A Comparative Effectiveness Study of the Trauma Recovery Empowerment Model (TREM) and an Attachment-Informed Variation of TREM (ATREM)

Background and Purpose: Interpersonal trauma has been associated with enduring health, mental health, and relational challenges.  With 90% of clients in public behavioral health care settings indicating histories of trauma, there is a critical need to examine the effectiveness of trauma treatment.  Group psychotherapy is uniquely suited to address the interpersonal needs of survivors with multiple opportunities for social support, a key contributor to resilience.  Trauma may serve as an impediment to being open to socially supportive interactions, so explicit relational adaptations may be needed to foster positive outcomes.  An evidenced-based women’s trauma group was modified to create a new protocol, Attachment-Informed Trauma Recovery Empowerment Model (ATREM), which included attachment-based concepts and strategies to determine if well-being could be enhanced beyond the Trauma Recovery Empowerment Model (TREM).  It was hypothesized that ATREM would be associated with greater improvement in attachment security, perceived social support, emotion regulation, substance use, depression, anxiety, and PTSD symptoms than TREM.

Methods: A quasi-experimental design was used to test the hypothesis.  A convenience sample of 69 women (n = 37 ATREM; n = 32 TREM) completed 16-week versions of the group interventions.  The participants were, on average, 42 years old and predominantly Caucasian, unemployed, and not in relationships.  Clinical outcomes were assessed with pre- and post-intervention questionnaires comprised of the following standardized scales: Relationship Scale Questionnaire, Social Group Attachment Scale, Social Support Scale, Difficulties in Emotional Regulation, Brief Symptom Inventory-18, PTSD Symptom Scale, and modified versions of the Lifetime Stressor Checklist Revised and the Addiction Severity Index.  The continuous variables were analyzed using paired t-tests for within-group comparisons and independent t-tests for between-group comparisons, and the categorical variables were analyzed using Chi-Square or Fisher’s Exact Test.

Results: Both ATREM and TREM were associated with statistically significant within-group improvement in individual and group attachment styles, perceived social support, emotion regulation capacities, depression, anxiety, and PTSD.  Only ATREM was associated with statistically significant improvement in individual attachment avoidance.  Also, ATREM demonstrated a non-significantly higher rate of completion than TREM.  The gains associated with ATREM did not exceed those associated with TREM as hypothesized.   

Conclusion and Implications: The comparable findings of ATREM and TREM, along with the additional gains for ATREM with individual attachment avoidance and group completion, suggest that ATREM may be a viable treatment alternative to the well-established, evidence-based TREM protocol.  Given that individual avoidance attachment is often considered challenging to modify, this finding for ATREM is especially noteworthy.  The outcomes provide preliminary, but encouraging, insights into the knowledge base on attachment-informed group therapy, a practice orientation that has been minimally investigated in comparison to attachment-informed individual, couples, and family therapy.  The inclusion of group attachment style is another innovation that contributes a unique perspective in understanding individual behavior in the group context.  ATREM offers both clients and therapists a protocol that may prepare them for more productive and meaningful group experiences which facilitate critical interpersonal repairs.