatment as usual = 106).
12 months
N = 152 (TREM = 61; treatment as usual = 91). Age: TREM $\bar{x}$ = 29; treatment as usual = 32.7.
Race/ethnicity TREM: Black/African American: 20.3%; White: 48.4%; Latina/Hispanic: 17.2%; American Indian: 9.4%.
Race/ethnicity treatment as usual: Black/African American: 17%; White: 55.7%; Latina/Hispanic: 14.2%; American Indian: 7.5%.
Education: TREM = 11.1 years; treatment as usual = 11.7 years.
Relationship status TREM: Married/living with partner: 42.2%; Divorced/separated: 21.9%; Never married: 35.9%.
Relationship status treatment as usual: Married/living with partner: 46.3%; Divorced/separated: 34.9%; and Never married: 18.9%. ASI
GSI/BSI
PSS
LSC-R: CEIA; Current Exposure to Other Stressors Scale
Fidelity checklist (Fallot & Harris, 2001)
Attendance
WCDVS Safety Scale (Giard et al., 2005)
WCDVS Feelings-Dissociation Scale (Giard et al., 2005)
WCDVS Feelings-Trauma Coping Index (Giard et al., 2005)
Social Role Functioning Index modified from BASIS-32
Attendance averaged 14.9 TREM sessions.
At 6 months: TREM had strongest effect symptoms of dissociation and sense of safety.
At 12 months: stronger support for effectiveness of TREM—improved dissociative symptoms, trauma coping, sense of safety, and mental health symptoms.
Dosage analysis—significant effect greater number of TREM sessions on PTSD and mental health symptoms, but not significant for alcohol or drug use. Lack of random assignment and nonequivalent group design on several sociodemographic variables at baseline.
Child welfare and perceptions of custody potential may have biased group assignment.
Self-selection by women into treatment programs may have biased sample.
ANCOVA used to control for known group differences.

Note. ANCOVA = analysis of covariance; PTSD = posttraumatic stress disorder; TREM = Trauma Recovery and Empowerment Model; SF-12 = Short-Form Health Survey-12 Questions; WCDVS = Women, Co-occurring Disorders and Violence Study.

Research Design, Setting, Sample Size, Attrition, and Attendance

Nine of the 12 articles used a quasi-experimental research design; one used a preexperimental pretest–posttest design, and two used random assignment to TREM or a waitlist control group. For the quasi-experimental designs, six studies made comparisons to a treatment-as-usual group (e.g., case management, psychiatric services), two used a one-group time-series design, and one compared TREM to an adaptation of TREM. Two studies collected follow-up data three months posttreatment, while five studies collected data before (baseline), during (six months post-baseline), and after (12 months post-baseline) treatment. TREM was conducted in outpatient and residential settings, correctional facilities, a methadone clinic, and a university. Most studies were in urban areas. The number of participants varied greatly across the 12 studies, with baseline sample sizes ranging from 20 to 342 participants, and outcome sample sizes ranging from 7 to 211 participants. Attrition, measured from baseline to either posttest or 6 and/or 12 months post-baseline, ranged from 10.5% to 65%. Of the nine unique data sets, five studies assessed for differences between participants who completed and those who ended treatment/the study prior to completion for sociodemographic characteristics (Masin-Moyer et al., 2020), outcome data at baseline (Karatzias et al., 2016; Paquin et al., 2013), or both (Fallot et al., 2011; Toussaint et al., 2007). Only one study found group differences based on attrition such that participants who ended treatment/the study early reported less alcohol use in the 30 days prior to baseline and lower alcohol severity at baseline than participants who completed treatment/the study (Fallot et al., 2011). Four studies reported no comparisons between participants who did or did not complete the study/treatment (Amaro, Dai, et al., 2007; Bowland et al., 2012; Cihlar, 2014; Swope, 2009). Average attendance ranged from 40% to 85% of TREM sessions.

Sociodemographic Characteristics

The average age of TREM participants in each study ranged from 30 to 61, with 10 of the 12 studies reporting average ages ranging from late 30s to 40s. The remaining two studies focused on older women with an average age of 61. Not all 12 articles reported on race/ethnicity, employment, educational attainment, and relationship status. The following reflects the racial/ethnic diversity of participants in the studies: six had a majority of White participants, three had a majority of African American participants, and two had equivalent majorities of White and Latina participants. In most studies, the majority of the women were not employed, were not in a relationship, and had a high school diploma as their highest level of educational attainment.

Mental Health Outcomes

Of the five studies assessing the impact of TREM on depression, statistically significant decreases in depression symptoms were reported in two studies (Bowland et al., 2012; Masin-Moyer et al., 2020) and statistically nonsignificant changes were reported in three studies (Cihlar, 2014; Fallot et al., 2011; Karatzias et al., 2016). Five studies also assessed the impact of TREM on anxiety and found statistically significant decreases in anxiety symptoms in four studies (Bowland et al., 2012; Fallot et al., 2011; Karatzias et al., 2016; Masin-Moyer et al., 2020) and statistically nonsignificant changes in one study (Cihlar, 2014). Rather than measuring mental health based on diagnostic categories, five studies measured general symptom severity or psychological/psychosomatic distress. Of these studies, one demonstrated statistically significant improvement at posttest (Karatzias et al., 2016), two showed no statistically significant changes (Cihlar, 2014; Fallot et al., 2011), and two others reported statistical significance only at 12-month post-baseline (Amaro, Dai, et al., 2007; Toussaint et al., 2007). PTSD symptoms decreased in six of the eight TREM studies either at posttest (Bowland et al., 2012; Karatzias et al., 2016; Masin-Moyer et al., 2020; Paquin, 2010; Paquin et al., 2013) or at 12-month post-baseline (Amaro, Dai, et al., 2007), and no statistically significant decreases were reported in two studies (Cihlar, 2014; Fallot et al., 2011).

Substance Use Outcomes

Substance use was assessed in six studies in a variety of ways. Statistically significant improvement was found for alcohol and drug addiction severity (Amaro, Dai, et al., 2007; Fallot et al., 2011), clinician-rated and self-reported substance use (Amaro, Larson, et al., 2007; Fallot et al., 2011), and drug abstinence at 6- and 12-month post-baseline (Amaro, Dai, et al., 2007). Three studies found no statistically significant changes in substance use for the various means of operationalization (Cihlar, 2014; Masin-Moyer et al., 2020; Toussaint et al., 2007).

Somatic and Well-Being Outcomes

Two of the four studies reported statistically significant decreases in somatic symptoms (Bowland et al., 2012; Karatzias et al., 2016) and the other two studies did not (Cihlar, 2014; Toussaint et al., 2007). While somatic symptoms, mental health, and substance use were assessed by several studies, many other indices of well-being received less attention. Statistically significant improvements were found for the following aspects of well-being, each measured by only one or two TREM studies: emotion regulation (Masin-Moyer et al., 2020), spiritual well-being (Bowland et al., 2013), individual and group attachment patterns (Masin-Moyer et al., 2020), perceived social support (Masin-Moyer et al., 2020), self-esteem (Karatzias et al., 2016), personal safety (Fallot et al., 2011; Toussaint et al., 2007), relationship power and sexual precautions (Amaro, Dai, et al., 2007), current stressors (Fallot et al., 2011), and trauma coping (Toussaint et al., 2007). TREM was also associated with statistically significant decreases in dissociation at posttest (Karatzias et al., 2016) or at 6- or 12-month post-baseline (Toussaint et al., 2007). In addition to self-report, statistically significant gains in trauma recovery skills, measured by clinician assessment ratings of 11 skill areas considered essential aspects of trauma healing, were found in one study (Fallot et al., 2011), but not in another (Cihlar, 2014). Several of the trauma recovery skill categories, including emotion modulation, self-soothing, self-protection, relational mutuality, and accurate labeling of self and other, coincide with the other measures of well-being discussed above.

Factors Related to Outcomes

There were statistically significant positive correlations between the number of TREM sessions attended and improvement in trauma recovery skills (Fallot et al., 2011; Swope, 2009) and various measures of symptom reduction, including posttraumatic stress (Cihlar, 2014; Swope, 2009; Toussaint et al., 2007), mental health (Toussaint et al., 2007), and drug severity (Swope, 2009). Similarly, clinician-rated participation also demonstrated statistically significant correlations with trauma recovery skill gains and drug severity symptom reduction (Swope, 2009). For TREM participants, the perception that treatment integrated mental health, substance use, and trauma was a significant predictor of posttraumatic stress, mental health, and drug severity symptom reduction (Swope, 2009). However, no significant relationships were found between alcohol use severity and attendance, participation, or perceptions of treatment integration (Cihlar, 2014; Swope, 2009; Toussaint et al., 2007). Additionally, higher pretreatment clinical severity was associated with greater posttreatment gains for trauma recovery skills, general mental health, and trauma symptoms, but not substance use (Swope, 2009). Finally, 11 - 18-weeklong shortened versions (Bowland et al., 2012; Karatzias et al., 2016; Masin-Moyer et al., 2020) and spiritually and attachment-based adaptations (Bowland et al., 2012; Masin-Moyer et al., 2019) of TREM have demonstrated effectiveness across multiple outcomes.

Because of variability from small to large effect sizes reported across studies, statistically significant findings should be interpreted with caution. However, the medium effect size reported for improved outcomes in mental health symptoms, dissociation, personal safety, and trauma coping (Fallot et al., 2011; Toussaint et al., 2007) as well as medium to large effect sizes reported in reduced posttraumatic stress symptoms (Cihlar, 2014; Paquin et al., 2013) and sexual risk behaviors (Amaro, Dai, et al., 2007) suggest that TREM has potential to be more beneficial than treatment as usual.

Discussion

TREM is a widely implemented, nationally supported integrated trauma group therapy (SAMHSA, n.d.). Despite receiving an early rating of “promising,” TREM has not advanced to a level of “supported” or “well-supported” rating category (Lundgren & Krull, 2018). The present scoping review provides an understanding of TREM’s rating by organizing and synthesizing the available empirical data. To date, 12 articles have evaluated the effectiveness of TREM disaggregated from other trauma group therapies, and the outcomes are highly varied. More studies demonstrated statistically significant gains for PTSD, anxiety, and psychological/psychosomatic distress than for other measures of well-being. Reported effect sizes suggest that participation in TREM is associated with meaningful change for women who have survived trauma. The importance of repeated assessment was highlighted by three studies in which significant changes in psychological distress and PTSD did not manifest until 12 months post-baseline, approximately four months posttreatment.

While several indicators of well-being, such as self-esteem, attachment, spirituality, perceived social support, and emotion regulation were each assessed by only one or two studies, the demonstrated positive gains are important preliminary data on an expansive view of recovery from interpersonal trauma. Recognizing and addressing adverse outcomes beyond PTSD, mental health, and substance use is consistent with research on the multidimensional consequences of trauma (Felitti, 1998) and the feminist, relational, and empowerment underpinnings of TREM (Harris & Anglin, 1998). With its added emphasis on skill building, affect regulation, mutual connection, and meaning-making, TREM extends beyond a focus on symptom management and demonstrates capacity to effect change in multiple quality of life domains. The more recent focus of TREM research on interpersonal dynamics may suggest ways to improve manualized treatment and offer insight into relationship enhancement and treatment retention (Chouliara et al., 2020; Karatzias et al., 2016; Masin-Moyer et al., 2020). Given the historically high rates of noncompletion of trauma group therapy (Chouliara et al., 2020; Masin-Moyer et al., 2020) and challenges with attendance (e.g., Amaro, Dai, et al., 2007; Karatzias et al., 2016), it is a strength of TREM studies that associations between interpersonal dynamics and treatment retention are being explored. Based on qualitative interviews with TREM participants, Chouliara et al. (2020) propose more focus on group dynamics related to empathy, trust, and enhancement of relational resources because support with life events and relationship challenges seems to differentiate between treatment completion and noncompletion. Consistent with Chouliara et al.’s (2020) recommendation, an attachment-based variation of TREM provides psychoeducation on attachment patterns, experiential and cognitive attachment-based activities, and explicit attention to social support and relational processing of in the moment group dynamics (Masin-Moyer et al., 2020). Sensitivity to attachment patterns has been associated with successful group completion in group therapy (Marmarosh et al., 2013). Another adaptation of TREM conceptualized support in terms of spirituality by including discussions of spiritual struggles related to abuse and the development of spiritual coping resources (Bowland et al., 2012). It is noteworthy that in both adapted protocols, favorable outcomes were demonstrated within a shortened duration of treatment (see Table 2).

Table 2.
Key Findings.

Reviewed 12 articles involving adult women to evaluate the effectiveness of TREM disaggregated from other trauma group therapies; outcomes varied.

TREM demonstrated statistically significant improvement in PTSD, anxiety, psychological/psychosomatic distress, and somatic symptoms. Statistically significant improvement for substance use was also found, but with more variability.

Importance of follow-up assessment was highlighted by studies in which significant changes in psychological distress and PTSD needed 12 months to manifest.

More limited set of findings suggests that TREM may be associated with gains in several additional domains, including emotion regulation, dissociation, spiritual well-being, attachment, social support, self-esteem, personal safety, relationship power, sexual precautions, current stressors, and trauma coping and recovery.

Statistically significant positive correlations between TREM attendance and trauma recovery skill improvement and symptom reduction were found.

Shortened and adapted versions of TREM demonstrated effectiveness across multiple outcomes.

Evidence-supported rating of TREM as a “promising” intervention, rather than empirically “supported,” is consistent with limitations of studies.

Note. TREM = Trauma Recovery and Empowerment Model; PTSD = posttraumatic stress disorder.

Limitations and Future Directions

Despite these strengths, the evidence-supported rating as “promising,” rather than “supported,” is consistent with the limitations of the studies. Except for the research on spiritually focused TREM, studies used quasi-experimental and preexperimental designs, creating threats to internal validity like selection bias, history, and maturation. Social desirability may also have affected outcomes in the studies where there was a dual role of researcher and group facilitator (Bowland et al., 2012; Masin-Moyer et al., 2020; Paquin et al., 2013). Additionally, sample sizes were small and attrition was high in several studies, and participants were recruited through nonprobability sampling, limiting generalizability. Few studies included a majority of women of color, and no data on lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) representation were reported. Efforts to advance TREM’s rating to “supported” need to correct for these limitations with random assignment to groups, larger sample sizes and more diverse representation of participants, and additional replication of findings. Further, examining interpersonal connections and emotional areas of well-being, like trust and shame (Chouliara et al., 2014), would provide a broader understanding of TREM’s impact and possible insights into treatment retention. Some caution is warranted with conclusions drawn from the present scoping review given that it includes a limited number of articles with methodological variances, did not involve statistical analysis, and did not include gray literature.

Conclusion

The present scoping review is the first systematic effort to describe the extant literature on TREM. It builds on the CEBC “promising” rating based on studies published prior to 2012. Since that time, six additional publications have reported outcomes of TREM (Bowland et al., 2012, 2013; Cihlar, 2014; Karatzias et al., 2016; Masin-Moyer et al., 2020; Paquin et al., 2013). Findings indicate that TREM is associated with statistically significant improvements related to PTSD, anxiety, and psychological/psychosomatic distress across multiple studies involving adult women. Furthermore, results suggest that treatment effects for PTSD and psychological distress may occur several months after treatment. A more limited set of outcomes suggests that TREM may be associated with gains in several other domains, including self-esteem, relationship power, social support, attachment, and spiritual well-being. TREM’s effects on substance use have been variable across studies, which may reflect variation in substance use operationalization or participants’ presenting concerns. Research in this area would be further strengthened with larger sample sizes and more diverse representation of participants, random assignment, examination of optimal duration, and identification of key components that facilitate change. This systematic description supports TREM’s “promising” rating and provides direction for future research.

Implications for Practice, Policy, and Research

Policy
Prioritize funding for research and training for integrated care.

Increase access to empirically supported treatment.

Practice
Develop understanding of evidence base of TREM.

Think expansively about potential benefits of group trauma therapy.

Research
Strengthen with replication, random assignment to groups, larger studies, and more diverse representation among participants.

Examine optimal duration and key components that facilitate change.

Note. TREM = Trauma Recovery and Empowerment Model.

Supplemental Material

Supplemental Material, sj-pdf-1-tva-10.1177_1524838020967862 - A Scoping Review of the Trauma Recovery and Empowerment Model (TREM)

Supplemental Material, sj-pdf-1-tva-10.1177_1524838020967862 for A Scoping Review of the Trauma Recovery and Empowerment Model (TREM) by Melanie Masin-Moyer, Jessica Cho Kim, Malitta Engstrom and Phyllis Solomon in Trauma, Violence, & Abuse

Reference	Design and Methods	Setting	N	Sociodemographics	Outcome Measures	Key Findings	Limitations and Strengths
Amaro, Dai, et al. (2007) and Amaro, Larson, et al. (2007)	Subsample of WCDVS. Quasi-experimental. Intervention group: 25-session modified TREM. Comparison group: Treatment as usual. Examined effectiveness of an integrated trauma group therapy. Data collection at baseline, 6 and 12 months. Examined effectiveness of trauma-enhanced substance use treatment combined with HIV/AIDS prevention on reducing sexual risk behaviors. Intervention group: 25-session modified version of TREM with HIV/AIDS prevention sessions included. Comparison group: Treatment as usual.	Residential outpatient or methadone program.	Baseline: N = 342 (TREM = 181; Comparison = 161). 6 Months = 139. 12 Months = 138. 6 Months: N = 232 (TREM = 122; Comparison = 110). 12 Months: N = 191 (TREM = 81; comparison = 110).	Age: TREM $\bar{x}$ = 35.9, SD = 7.5; treatment as usual $\bar{x}$ = 39.0, SD = 8.3. Race/ethnicity: TREM = Black/African American: 37.6%; White: 26.5%; Latina/Hispanic: 31.5%; Other: 4.4%. Race/ethnicity: Treatment as usual = Black/African American: 13.7%; White: 43.5%; Latina/Hispanic: 37.9%; Other: 5.0%. Education < high school: TREM = 56.9%; treatment as usual = 51.5%. Unemployed: TREM = 93.9%; treatment as usual = 90.1%.	Addiction Severity Index (ASI; McLellan et al., 1980) Global Severity Index (GSI) from the Brief Symptom Inventory (BSI; Derogatis & Spencer, 1993) Posttraumatic Stress Scale (PSS; Foa et al., 1993) Attendance Relationship Power Scale (Pulerwitz et al., 2000) Lifetime Symptom Checklist–Revised (LSC-R; Wolfe et al., 1997); revised by WCDVS (McHugo, Caspi et al., 2005). Frequency of Child Abuse and Current Exposure to Interpersonal Abuse (CEIA; McHugo, Caspi et al., 2005)	Alcohol and drug addiction severity significantly decreased in both TREM and comparison but no significant change between groups. Higher drug abstinence rates found in TREM past 30 days at both 6- and 12-month follow-up. Mental health symptomatology severity significantly improved for TREM at 12-month follow-up. PTSD symptoms significantly improved for TREM group at 12-month follow-up. Attendance averaged 10 TREM sessions; Completion rate (>12 of 25 sessions) = 44%. Integrated trauma and substance use services may lead to reduced drug use and increased relationship power. Treatment as usual group was three times as likely at 6-month follow-up and five times more likely at 12-month follow-up to engage in unprotected sex than TREM group. Relationship power was significantly associated with unprotected sex. Attendance averaged 9.7 TREM sessions.	Small sample size to detect differences by racial/ethnic group. Lack of randomization and baseline differences in conditions. No biological measure of drug use may result in underidentification. Lacked end of treatment measure. Most but not all participants completed TREM within first 6 months. First study to examine changes in sexual HIV risk-related behaviors through integration of trauma-related services into treatment for substance use disorders. Independent associations among HIV sessions, other TREM sessions, and other skill-building groups with study outcomes are unclear. Confounding of baseline differences with TREM group status. Unobserved differences could account for association of TREM group status and unprotected sex outcome.
Bowland et al. (2012, 2013)	Randomized controlled trial. Evaluated effectiveness of 11-session spiritually focused adaptation of TREM with older women in reducing trauma-related depressive, posttraumatic stress, somatic symptoms, and anxiety. TREM modified to include feminist theological perspectives. Examined whether spiritually adapted TREM would increase spiritual well-being and whether religious/spiritual coping was a mediator of the relationship between the intervention and the outcomes of depression, posttraumatic stress, anxiety, somatic symptoms, and spiritual well-being.	Washington University in St. Louis, MO.	Baseline: N = 43 (TREM = 21; Control = 22). 11-Week posttest: N = 36.	Age: $\bar{x}$ = 61.3 years with a range of 55–83. Race/ethnicity: White: 84%; African American/Black: 14%. Income <US$50–US$65,000. Associate’s or bachelor’s degree: 27. Partnered: 23. Catholic: 30%; Protestant: 37%; nondenominational Christian: 14%; Other: 19%. Approximately 70% experienced sexual or physical abuse or neglect by parent; 42 of the 43 women reported being exposed to multiple types of violence and abuse.	Geriatric Depression Scale (Yesavage et al., 1982) Posttraumatic Stress Diagnostic Scale (Foà, 1995) Beck Anxiety Inventory (Beck et al., 1988) Patient Health Questionnaire (Kroenke et al., 2002) A spiritual distress measure combined questions from Spiritual Assessment Inventory (Hall & Edwards, 1996). A measure of religious coping (RCOPE; Pargament et al., 2000) An Unnamed Forgiveness Scale (Idler, 1999) Spiritual Well-Being Scale (Ellison, 1983) Brief RCOPE (Pargament et al., 1998)	Spiritual TREM (treatment group) had lower depressive symptoms, anxiety, and physical symptoms at posttest compared with control group. Treatment exhibited largest effect on depressive symptoms. Effect sizes were medium to large. posttraumatic stress symptoms dropped in treatment group. Gains maintained at 3-month follow-up. Spiritual well-being increased in treatment group but not in control group. Intervention had effect on religious/spiritual coping scores primarily through reducing negative coping. Positive coping subscale changes were not significant. Religious/spiritual coping mediated depressive and anxiety symptoms, but somatic symptoms and spiritual well-being scores were not significantly affected.	Social desirability bias possible as investigator delivered intervention. Small sample. No interrater reliability for fidelity to intervention. No measure of social support to examine whether it is mechanism of change.
Cihlar (2014)	Quasi-experimental. Intervention group: 25-week version of TREM. Comparison group: Treatment as usual. Examined whether TREM was associated with reduced PTSD symptoms, general mental health symptoms, substance use, increased social role functioning and increased relation to self and others as well as increased trauma-related coping skills. Measurements taken at baseline, posttreatment, and 3-month follow-up. Qualitative analysis to explore whether participants support use of TREM.	Community setting; Green Door Agency in Northwest Washington, DC.	Baseline: N = 20 (TREM = 15; treatment as usual = 5). Posttreatment: N = 11 (TREM = 6; treatment as usual = 5). 3-month follow-up N = 9 (TREM = 5; treatment as usual = 4). Analyses based on N = 11.	Formerly incarcerated women. $Age : =$ 48.5, SD = 6.04. Race/ethnicity: 91% African American/Black. Employed: 9%. Never married: 50%; Divorced: 36%. Mental health diagnosis: 73%. Education: approximately 11 years.	ASI. Brief Symptom Inventory-18 (BSI-18; Derogatis & Derogatis, 2001) Behavior and Symptom Identification Scale (BASIS-32, Eisen et al., 1999) Trauma Recovery and Empowerment Profile (TREP; Harris & Fallot, 2001). Modified Posttraumatic Symptom Scale (MPSS; Falsetti et al., 1993) Attendance	Qualitative data revealed participant support for TREM. Results somewhat support effectiveness of TREM. 60% completion rate. Attendance averaged 16.25 of the 25 TREM sessions. Despite no significance, medium to large effect sizes found in all but two outcome measures (BSI-18 and TREP’s trauma coping at posttreatment but medium/large at follow-up). Statistically significant correlations were found between number of TREM sessions attended and outcome measures at 3-month follow-up.	Very small convenience sample. Participants were voluntary. Participants received other services besides TREM. Limited attendance with only 6 of the 10 participants completing 60% or more of intervention. Potential gains that were not measured included knowledge gained through psychoeducation. Self-report data (lack of understanding, bias, or social desirability). For qualitative findings—group interviews (not individual).
Fallot et al. (2011)	Quasi-experimental. Intervention group: 33-week TREM, 75-minute sessions. 14 TREM groups were conducted with 6–12 participants per group. Comparison group: Treatment as usual. Examined the effectiveness of TREM beyond usual services. In-person interview at baseline, 6 and 12 months.	Urban community mental health agencies.	Baseline: N = 251 (TREM = 153; treatment as usual = 98). 6-month and/or 12-month follow-up N = 207 (TREM = 131; treatment as usual = 76).	Age: TREM $\bar{x}$ = 42, SD = 8.6; treatment as usual $\bar{x}$ = 42, SD = 8.5. Race/ethnicity for TREM: African American/Black: 86.9%; White: 9.8%; and Other: 3.3%. Race/ethnicity for treatment as usual: African American/Black: 74.5%; White: 22.4%; Other: 3.1%. Education: TREM = 11.3 years; treatment as usual: 11.4 years. Relationship status TREM: Married/partnered: 20.3%; Widowed/separated/divorced: 42.5%; Never married: 37.3%. Relationship status treatment as usual: Married/partnered: 33.7%; Widowed/separated/divorced: 37.8%; Never married: 28.6%. Employment TREM: Currently employed = 17.1%. Employment treatment as usual: Currently employed = 18.4%.	ASI GSI/BSI PSS LSC-R TREP SF-12 Health Survey (Salyers et al., 2000) Substance Use Scale—combination of Alcohol Use Scale and Drug Use Scale (SUS; Drake et al., 1990) Attendance	Attendance averaged 21.4 TREM sessions. Significant improvement for alcohol and drug problem severity in TREM. Both groups improved on most variables (not SF-12 scales or current trauma exposure variables). TREM had significantly better outcomes for anxiety, personal safety, and current stressors. Significant improvement over time within TREM for clinician ratings on the TREP (trauma recovery skills) and the SUS. TREM group attendance was correlated with greater changes in TREP scores.	Nonrandomized design. Nonequivalence of TREM and treatment as usual at baseline; impact of this variation is unknown. Propensity scores to control for differences. Self-report data may have biased findings; bias minimized by focusing on differences over time. Self-report and clinician-report data.
Karatzias et al. (2016)	Pretest–posttest design. Pilot data on effectiveness and acceptability of group manualized therapy for women who are survivors of interpersonal trauma. Abbreviated 18-session version of standard 29-session TREM; 90-minute sessions offered weekly or biweekly.	Outpatient clinics in five National Health Service (NHS) Boards in Scotland.	Pretest (started treatment): N = 71. Posttest (completed treatment): N = 42.	Age: $\bar{x}$ = 40.4, SD = 10.6. Attended higher education: 56.3%. Unemployed or retired: 70.4%. Divorced or single: 71.8%. Race/ethnicity not reported.	Clinical Outcomes in Routine Evaluation (CORE; Evans et al., 2000) PTSD Checklist (PCL-C; Blanchard et al., 1996). Symptom Checklist (SCL-90-R; Derogatis, 1979) Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986). Rosenberg Self-Esteem Scale (RSES; Rosenberg, 2015). Attendance.	Significant improvements over time for CORE well-being and total, SCL-90 somatization, anxiety, phobic anxiety, GSI, PCL-C avoidance, hyperarousal, and total DES and RSES. Treatment effect sizes were small to medium. Posttreatment: 9.9%–54.9% achieved clinical significance across measures compared to 9.9%–62% at follow-up. DES: 54.9% of participants achieved clinical significance. RSES: 40.8% achieved clinical significance. At follow-up, a higher percentage of participants achieved clinical significance for CORE total (25.4%), SCL-90 GSI (29.6%), RES (44%), and DES (60.6%) compared to ratings at posttreatment. TREM may be useful for general distress and anxiety, including traumatic symptomatology, dissociation, and self-esteem symptoms. Attendance averaged 10.5 TREM sessions; 41% noncompletion.	High attrition (40%). Small sample size. Self-report measures. No control group. Limits generalizability to people with severe mental illness. Longitudinal design would yield more robust causal inferences.
Masin-Moyer et al. (2020)	Dissertation/published article. Quasi-experimental. Experimental group: ATREM (attachment-informed variation of TREM). Comparison group: TREM. 16-week duration with intervention group using more explicit attention to relationship, informed by attachment theory, among adult women with substance use disorder and/or mental health diagnosis as well as a history of trauma.	Rural/suburban setting. Three agencies: outpatient mental health treatment, residential substance use treatment, outpatient victim services.	Preintervention: N = 129. Postintervention (>10 sessions): N = 69 (ATREM = 37; TREM = 32).	Age: $\bar{x}$ = 42.4%, SD = 12.2. Race/ethnicity: White: 92.8%; Other race/ethnicities: 7.2%. Education < High school: 55.1%; > High school: 44.9%. Presently working: 21.7%; not presently working: 78.3%. Married/significant other: 36.2%; not in a relationship: 63.8%.	ASI BSI-18 PSS LSC-R Difficulties in Emotional Regulation Scale (DERS; Gratz & Roemer, 2004). Relationship Scale Questionnaire (Griffin & Bartholomew, 1994) Social Group Attachment Scale (Smith et al., 1999) Social Provisions Scale (Cutrona & Russell, 1987). Attendance	TREM associated with significant pretest–posttest improvement on all clinical measures except substance use and attachment avoidance. ATREM was associated with significant pre-test–posttest improvement on all measures except for substance use. No significant differences between ATREM and TREM on clinical measures. Attendance requirement of 60% (>9 of 16) of TREM sessions was met by all participants.	Unmeasured baseline differences. Small sample size. Relational nature of both ATREM and TREM makes detecting differential treatment effects challenging. Fidelity checklist monitored delivery of content but not experiential processing. Primary researcher facilitated ATREM groups which could contribute to social desirability bias in responses.
Paquin (2010) and Paquin et al. (2013)	Dissertation. Archival data. Pretest–posttest time-series design; 22 sessions, twice weekly for 11 weeks. Examined group fit and effectiveness of TREM for PTSD symptom reduction.	Midwestern women’s state correctional facility.	Pretest: N = 73 (6 groups). Posttest: N = 51.	Age: $\bar{x}$ = 38.26, SD = 8.17. Race/ethnicity: African American/Black: 34.2%; White: 61.6%; Latina/Hispanic: .04%.	PSS Attendance	TREM effectiveness: PTSD symptoms decreased significantly between pre- and posttest. Attendance averaged 18.68 TREM sessions. Fit with group for avoidance decreased (diverged) and the conflict increased (converged) across sessions. Increasing fit with the group on perceptions of group conflict was associated with attending more group sessions (commitment). Increasing fit with the group on perceptions of group avoidance was associated with PTSD symptom change (goal accomplishment).	Time-series design analyzed data points after each of 22 sessions for six groups over course of treatment (11 weeks). Reliance on archival data; limited to existing parameters established of measuring PTSD during first and last sessions of treatment. 30% of final sample did not complete both pre- and posttest PTSD outcome measures. Self-report of symptoms and social desirability. Pretreatment variables such as personality characteristics, race/ethnicity, age, extra-group relationships, or perceptions of the group leader could possibly account for more of the variance than P-G fit on perceptions of group climate in terms of attendance and PTSD symptom change. Findings could be limited to the experiences of incarcerated women.
Swope (2009)	Dissertation. The DC Trauma Collaboration Study. Quasi-experimental. Intervention group: 33-week version of TREM. Comparison group: Services as usual. Examined how participants’ pretreatment clinical severity related to engagement and outcomes. In-person assessments conducted at baseline, 3, 6, 9, and 12 months.	Mental health agencies in two urban areas.	Baseline: N = 246 (TREM = 150; Services as usual = 96). 12 months N = 170 (TREM = 108; Services as usual = 62).	Age: $\bar{x}$ = 42. Race/ethnicity for TREM: African American/Black: 87.6%; White: 9.8%; Latina/Hispanic, American Indian, Asian, or Other: 2.6%. Race/ethnicity for services as usual: African American/Black: 74.5%; White: 22.4%; Latina/Hispanic, American Indian, Asian, or Other: 3.1%. Relationship status of the sample: Married or significant other = 25.5%; Divorced or separated = 33.8%; Never married = 33.9%; Widowed = 6.8%.	ASI GSI/BSI PSS LSC-R Attendance WCDVS Trauma Coping Measure WCDVS Perceptions of Integration Clinician-Rated Participation and Engagement TREP	Greater pretreatment clinical severity on measures of trauma symptoms, general psychiatric functioning, and drug and alcohol use were associated with greater posttreatment reduction in general mental health and trauma symptoms and greater gains on the TREP. More frequent attendance was associated with a greater reduction in drug use and PTSD symptoms from baseline to 12 months, and greater gains in coping and life skills. Higher clinician-rated participation was associated with improvements with drug use severity, coping, and life skills. Perceived integrated counseling rating at 3-month and 6-month assessments was significant predictor of posttreatment symptom reduction on PSS, GSI, and ASI-D, but only among TREM.	Post hoc analyses. Limited generalizability (only outpatient women).
Toussaint et al. (2007)	Subsample of WCDVS. Quasi-experimental. Intervention group: TREM adapted to 24 sessions. Comparison group: Treatment as usual. Examined effectiveness of trauma-specific treatment for women with co-occurring trauma and substance use disorders. Data collection at baseline, 6 and 12 months.	Residential substance use treatment program for women with co-occurring mental health and substance use disorders and their dependent children.	Baseline: N = 170 (TREM = 64; treatment as usual = 106). 12 months N = 152 (TREM = 61; treatment as usual = 91).	Age: TREM $\bar{x}$ = 29; treatment as usual = 32.7. Race/ethnicity TREM: Black/African American: 20.3%; White: 48.4%; Latina/Hispanic: 17.2%; American Indian: 9.4%. Race/ethnicity treatment as usual: Black/African American: 17%; White: 55.7%; Latina/Hispanic: 14.2%; American Indian: 7.5%. Education: TREM = 11.1 years; treatment as usual = 11.7 years. Relationship status TREM: Married/living with partner: 42.2%; Divorced/separated: 21.9%; Never married: 35.9%. Relationship status treatment as usual: Married/living with partner: 46.3%; Divorced/separated: 34.9%; and Never married: 18.9%.	ASI GSI/BSI PSS LSC-R: CEIA; Current Exposure to Other Stressors Scale Fidelity checklist (Fallot & Harris, 2001) Attendance WCDVS Safety Scale (Giard et al., 2005) WCDVS Feelings-Dissociation Scale (Giard et al., 2005) WCDVS Feelings-Trauma Coping Index (Giard et al., 2005) Social Role Functioning Index modified from BASIS-32	Attendance averaged 14.9 TREM sessions. At 6 months: TREM had strongest effect symptoms of dissociation and sense of safety. At 12 months: stronger support for effectiveness of TREM—improved dissociative symptoms, trauma coping, sense of safety, and mental health symptoms. Dosage analysis—significant effect greater number of TREM sessions on PTSD and mental health symptoms, but not significant for alcohol or drug use.	Lack of random assignment and nonequivalent group design on several sociodemographic variables at baseline. Child welfare and perceptions of custody potential may have biased group assignment. Self-selection by women into treatment programs may have biased sample. ANCOVA used to control for known group differences.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

The supplemental material for this article is available online.

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