Staff perspective: Moral Distress and Moral Injury - How Prevalent Are They in U.S. Veterans?
Moral injury remains a murky concept, despite the growing body of literature on this important topic. While there’s not a consensus on exactly what moral injury is, Phelps et al. (2024) describe it as enduring psychological, social, and spiritual distress that can occur when individuals are exposed to high-pressure situations that violate or clash with their deeply-held moral beliefs or values. Moral injury may stem from one’s own actions or inactions, the actions of others, or a perceived betrayal by trusted leaders or institutions. In military contexts, including those with complex rules of engagement, moral injury may occur after engaging in or witnessing acts that conflict with one’s sense of right and wrong, such as causing harm to civilians, being unable to prevent the loss of life, seeing human suffering, or feeling deeply misled by command.
Litz et al. (2022) nicely differentiate moral injury from moral distress, noting that moral injury requires exposure to potentially morally injurious events (PMIEs) that involve both agentic acts (committing or failing to prevent transgressions oneself) and non-agentic experiences (witnessing or being directly affected by others' transgressions). In contrast, moral stress involves exposure to moral stressors that are less severe or lower-magnitude transgressive experiences. Moral distress is a preclinical condition with less functional impairment than moral injury.
Refinements in the definition of moral injury like those mentioned above, as well as the development of psychometrically-validated measures, are helping us better understand this concept. The Moral Injury Outcomes Scale (MIOS; Litz et al., 2022) has individuals consider whether they have been exposed to different types of PMIEs, and if they have, they proceed to respond to 14 items based on two subscales: shame and trust violation. Afterwards, they indicate the impact of moral injury symptoms on different aspects of their life by responding to an eight-item functional outcome measure adapted from the Brief Inventory of Psychosocial Functioning. Learn more about the MIOS here: https://sites.bu.edu/litzlab/additional-resources-on-moral-injury/.
Last year, I wrote about another useful self-report measure called the Moral Injury and Distress Scale (MIDS; Norman, Griffin, Pietrzak, McLean, Hamblen, & Maguen, 2024). Discover more about it here: https://ptsd.va.gov/professional/assessment/te-measures/mids.asp.
Between 2-10 November 2023, Litz et al. used the MIOS to survey a nationally representative sample of 3,002 U.S. veterans online about exposure to PMIEs and identify rates of moral distress and moral injury. The results are hot off the press (Litz et al., 2025). The goal was to estimate the prevalence and significance of these conditions to help educate clinicians and inform future directions in the field. The authors stress that “understanding the prevalence and characteristics of moral distress and moral injury is essential for tailoring prevention efforts, supporting affected individuals, and informing clinical and policy decisions.” Based on the survey results, 44.7% of the respondents endorsed PMIEs. What do you think about this rate? Are you surprised? More specifically:
- 45.2% reported non-agentic experiences in which they witnessed others’ transgressions
- 40.2% reported non-agentic experiences in which they were directly affected by others’ transgressions
- 14% reported agentic experiences in which they committed or failed to prevent transgressions
Interestingly, exposure to PMIEs was more likely among veterans who were female, younger, lower-income, unmarried, and had some college education. PMIE exposure was also more likely to be reported by veterans who had deployed to a warzone or held junior enlisted ranks. According to the authors, these findings suggest that exposure to PMIEs is not an inevitable part of military service. In other words, we shouldn’t make the assumption that all service members experience PMIEs. Why veterans with these backgrounds were more apt to experience PMIEs is unclear. Also, I’m curious if those who completed the survey may have underreported PMIEs, particularly PMIEs involving acts of perpetration.
With respect to rates of moral distress and moral injury in the full sample, these were relatively low. The prevalence was 4.1% for moral distress and 5.9% for moral injury. Keep in mind that lower overall rates were expected, since veterans who did not endorse PMIEs were included in the rates but were not at risk for these conditions. However, even among those who reported experiencing PMIEs, the rates were not very high—9.1% for moral distress and 13.1% for moral injury. The authors suggest that these relatively low rates underscore that, like PTSD, moral distress and moral injury are tied to specific stressful events and that PMIE exposure, in and of itself, does not automatically lead to moral distress or moral injury. At the same time, for those who suffer from moral distress or moral injury, providing access to psychoeducation, support, and treatment is critical. Additionally, it’s essential when working with clients that we try to prevent moral distress from morphing into moral injury—a much more debilitating and enduring condition.
Certain factors were associated with a greater likelihood of moral injury, including Hispanic ethnicity, not being married, older age, and endorsing agentic PMIEs (events involving committing or failing to prevent transgressions). Moral distress was more likely among those veterans who were female, older, had deployed to warzones (especially multiple times), and those who had experienced agentic PMIEs. Based on these findings, the authors propose that moral distress and moral injury are shaped by a person’s characteristics and social support, as well as occupational, structural, and broader institutional factors that influence how they process and recover from transgressive experiences. I’m glad to see research results like this on prevalence rates in veterans, yet the findings reveal we have much more to uncover.
Additional Resources
For more information about moral injury, visit the National Center for PTSD: https://www.ptsd.va.gov/understand/related/moral_injury_ptsd.asp
For a practical book on moral injury, with chapters dedicated to different clinical approaches for helping clients with moral injury, check out Addressing Moral Injury in Clinical Practice: https://www.apa.org/pubs/books/addressing-moral-injury-clinical-practice
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Paula Domenici, Ph.D., is the Director, Civilian Public & Private Partnerships (CP3) at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for service members and veterans.
References
Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L.,
Frankfurt, S., Zerach, G., & Levi-Bels, Y., and the Moral Injury Outcome Scale Consortium.
(2022). Defining and assessing the syndrome of moral injury: Initial
findings of the moral injury outcome scale consortium. Frontiers in Psychiatry,
13, 923928. https://doi.org/10.3389/fpsyt.2022.923928
Litz, B. T., Walker, H. E., Pietrzak, R. H., Rusowicz-Orazem, L. (2025), The prevalence of moral
distress and moral injury among U.S. veterans, Journal of Psychiatric Research, 189,
435-444. https://doi.org/10.1016/j.jpsychires.2025.06.031
Norman, S. B., Griffin, B. J., Pietrzak, R. H., McLean, C., Hamblen, J. L., & Maguen, S. (2024).
The moral injury and distress scale: Psychometric evaluation and initial validation in
three high-risk populations. Trauma Psychology: Theory, Research, Practice, and Policy,
16(2), 280-291. https://doi.org/10.1037/tra0001533
Phelps, A., Adler, A. B., Belanger, S. A., Bennet, C., Cramm, H., Dell, L., Fikretoglu, D., Forbes,
D., Heber, A., Hosseiny, F., Morganstein, J. C., Murphy, D., Nazarov, A., Pedlar, D.,
Richardson, J. D., Sadler, N., Williamson, V., Greenberg, N., & Jetly, R. (2024).
Addressing moral injury in the military. BMJ Military Health, 170(1),
51-55. http://dx.doi.org/10.1136/bmjmilitary-2022-002128
Moral injury remains a murky concept, despite the growing body of literature on this important topic. While there’s not a consensus on exactly what moral injury is, Phelps et al. (2024) describe it as enduring psychological, social, and spiritual distress that can occur when individuals are exposed to high-pressure situations that violate or clash with their deeply-held moral beliefs or values. Moral injury may stem from one’s own actions or inactions, the actions of others, or a perceived betrayal by trusted leaders or institutions. In military contexts, including those with complex rules of engagement, moral injury may occur after engaging in or witnessing acts that conflict with one’s sense of right and wrong, such as causing harm to civilians, being unable to prevent the loss of life, seeing human suffering, or feeling deeply misled by command.
Litz et al. (2022) nicely differentiate moral injury from moral distress, noting that moral injury requires exposure to potentially morally injurious events (PMIEs) that involve both agentic acts (committing or failing to prevent transgressions oneself) and non-agentic experiences (witnessing or being directly affected by others' transgressions). In contrast, moral stress involves exposure to moral stressors that are less severe or lower-magnitude transgressive experiences. Moral distress is a preclinical condition with less functional impairment than moral injury.
Refinements in the definition of moral injury like those mentioned above, as well as the development of psychometrically-validated measures, are helping us better understand this concept. The Moral Injury Outcomes Scale (MIOS; Litz et al., 2022) has individuals consider whether they have been exposed to different types of PMIEs, and if they have, they proceed to respond to 14 items based on two subscales: shame and trust violation. Afterwards, they indicate the impact of moral injury symptoms on different aspects of their life by responding to an eight-item functional outcome measure adapted from the Brief Inventory of Psychosocial Functioning. Learn more about the MIOS here: https://sites.bu.edu/litzlab/additional-resources-on-moral-injury/.
Last year, I wrote about another useful self-report measure called the Moral Injury and Distress Scale (MIDS; Norman, Griffin, Pietrzak, McLean, Hamblen, & Maguen, 2024). Discover more about it here: https://ptsd.va.gov/professional/assessment/te-measures/mids.asp.
Between 2-10 November 2023, Litz et al. used the MIOS to survey a nationally representative sample of 3,002 U.S. veterans online about exposure to PMIEs and identify rates of moral distress and moral injury. The results are hot off the press (Litz et al., 2025). The goal was to estimate the prevalence and significance of these conditions to help educate clinicians and inform future directions in the field. The authors stress that “understanding the prevalence and characteristics of moral distress and moral injury is essential for tailoring prevention efforts, supporting affected individuals, and informing clinical and policy decisions.” Based on the survey results, 44.7% of the respondents endorsed PMIEs. What do you think about this rate? Are you surprised? More specifically:
- 45.2% reported non-agentic experiences in which they witnessed others’ transgressions
- 40.2% reported non-agentic experiences in which they were directly affected by others’ transgressions
- 14% reported agentic experiences in which they committed or failed to prevent transgressions
Interestingly, exposure to PMIEs was more likely among veterans who were female, younger, lower-income, unmarried, and had some college education. PMIE exposure was also more likely to be reported by veterans who had deployed to a warzone or held junior enlisted ranks. According to the authors, these findings suggest that exposure to PMIEs is not an inevitable part of military service. In other words, we shouldn’t make the assumption that all service members experience PMIEs. Why veterans with these backgrounds were more apt to experience PMIEs is unclear. Also, I’m curious if those who completed the survey may have underreported PMIEs, particularly PMIEs involving acts of perpetration.
With respect to rates of moral distress and moral injury in the full sample, these were relatively low. The prevalence was 4.1% for moral distress and 5.9% for moral injury. Keep in mind that lower overall rates were expected, since veterans who did not endorse PMIEs were included in the rates but were not at risk for these conditions. However, even among those who reported experiencing PMIEs, the rates were not very high—9.1% for moral distress and 13.1% for moral injury. The authors suggest that these relatively low rates underscore that, like PTSD, moral distress and moral injury are tied to specific stressful events and that PMIE exposure, in and of itself, does not automatically lead to moral distress or moral injury. At the same time, for those who suffer from moral distress or moral injury, providing access to psychoeducation, support, and treatment is critical. Additionally, it’s essential when working with clients that we try to prevent moral distress from morphing into moral injury—a much more debilitating and enduring condition.
Certain factors were associated with a greater likelihood of moral injury, including Hispanic ethnicity, not being married, older age, and endorsing agentic PMIEs (events involving committing or failing to prevent transgressions). Moral distress was more likely among those veterans who were female, older, had deployed to warzones (especially multiple times), and those who had experienced agentic PMIEs. Based on these findings, the authors propose that moral distress and moral injury are shaped by a person’s characteristics and social support, as well as occupational, structural, and broader institutional factors that influence how they process and recover from transgressive experiences. I’m glad to see research results like this on prevalence rates in veterans, yet the findings reveal we have much more to uncover.
Additional Resources
For more information about moral injury, visit the National Center for PTSD: https://www.ptsd.va.gov/understand/related/moral_injury_ptsd.asp
For a practical book on moral injury, with chapters dedicated to different clinical approaches for helping clients with moral injury, check out Addressing Moral Injury in Clinical Practice: https://www.apa.org/pubs/books/addressing-moral-injury-clinical-practice
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Paula Domenici, Ph.D., is the Director, Civilian Public & Private Partnerships (CP3) at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for service members and veterans.
References
Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L.,
Frankfurt, S., Zerach, G., & Levi-Bels, Y., and the Moral Injury Outcome Scale Consortium.
(2022). Defining and assessing the syndrome of moral injury: Initial
findings of the moral injury outcome scale consortium. Frontiers in Psychiatry,
13, 923928. https://doi.org/10.3389/fpsyt.2022.923928
Litz, B. T., Walker, H. E., Pietrzak, R. H., Rusowicz-Orazem, L. (2025), The prevalence of moral
distress and moral injury among U.S. veterans, Journal of Psychiatric Research, 189,
435-444. https://doi.org/10.1016/j.jpsychires.2025.06.031
Norman, S. B., Griffin, B. J., Pietrzak, R. H., McLean, C., Hamblen, J. L., & Maguen, S. (2024).
The moral injury and distress scale: Psychometric evaluation and initial validation in
three high-risk populations. Trauma Psychology: Theory, Research, Practice, and Policy,
16(2), 280-291. https://doi.org/10.1037/tra0001533
Phelps, A., Adler, A. B., Belanger, S. A., Bennet, C., Cramm, H., Dell, L., Fikretoglu, D., Forbes,
D., Heber, A., Hosseiny, F., Morganstein, J. C., Murphy, D., Nazarov, A., Pedlar, D.,
Richardson, J. D., Sadler, N., Williamson, V., Greenberg, N., & Jetly, R. (2024).
Addressing moral injury in the military. BMJ Military Health, 170(1),
51-55. http://dx.doi.org/10.1136/bmjmilitary-2022-002128