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Takeaway: The Moral Injury and Distress Scale (MIDS), the first measure to assess moral injury symptoms indexed to a specific event and validated across several high-risk populations, is being adopted throughout VA as a tool for identifying Veterans with moral injury: the distressing psychological, behavioral, social, and sometimes spiritual aftermath of witnessing, failing to prevent, or participating in events that contradict one’s deeply held values and beliefs.
VA mental health professionals and investigators, who have long been aware of moral injury’s lasting effects on Veterans, continue to work toward consensus about what it is (and isn’t), about how to distinguish it from other mental health conditions, and about how to relieve the suffering it causes. A major challenge in implementing moral injury care across VA is that best practices, protocols, and guidelines are still developing.
While not a diagnosis, moral injury is clinically significant, often overlapping with or accompanying other diagnoses such as depression, anxiety, PTSD, or substance use disorders. Both moral injury and PTSD start with a traumatic event, and both may cause people to feel distress, guilt, shame, or mistrust long after the event. But there are also important differences. People with PTSD often startle easily or live in a state of constant vigilance—conditions less common among those with moral injury. People with moral injury, on the other hand, are more likely to experience persistent and profound feelings of guilt, shame, or betrayal; withdrawal from close relationships or social groups; a diminished sense of purpose; or the feeling that they deserve unhappiness or punishment for past action or inaction.
One point on which VA’s mental health professionals are approaching consensus is that there’s a difference between moral distress, a negative emotional reaction any person is likely to feel after a traumatic event, and moral injury. Moral injury refers to deeper wounds of the mind and spirit that persist long after the event and interfere with day-to-day living.
There are two components to moral injury: the precipitating event or events, and the lingering wounds inflicted by those events. Assessments and research so far have tended to focus on one or the other. In a 2022 article in VA’s PTSD Quarterly, Shira Maguen, PhD, a psychologist and HSR investigator at the San Francisco VA, and Sonya Norman, PhD, of VA’s National Center for PTSD (NCPTSD), wrote of the need for a “gold-standard outcome measure” that would “include both an assessment of [potentially morally injurious event] exposure and of moral emotions, cognitions, and behavioral consequences of these exposures that are grounded in a theoretical model.”
Drs. Maguen and Norman assembled a team to design and validate this gold standard, and Brandon Griffin, a psychologist with the Central Arkansas VA Health Care System and researcher with the VA Center for Mental Healthcare and Outcomes Research (CeMHOR), joined as an investigator. The Moral Injury and Distress Scale (MIDS) was rolled out in 2023. It is the first measure to assess moral injury symptoms indexed to a specific event that was validated across several high-risk populations, including Veterans, healthcare workers, and first responders.
A key feature of the MIDS is its simplicity: It is self-administered and, like moral injury itself, it is sequenced in two stages. Part One consists of three items designed to determine whether a person was exposed to a potentially morally injurious event (PMIE). If so, the person continues to Part Two, which consists of 18 questions that assess any PMIE-related cognitive, emotional, behavioral, social, or spiritual impacts experienced over the last month. Agreement with each item on the MIDS (e.g., “I do not feel like I deserve to be happy.”) is rated on a 5-point scale (0 = not at all, 4 = extremely).
The MIDS is easy to use. All items on Part Two can be summed into a single total score. A score of 27 or higher is associated with psychiatric and functional problems—and elevated risk for suicide—that can be addressed through further evaluation and treatment.
In the two years since its introduction, the MIDS has been downloaded more than 28,000 times.
Shira Maguen, PhD, is Mental Health Director of the Post-9/11 Integrated Care Clinic and Staff Psychologist on the PTSD Clinical Team (PCT) at the San Francisco VA Health Care System, and Professor of Psychiatry and Behavioral Sciences at the University of California-San Francisco School of Medicine.
Sonya Norman, PhD, is Director of the PTSD Consultation Program through the Executive Division of the National Center for PTSD. She also serves as Professor of Psychiatry at the University of California-San Diego School of Medicine.
Brandon Griffin, PhD, is a clinical psychologist with the PTSD Specialty Care Clinic at the Central Arkansas VA Health Care System and a researcher with the Center for Mental Healthcare and Outcomes Research (CeMHOR). He is an assistant professor of psychiatry at the University of Arkansas for Medical Sciences.
Norman SB, Griffin BJ, Pietrzak RH, et al. The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations. Psychological Trauma: Theory, Research, Practice, and Policy. February 2024;16(2):280-291.
Maguen S, Griffin B J, Pietrzak RH, et al. Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury. Journal of Traumatic Stress. August 2024;37(4):685-696.
Maguen S, Griffin BJ, Pietrzak RH, et al. Prevalence of Moral Injury in Nationally Representative Samples of Combat Veterans, Healthcare Workers, and First Responders. Journal of General Internal Medicine. January 29, 2025; online ahead of print.
Moral Injury and Distress Scale (MIDS)—National Center for PTSD
