How Progress Is Measured in Religious Trauma Therapy After the First Sessions
Last reviewed: 10/26/2026
Reviewed by: Dr. Kiesa Kelly
A few months into therapy, the questions can change. You are no longer asking whether you can trust this clinician with your story. You are asking whether any of this is working, and how anyone would know. Measuring progress in religious trauma therapy is harder than it sounds, because the harm rarely sits in one place. Some of it may look like post-traumatic stress: nightmares, a jolt of fear at a familiar hymn, a part of town you avoid. Some of it lives in belief, identity, family, and a community you lost or still live inside.
There is also no single number to watch. Religious trauma is not a diagnosis with its own score. Since a December 2024 update, the DSM-5-TR lists a "Moral, Religious, or Spiritual Problem" as something that can be a focus of clinical attention, and it says the problems in that section "are not mental disorders" [1]. This article picks up where the early sessions leave off. If you are still near the start, our guide to what the first sessions of religious trauma therapy look like covers baselines and early signs of progress.
In this article, you'll learn:
What standard measures track in the middle of treatment, and what they leave out
Three misconceptions that make progress harder to see
Why your scores and your sense of yourself can move at different speeds
How often progress tends to be reviewed, and why there is no single rule
What a flat stretch can mean, and what can happen next
Questions to bring to your clinician about your results
Measuring progress in religious trauma therapy: the short answer
Progress can be tracked in two ways at once: brief, repeated questionnaires, and a running conversation about how your life is going. Researchers call the first part measurement-based care, defined in one major review as "the systematic evaluation of patient symptoms before or during an encounter to inform behavioral health treatment" [2]. The same review notes that it is underused: typically fewer than 20 percent of behavioral health practitioners build it into their practice [2]. A 2023 research review describes three phases: collecting data, feeding it back, and adapting therapy in response [3]. The numbers start a conversation. They do not end one.
In our clinical experience, that conversation in religious trauma work covers three layers: post-traumatic symptoms, day-to-day functioning, and the spiritual, moral and relational ground that symptom checklists were not built to measure. Much of the middle of treatment happens in that third layer. Our page on religious trauma therapy in Nashville describes how we approach this work, by secure telehealth across Tennessee or in person at our Nashville office.
🧭 Key takeaway: Ask for your progress to be followed on more than one track. The questionnaires are the start of a conversation, not a verdict on you.
Three misconceptions that make progress harder to see
"There is a religious trauma score that shows how healed I am." No such score is established. There is no DSM diagnosis called religious trauma; the closest DSM category is listed among problems that "are not mental disorders" [1]. The scales built specifically for religious trauma are new. One, developed with 452 Muslim adults in Turkey who took part online, found six factors, including spiritual disappointment and feelings of sin and guilt [4]. That is a useful start, but there is no published evidence yet that it can track one person's progress in therapy. A 2024 review of religious and spiritual abuse research also notes that some measures used in this research were adapted from non-religious trauma and abuse measures to fit a Christian context "without empirical testing" [5].
"If my PTSD score drops, the work is done." A PTSD checklist measures PTSD symptoms. A falling score is real progress, and it matters. But distress about faith, guilt or meaning can move on its own schedule. In one 2025 study of people with major depression who received 16 weeks of CBT, people with religious or spiritual problems showed "substantial reductions" in their struggle scores, yet those scores "remained elevated" compared with other groups even after therapy ended [6]. That study was about depression, not religious trauma, so it is a hint rather than proof. It is still a good reason to keep the spiritual layer in view.
"Filling out questionnaires means my therapist trusts numbers more than me." Good measurement works the other way. Research on routine outcome monitoring found that "Patients support ROM when its purpose is clear and integrated within therapy" [3]. The numbers are there so that the two of you can notice change, or the lack of it, sooner than memory alone allows. If a score ever seems to describe someone other than you, that mismatch is worth raising in session.
🧩 Key takeaway: No single score captures religious trauma. Symptom scores, daily life and the spiritual layer each tell part of the story.
What gets measured
Religious trauma describes a kind of experience rather than a single diagnosis, and not everyone affected meets criteria for PTSD. The PTSD measures and guidelines below were written for PTSD, so their numbers are one lens on your progress, not the whole picture.
Symptom-level change
A widely used self-report measure of PTSD symptoms is the PCL-5, a 20-item checklist that takes about 5 to 10 minutes [7]. Its total runs from 0 to 80, and the VA's National Center for PTSD lists "Monitoring symptom change during and after treatment" among its purposes [7]. Its initial validation found strong reliability in trauma-exposed college students [8]. The standard version asks about the past month, and the VA also offers a past-week version [7]. The VA adds that interpretation of scores should be made by a clinician [7].
How much change counts? The honest answer is that the evidence is thin. The VA says "There is limited evidence to guide decisions about response and clinically meaningful improvement," and suggests a drop of 10 points as one indicator of response [7]. One study of male veterans found that a change of about 15 to 18 points was large enough to count as reliable rather than random, and that a score of 28 or lower suggested a person was more likely to belong to the non-PTSD group [9]. Its authors cautioned that these values should be read alongside other definitions of meaningful change [9].
A depression measure can be used alongside it. The PHQ-9 scores nine items from 0 to 3, and totals of 5, 10, 15 and 20 mark mild, moderate, moderately severe and severe depression [10].
Day-to-day functioning
Symptom scores leave out much of what you actually care about. Can you drive past your old church without pulling over? Can you sit through a family dinner where grace is said? Functioning measures ask about life rather than symptoms. The WHO Disability Assessment Schedule (WHODAS 2.0), for example, covers six areas: understanding and communicating, getting around, self-care, getting along with people, life activities, and taking part in community life [11]. It can be self-administered and takes about 5 to 20 minutes [11].
Functioning is a goal of trauma treatment, not a side effect. The UK's NICE guideline on PTSD says trauma-focused CBT should "have a focus on re-establishing adaptive functioning, for example work and social relationships" [12]. In the veteran study above, people whose scores showed reliable change also reported better psychosocial functioning [9].
The two examples below are composites, not real clients.
Picture someone four months into therapy. Her PCL-5 score has dropped by more than 10 points since her first session. The nightmares come less often, and she no longer leaves a store when a worship song comes on over the speakers. On paper, that looks like steady progress, and it is. But Sunday mornings are still the hardest part of her week. She does not miss the services; she misses the people, and she cannot tell whether she is grieving a community or still afraid of it. None of the checklist's items ask about that, so it only shows up when she says it out loud in session.
Or: a man's scores have barely moved for six weeks. Yet in the same stretch, he has had his first honest conversation with his brother about leaving the church, and he has started sleeping through the night before family visits. The questionnaire did not register either change. His clinician did, because the two of them had agreed early on to track two concrete goals alongside the numbers, and they review those goals by name.
What symptom checklists can miss
Religious harm often reaches places a PTSD checklist was not built to measure: what you believe, who you are without the rules you grew up with, and grief for relationships that changed. The DSM-5-TR wording reflects this. It describes religious or spiritual problems as including "loss or questioning of faith," and moral problems as experiences that disrupt "one's understanding of right and wrong, or sense of goodness of oneself, others or institutions" [1].
There are research tools for parts of this territory. The Religious and Spiritual Struggles Scale has 26 items across six areas: struggles with God, fears about evil spiritual forces, negative experiences with religious people or institutions, moral struggles, doubt, and a loss of ultimate meaning [13]. The Moral Injury and Distress Scale asks about the emotional, cognitive, behavioral, social and spiritual effects of a potentially morally injurious event [14]. Both are useful maps. Neither was developed or validated with people recovering from religious harm: the first was developed with general adult and student samples [13], and the second with veterans, health care workers and first responders [14]. If your clinician uses one, it is reasonable to ask how they read it given that gap. Our article on moral injury and PTSD explains how those two experiences differ.
🌿 Key takeaway: The parts of religious harm that matter most to you may not appear on any form, so name them as goals early and review them by name.
How often progress is reviewed
There is no single rule, and the research is open about that. A major review of measurement-based care lists "the critical timing of administration" as a question still to be answered [2]. Another review found that "Greater frequency of data collection is more important for shorter-term therapies," and that graphs help [3]. A 2024 review expects the field to keep working out "what kinds of feedback, provided at what time, to which individuals" help most [15]. If you track the PCL-5 yourself, our guide to when to retake the PCL-5 explains why spaced checkpoints read more clearly than frequent retesting.
Treatment length is not fixed either. NICE says trauma-focused CBT and EMDR are typically "provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas" [12]. An American Psychological Association patient page on therapy in general, from its clinical psychology division, says treatment length "is often tentative and revisited throughout the course of treatment" [16]. If your harm built up over years rather than in a single event, ask your clinician how that "more if clinically indicated" clause applies to you.
In practice, the rhythm is worth agreeing on out loud: how often you will repeat a questionnaire, when you will step back and review the overall picture, and which of your own goals you will check in on. If your therapy uses EMDR or another trauma-focused approach, ask how progress within that method will be judged too.
📅 Key takeaway: Agree on a review rhythm with your clinician rather than assuming one exists.
What a plateau can mean, and what can happen next
In our clinical experience, many people in therapy hit stretches where their scores flatten out. A flat stretch is information, not a verdict, and it can mean several different things: the easier gains are done and harder material is next, life outside therapy has gotten heavier, avoidance has quietly crept back in, or the work is aimed at the wrong target.
What happens next matters more than the plateau itself, and this is where measurement earns its place. Studies of feedback systems find small benefits overall, and the picture for people who are "not on track" is mixed. One meta-analysis of randomized trials found an effect of d = 0.14 overall and d = 0.29 in not-on-track patients [17]. Another, pooling 58 studies, found d = 0.15 overall and d = 0.17 in not-on-track cases [18]. Both are modest effects. The 2023 review adds an important caution: routine monitoring "does not work for all patients" [3].
In our experience, a plateau is a reason to review the plan rather than to end it. That might mean revisiting the treatment plan, changing the focus, adding sessions, or working on one specific symptom. NICE suggests considering CBT aimed at specific symptoms such as sleep disturbance or anger for adults with PTSD or clinically important PTSD symptoms who have residual symptoms after trauma-focused treatment, and it asks services to assess "the need for further treatment or support for people who have not benefited fully from treatment" [12]. That page asks that you have "a sufficient amount of treatment" before deciding it is not working, and adds that if progress seems insufficient after a reasonable period, "it is always appropriate to discuss your treatment with another therapist and/or request a re-evaluation of the treatment plan with your therapist" [16].
A plateau is different from getting worse. If your scores rise sharply, if you feel unsafe, or if you have thoughts of harming yourself, tell your clinician right away. In a crisis, call or text 988, the Suicide & Crisis Lifeline, which is available 24/7, or call 911 in an emergency [19].
A rule of thumb you can apply between sessions:
If your scores are falling and your own goals are moving, keep going and keep measuring.
If your scores are falling but the faith, family or community goals are stuck, ask whether the plan should shift toward them.
If both have been flat across several reviews, ask for a formal review of the treatment plan, or a second opinion.
If things are getting worse, raise it with your clinician at your next session or sooner. If you feel unsafe, call or text 988, or call 911 in an emergency.
🔄 Key takeaway: A flat stretch is a reason to review the plan together, not a sign that you have failed at therapy.
Talking with your clinician about the results
Your scores are about you, and you are entitled to understand them. These questions work well at any review point:
"Which measures are we using, and what is each one not designed to capture?"
"What change on these scores would tell us the work is helping?"
"How often will we repeat them, and when will we look at the bigger picture?"
"Can I see my scores over time, ideally on a graph?"
"How are we tracking the goals that are about faith, family or community?"
"If we stay flat for a while, what will we try next?"
Write the answers down, so you can compare them at your next review. You can also read about our clinicians and their areas of focus before you choose who to work with.
💬 Key takeaway: Your scores are yours to understand. Ask what they show, what they miss, and what happens if they stall.
Next step: getting support
The question that brought you here was whether therapy is working and how anyone would know. The honest answer is that no single number can tell you. Symptom scores can show real change in post-traumatic stress and depression. Functioning measures and your own named goals show whether life is getting larger. The spiritual and relational layer still has to be tracked in words, because the tools for it are young. Used together and reviewed openly, those three tracks can tell you whether to keep going, change course, or ask for a second look.
Carrying something that still feels close?
Trauma-focused care — including approaches like EMDR — can help you process what happened at a pace that feels safe, with a clinician who understands trauma responses.
Frequently Asked Questions
Is there a test that measures religious trauma itself?
Not a well-established one. There is no DSM diagnosis called religious trauma, and the few scales built for it are new. One was developed with 452 Muslim adults in Turkey, and there is no published evidence yet that it can track change in therapy. A common approach is to use validated measures of related problems, such as PTSD symptoms and depression, alongside goals you set with your clinician for faith, family and community.
Why doesn't therapy work for everyone, even the right kind of therapy?
No therapy helps every person, and one review of progress tracking says the same about measurement itself: it does not work for all patients. What tracking can do is show earlier when someone is not on track. Change takes time, so it helps to agree with your clinician on what a fair trial looks like. If progress still seems stalled after a reasonable period, it is appropriate to ask for a review of the plan or a second opinion from another therapist.
How often should my progress be measured in therapy?
There is no fixed rule. Researchers still list the best timing as an open question, and one review found that frequent measurement matters most in shorter therapies. What helps most is agreeing on a rhythm with your clinician: when a brief questionnaire will be repeated, and when you will step back to review the whole picture, including goals that no questionnaire covers.
What if my PTSD score improves but I still feel lost about my faith?
That can happen. A PTSD checklist measures PTSD symptoms; it does not ask about belief, meaning or belonging. In one study of people treated with CBT for major depression, those who also had religious or spiritual problems saw their spiritual struggle scores fall, but stay higher than in comparison groups after therapy ended. That study was about depression, not religious trauma. Tell your clinician, so the plan can shift toward what is still unresolved.
About the Author
Dr. Kiesa Kelly is a licensed clinical psychologist and the founder of ScienceWorks Behavioral Healthcare. Her clinical work includes trauma and PTSD, OCD, insomnia, and ADHD and autism, and her preferred approach for treating trauma is EMDR, in which she has completed basic training and further training in EMDR for attachment injuries. She has more than 20 years of experience with psychological assessment.
She holds a PhD in Clinical Psychology with a concentration in neuropsychology from Rosalind Franklin University of Medicine and Science, and completed practica, internship, and an NIH-funded postdoctoral fellowship at the University of Chicago, the University of Wisconsin, the University of Florida, and Vanderbilt University. Dr. Kelly is a psychologist, not a physician, and she does not offer theological guidance.
References
1. VanderWeele TJ, Wortham JS, Carey LB, Case BW, Cowden RG, Duffee C, Jackson-Meyer K, Lu F, Mattson SA, Padgett RN, Peteet JR, Rutledge J, Symons X, Koenig HG. Moral trauma, moral distress, moral injury, and moral injury disorder: definitions and assessments. Front Psychol. 2025;16:1422441. https://doi.org/10.3389/fpsyg.2025.1422441
2. Lewis CC, Boyd M, Puspitasari A, Navarro E, Howard J, Kassab H, Hoffman M, Scott K, Lyon A, Douglas S, Simon G, Kroenke K. Implementing Measurement-Based Care in Behavioral Health: A Review. JAMA Psychiatry. 2019;76(3):324-335. https://doi.org/10.1001/jamapsychiatry.2018.3329
3. Barkham M, De Jong K, Delgadillo J, Lutz W. Routine Outcome Monitoring (ROM) and Feedback: Research Review and Recommendations. Psychother Res. 2023;33(7):841-855. https://doi.org/10.1080/10503307.2023.2181114
4. Ok Ü, Gören AB, Gülmez Ç. Construction and Validation of a Muslim Religious Trauma Scale. J Loss Trauma. 2025;30(2). https://doi.org/10.1080/15325024.2024.2412294
5. Perry S. Religious/Spiritual Abuse, Meaning-Making, and Posttraumatic Growth. Religions. 2024;15(7):824. https://doi.org/10.3390/rel15070824
6. Kéri S. Existential thinking and religious/spiritual struggles in patients with major depressive disorder receiving cognitive-behavioral therapy. Sci Rep. 2025;15(1):42205. https://doi.org/10.1038/s41598-025-26014-z
7. U.S. Department of Veterans Affairs, National Center for PTSD. PTSD Checklist for DSM-5 (PCL-5). [accessed 2026 Oct 26]. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
8. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J Trauma Stress. 2015;28(6):489-498. https://doi.org/10.1002/jts.22059
9. Marx BP, Lee DJ, Norman SB, Bovin MJ, Sloan DM, Weathers FW, Keane TM, Schnurr PP. Reliable and clinically significant change in the clinician-administered PTSD Scale for DSM-5 and PTSD Checklist for DSM-5 among male veterans. Psychol Assess. 2022;34(2):197-203. https://doi.org/10.1037/pas0001098
10. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
11. World Health Organization. WHO Disability Assessment Schedule (WHODAS 2.0). [accessed 2026 Oct 26]. https://www.who.int/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule
12. National Institute for Health and Care Excellence. Post-traumatic stress disorder. NICE guideline NG116. London: NICE; 2018. https://www.nice.org.uk/guidance/ng116/chapter/Recommendations
13. Exline JJ, Pargament KI, Grubbs JB, Yali AM. The Religious and Spiritual Struggles Scale: Development and initial validation. Psychol Relig Spiritual. 2014;6(3):208-222. https://doi.org/10.1037/a0036465
14. Norman SB, Griffin BJ, Pietrzak RH, McLean C, Hamblen JL, Maguen S. The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations. Psychol Trauma. 2024;16(2):280-291. https://doi.org/10.1037/tra0001533
15. McAleavey AA, de Jong K, Nissen-Lie HA, Boswell JF, Moltu C, Lutz W. Routine Outcome Monitoring and Clinical Feedback in Psychotherapy: Recent Advances and Future Directions. Adm Policy Ment Health. 2024;51(3):291-305. https://doi.org/10.1007/s10488-024-01351-9
16. American Psychological Association, Division 12 (Society of Clinical Psychology). How Long Will It Take for Treatment to Work? Clinical Practice Guideline for the Treatment of PTSD: For Patients & Families. 2017. https://www.apa.org/ptsd-guideline/patients-and-families/length-treatment
17. Rognstad K, Wentzel-Larsen T, Neumer SP, Kjøbli J. A Systematic Review and Meta-Analysis of Measurement Feedback Systems in Treatment for Common Mental Health Disorders. Adm Policy Ment Health. 2023;50(2):269-282. https://doi.org/10.1007/s10488-022-01236-9
18. de Jong K, Conijn JM, Gallagher RAV, Reshetnikova AS, Heij M, Lutz MC. Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clin Psychol Rev. 2021;85:102002. https://doi.org/10.1016/j.cpr.2021.102002
19. 988 Suicide & Crisis Lifeline. [accessed 2026 Oct 26]. https://988lifeline.org/
Disclaimer
This article is for informational and educational purposes only and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. It offers no religious or theological guidance, and reading it does not create a therapist-client relationship. Questionnaires and screeners cannot diagnose PTSD or any other condition on their own. If you are in crisis or thinking about harming yourself, call or text 988, or call 911 in an emergency.