March/April 2007

Cutting Through the Chaos — Trauma and Abuse Recovery
By Kate Jackson
Social Work Today
Vol. 7 No. 2 P. 40

An innovative program in the nation’s capital gives women with mental illness and substance abuse issues the tools to understand the impact trauma has on their lives.

Picture a young woman who, as a child, was raped repeatedly by her father. Perhaps she was told she caused it, deserved it, or imagined it. When she was beaten, she called the experience “discipline,” if she called it anything at all. Somewhere deep down inside she knew these events happened because she was bad. Told not to discuss it “or else,” she retreated into silence and began to doubt whether what she remembers actually happened.

Over time, she experiences anxiety and bouts of depression. Nagging headaches go untreated. There’s no place where she feels entirely safe and no one whose company brings her comfort. She turns to alcohol, then marijuana, for solace and escape. Still, she experiences flashbacks, hears voices, and seems to lose time. She can’t hold down a job and has no health insurance. She ricochets from one abusive boyfriend to another until she confronts one whose brutality lands her in the hospital. Physical wounds tended, she’s released, but because she hasn’t formed safe, nurturing friendships, she has nowhere to turn and ends up living on the street. One experience after another pushes her farther into the margins of society.

It’s disenfranchised women such as these who find their way to Community Connections. Established in 1984, it’s a private not-for-profit provider of mental health, substance abuse, and trauma services in Washington, DC. “Generally, when women come to us, it’s almost always a crisis. They’re on the edge of losing their children or have lost their children, they’ve been court-ordered to receive mental health treatment, or they’re losing their housing,” explains clinical supervisor Jo-Ann Leitch, MSW, LICSW. “For many years, these women have been barely holding it together, just living on the edge, but then some sort of crisis happens, and they fall off the edge. That’s when we see them.”

Jerri Anglin, MSW, LICSW, another clinical supervisor who leads a team of social workers that provides trauma-informed case management services, says, “We’ll help them with applications for benefits or temporary financial assistance, we’ll make a Medicaid application so we can get them some health insurance, and we’ll get them set up for an initial psychiatric evaluation with our psychiatrist.” They come for these concrete services, Leitch says, but after their fundamental needs are met, they receive help for a problem they don’t even understand that they have.

Until clinicians at Community Connections developed a model for trauma recovery services for this population, these powerless women not only fell off the edge but through the cracks of the social service system. Untreated, says Anglin, many may have landed in prison or problematic relationships, addicted to drugs, or in prostitution. “They’d have been left treading water,” she says, with no opportunity to rise above their dire straits.

The Trauma Recovery and Empowerment Model (TREM) is a group intervention created in the 1990s by a Community Connections Trauma Work Group. Led by the organization’s codirector, Maxine Harris, PhD, the clinicians, with input from clients, devised a comprehensive group intervention to serve women survivors of physical, emotional, and sexual abuse—those whose marginal social status and mental illness had either denied them access to or made them unlikely candidates for traditional recovery work. Building on success with that model, it then devised variations for men (M-TREM) and adolescent girls (G-TREM); a four-session program for women on short-stay units; and a roster of companion interventions for individuals with special needs—for example, those with HIV or substance abuse issues.

Today, Community Connections trains social workers and others nationwide to lead TREM groups, and the model is used in a range of settings including prisons, welfare to work programs, outpatient and residential substance abuse programs, outpatient mental health facilities, and domestic violence and homeless shelters. Although TREM was designed as a group model, its core principles and techniques can also guide and inform clinicians working one-on-one with clients in trauma recovery.

Program guidelines are detailed in a manual for group leaders, Trauma Recovery and Empowerment: A Clinician’s Guide for Working with Women in Groups, written by Harris and the Community Connections Trauma Work Group. TREM strategies are also explored in a self-help workbook called Healing the Trauma of Abuse: A Woman’s Workbook, written by Mary Ellen Copeland and Harris, that can be used by women unable to participate in a group.

Why a New Model?
Before the advent of TREM, women on the fringes of society in the nation’s capital who suffered from the aftereffects of trauma were likely to go untreated thanks to a triad of failures: of the women afflicted, clinicians in general, and the larger social service system. The TREM model, in various ways, addresses each of these associated weaknesses and arose in recognition of the obvious truths that underlie them: It’s difficult to help a person who cannot ask for help because she doesn’t understand the true nature or extent of her problem. It’s difficult for a person who can’t acknowledge a problem to get help when those charged with caring for her don’t ask about or acknowledge the problem. And, finally, it’s challenging to offer trauma recovery services to people whose lives have been so derailed by abuse that their circumstances or symptoms pose obstacles to treatment.

A Failure to Understand
Many women who’ve experienced abuse do not perceive it as being at the root of their problems. Their challenges may be so many and so complex that the root issues have long been obscured. They may recognize the laundry list of complaints that Community Connection clinicians call aftereffects of trauma and abuse: anxiety, depression, pain, sleep disorders, self-medication, other forms of self-harm, and, in some cases, homelessness, addiction, and prostitution. But for various reasons, they’ve never tethered these consequences to the acts of abuse from which they so often arise.

According to Rebecca Wolfson Berley, MSW, director of trauma education, “most women do not come into mental health service programs with any kind of chief complaint of trauma or specific incidents or histories. Instead, they may seek help for the aftereffects or arrive in search of concrete services such as help with housing. Seldom do they perceive their past traumatic experiences to be catalysts of their current distress.”

A Failure to Ask
Trauma, observes Wolfson, “can be a very scary topic for clinicians”—one that causes a great deal of hesitancy. Once someone opens the door to acknowledging abuse, women have a fairly easy time saying they are trauma survivors, she says, adding that many social workers and other mental health professionals don’t open that door. “There’s a real fear that, by asking questions about trauma, they’re going to make things worse and open a can of worms.” Consequently, many clinicians in mental health programs don’t ask about histories of trauma during initial assessments or identify the connections between symptoms and issues related to abuse.

“We very much believe that some presenting symptoms may be related to trauma, either as coping mechanisms for dealing with memories of trauma or as ways for women to survive in the world.” At Community Connections, clinicians do ask about trauma and are mindful of the connections between abuse and symptoms. “If someone has complaints about losing a lot of time and spacing or tuning out, that may be a psychosis and it may be dissociation, which comes from a history of trauma,” says Wolfson Berley. As a result, she explains, “we usually view women through a trauma lens when we think about where some of the symptoms come from.”

A Failure to Accommodate or Embrace
When Community Connections was developing TREM, says Wolfson Berley, the women in its population weren’t considered “a good match” for existing treatment options. Adds training specialist Lori L. Beyer, MSW, LICSW, they were thought to be too vulnerable and too lacking in ego strength to do the work. The fear was that they’d unravel further and decompensate. “We were sweeping a huge issue under the rug by not looking at their trauma and abuse.”

There weren’t options that could embrace women with mental illness, had any psychosis, cognitive deficits, or those who couldn’t attend a group 100% of the time, explains Wolfson Berley. “Since our population at the time had lots of women with diagnoses of schizophrenia and schizoaffective disorder who were dually diagnosed and would probably be going in and out of hospitals or detox during the course of a long-term group, we knew we needed a model that would not kick people out for missing three groups in a row and that would tolerate and account for the fact that some women would sit in the room and have moments when they tuned out.” Together, the clients and clinicians built a better model that embraces and accommodates these marginalized women.

The Program
Far from a psychodynamic approach, TREM succeeds through cognitive restructuring, psychoeducation, and skill building. Its cornerstones are empowerment, peer support, and practical skill building. The psychoeducational focus teaches women to recognize the deleterious effect of trauma on their lives and acquire tools for self-help.

The intervention, originally composed of 33 weekly, 75-minute sessions, now involves 29 leader-driven sessions, during which an individual topic is explored through structured conversations, questions, and experiential exercises. The sessions are divided among three core topic sections.

The overarching theme of the introductory section is empowerment: helping women protect and comfort themselves, set physical and emotional boundaries, and increase self-esteem. Group leaders introduce the notion that disempowerment and diminished self-esteem are linked with a history of trauma and explore women’s feelings about womanhood and their bodies, while examining the distortions that often influence their perceptions. In this safe environment, leaders foster healthy attitudes about boundaries—physical and emotional. These discussions also allow participants to understand that behaviors they or others have labeled negatively, such as drug or alcohol use, dissociation, or self-mutilation, were skills that helped them survive. Then, leaders can introduce positive ways that participants can soothe and comfort themselves.

Typically, says Anglin, participants were never soothed properly by a parent or caregiver because they were abused or neglected, so they never received comfort. The extreme methods they often use—getting high or cutting themselves—may get them through the night but ultimately take a toll. TREM leaders, however, try to remove all judgment and let women know that they shouldn’t blame themselves for such extreme behaviors.

Says Anglin, “We tell them from the very start, ‘We’re glad you did all those things. Had you not been hypervigilant when you were a kid, you wouldn’t have been watching out for yourself, and you wouldn’t be around today. If you didn’t soothe by getting high to get yourself through, you might have killed yourself and wouldn’t be here today. If you hadn’t dissociated when your father was raping you, it may have been too painful to stay in your body.” TREM leaders relabel those behaviors as survival tools, and, says Anglin, “give these women less costly strategies—a repertoire of activities—they can use to take care of themselves when they experience stress.”

In the second section of sessions—trauma recovery—the spotlight begins to shine more directly on abuse. This isn’t a platform for a continual retelling or reliving of incidents of abuse nor for uncovering “buried” episodes of trauma. Rather, it focuses both on helping women recognize the link between abuse and its consequences—the life chaos and the physical, emotional, and social symptoms—and then providing the tools and skills with which they can combat the repercussions of trauma. “One of the unique things about our model is that you do not need to regress and recount every memory. You really need to know you were traumatized, but you don’t need to remember the events minute by minute.” Beyer recalls a woman who came to a group and asked for help to retrieve childhood memories. “My response was no. I said, ‘If that happens, it happens, but we’re not about recreating memories or helping you unearth exactly what happened. Rather, this treatment is much more about what symptoms and behaviors you’re having now and how you would like to function.’”

TREM stresses skill building because trauma typically destroys opportunities for developing life-enhancing tactics. “If you’ve experienced childhood abuse,” explains Anglin, “you missed out on so many of the necessary skill acquisition experiences that we all have growing up, everything from how to have a healthy relationship, how to develop a secure self-identity, to how to accurately label situations and feelings.”

Part three, advanced trauma recovery, continues with the exploration of practical coping and skill-building strategies and is followed by sessions for self-assessment and planning that will help women build on the healing strategies they learned in the program.

A four-year National Institute of Mental Health study is underway to assess the effectiveness of TREM. In the meantime, promising preliminary studies indicate an impressive level of engagement among participants and a significant reduction in deleterious behaviors. A large majority of women report finding the group helpful, says Roger D. Fallot, PhD, director of research and evaluation at Community Connections. The largest study yet showed that approximately 70% of women enrolled completed more than 70% of the sessions. “For women who are often reluctant to engage in services, this is a very high rate of participation,” he says. In one recent study, he adds, TREM participants showed greater improvement with respect to trauma-related symptoms and drug and alcohol abuse than those who received only the usual social services.

Bridges of Hope
Leitch views the model as a way to get beyond what she sees as an “us and them” mentality. The clients served by TREM, she suggests, are at the extreme end of a spectrum of life problems experienced by all women. “We all move up and down this continuum. Some start a little further up on the side of impairment, but they can move down to become more functioning individuals.”

The work Leitch and her colleagues do lays a foundation that can be built upon. Women may come into the program with grandiose expectations that the trauma will be behind them. But those who complete the program, she says, are likely to come away with an understanding of what has happened to them and are better prepared to integrate these experiences into their lives in healthier ways. We begin to see women addressing their addictions, thinking through their responses to problems, and choosing healthier soothing skills.

“Helping women deal with trauma in a safe way, and sometimes giving them the chance to move forward in life as they never could before can be an incredibly rewarding part of one’s career,” says Wolfson Berley. “And for most people here at Community Connections who do trauma recovery work, it’s one of their favorite parts of the job.” It can be the hardest, she adds, but “it’s also the area where we feel very proud to be helpful.”

Anglin agrees: “I never question what I’m doing or that what I do has meaning. I know what I do every day has meaning.”

Progress may be measured in inches, rather than miles, but it can nonetheless be life-changing. Success can mean very different things to participants. While one may learn how to set small limits and boundaries with her family or husband, another may gain insights that will let her do more of the activities she enjoys doing in life. Still others may come to accept the limitations their histories have imposed on them so they can make realistic goals and appropriate decisions. “We can’t ever take this experience away—it’s part of them,” says Leitch. “But we can help them cope better and help it be less destructive.”

For more information, visit www.communityconnectionsdc.org.

— Kate Jackson is a Los Angeles-based freelance writer and editor and former staff writer for Social Work Today.

Giving Men a Voice for Their Feelings
Community Connections’ Trauma Recovery and Empowerment Model for men (M-TREM) is similar to the model for women, but the content is tailored to men’s unique needs and the model spans 24 weeks rather than 29.

According to Rebecca Wolfson Berley, MSW, director of trauma education, “Women often have been disempowered and don’t feel a great deal of personal strength.” But once given the opportunity, they have little difficulty acknowledging that they have been victims. Men, she says, are less disempowered but have much more trouble with the notion of being a victim. According to Jerri Anglin, MSW, LICSW, clinical supervisor, traumatized men have had to wear many masks in society. “They’ve had to assume a certain kind of bravado to help them power through, and they’ve never been allowed to acknowledge vulnerability or that abuse has happened.”

In M-TREM, the emphasis doesn’t need to be on empowerment but rather on helping men establish an emotional vocabulary with which to understand and express their experience and feelings. “Men get and understand ‘No, I’m angry,’ but they can’t necessarily connect as much with a host of other emotions, so the early sessions in the men’s model are about getting in touch with what else there is in the world other than to be mad,” says Wolfson Berley. The first session, she explains, is about male myths (men don’t cry, men have lots of sex, men are the breadwinners), what it means to be a man, and some of the societal expectations and pressures that affect men. By and large, Wolfson Berley observes, “if you are a man with major mental illness, you’re not living up to those expectations.” The initial task with men, Anglin suggests, is to help them take down the masks a bit. In many ways, she says, “men have a steeper hill to climb.”

— KJ