Staff Perspective: A New Moral Injury Measure
A few months ago, I was treating a patient with PTSD, but after greater exploration of his distress, which included guilt, shame, and feeling betrayed by his military boss, we fleshed out that moral injury was a salient part of his clinical picture.
Currently, there is no consensus in the field on the exact definition of moral injury, but one I like refers to it as “enduring psychosocial and spiritual harms following exposures to high-stakes events that involve transgressions of one’s deeply held moral convictions or beliefs of right and wrong through one’s own or others’ action or inaction, or perceived betrayal by those in positions of authority or trust” (Phelps et al., 2022).
A new self-report measure called the Moral Injury Distress Scale-MIDS (Norman, Griffin, Pietrzak, McLean, Hamblen, & Maguen, 2024) helped me and my patient identify his moral injury. This measure and other moral injury resources from the National Center for PTSD website (https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp) definitely enhanced our work together and were educational and validating to him.
In this blog, I want to focus on several strengths of the MIDS and encourage mental health professionals to use it as part of their routine intake paperwork with patients at risk for exposure to possible morally conflicting events. One strength of this instrument is that it has demonstrated strong psychometric properties with veterans, first responders and health care providers, broadening the populations with whom it can be used. Some older moral injury measures were designed only for use with military-connected patients.
Another benefit of the MIDS is that it opens the door to the topic of morally injurious events by providing patients with examples of experiences that may defy a person’s beliefs, values or ethics (e.g., health care workers or first responders who may have to make decisions that affect the well-being or survival of others, military service members who may cause harm or fail to protect others during war, border patrol or police officers who may receive orders that contradict their morals/values). Then it asks them whether they have (1) acted in ways that violated their own moral or values; (2) violated their own moral values by failing to do something they should have done and/or (3) saw things that violated their values or morals. If patients endorse any of these experiences, they rate how bothered they are by what happened on a 5-point Likert scale ranging from not at all to extremely. If patients don’t report any of these experiences, they stop filling out the measure..
Furthermore, a nice feature of the MIDS is that it has patients who have endorsed experiencing morally injurious events (based on questions 1-3 above) identify the incident that is most troubling to them or that they think about the most and share qualitative information about it. This includes: (a) briefly describing that event or series of events; (b) indicating what is most upsetting about it to them; (c) discussing what they would have done differently; and (d) indicating how often and how long ago the event or series of events occurred. Answers to these questions give the clinician greater understanding and context about the transgressive experience the patient is struggling with; it also may be affirming for the patient to share this information.
Next, the MIDS has patients think about the most distressing morally injurious event they have just identified and consider its impact on their life by indicating how true 18 statements about moral injury symptoms and moral distress are. Specifically, they indicate the degree to which each of the problems has affected them during the past month on a 5-point Likert scale ranging from not at all to extremely. This instruction directly connects their exposure to the morally injurious event with their moral injury symptoms and moral distress, which is an important link that some other moral injury instruments lack. There are self-reports that ask only about exposure to morally injurious events or only about moral injury symptoms in general, which can lead to erroneous assumptions or conclusions. For example, just because a patient indicates they have been exposed to several morally conflicting events does not mean they have moral injury.
An additional plus of the MIDS is that these 18 statements – linked to what a patient did, failed to do, or witnessed that went against their morals and values — reflect a fairly comprehensive set of emotional, cognitive, spiritual, social, and behavioral consequences or problems. These items get at the range of psychosocial and spiritual harms described in the definition above. Sample symptoms or problems that patients rate include the following:
- I have withdrawn from others more often.
- I feel guilty.
- I do not feel like I deserve to be happy.
- I feel helpless.
- I do not seek support because I feel like I do not deserve it.
- I feel betrayed by leaders or institutions.
- I should not be forgiven.
- My spirituality/faith is no longer a source of comfort.
- I do not take good care of myself.
At this time, researchers are recommending a cutoff of 27 based on a unidimensional sum. This cut score seems to differentiate those with milder moral distress from those with impairing moral injury or more severe moral injury (Maguen, Griffin, Pietrzak, McLean, Hamblen, & Norman, 2024).
Download the MIDS or learn more about it here: https://ptsd.va.gov/professional/assessment/te-measures/mids.asp. This fillable measure is straightforward, easy for patients to complete, and illuminating. I hope you will consider using the MIDS in your clinic practice. It has certainly enhanced my case formulations and treatment decisions.
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.
Maguen, S., Griffin, B. J., Pietrzak, R. H., McLean, C. P., Hamblen, J. L., & Norman, S. B. (2024).
Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury. Journal of
Traumatic Stress, 37(4), 685-696. https://doi.org/10.1002/jts.23050
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. Psychological Trauma: Theory, Research, Practice, and Policy, 16(2), 280-291.
https://doi.org/10.1037/tra0001533
Phelps, A. J., Adler, A. B., Belanger, S. A. H., Bennett, 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., & Members of the Five Eyes
Mental Health Research and Innovation Collaborative (2022). Addressing moral injury in the
military. BMJ Military Health, 170(1), 51–55. https://doi.org/10.1136/bmjmilitary-2022-002128
A few months ago, I was treating a patient with PTSD, but after greater exploration of his distress, which included guilt, shame, and feeling betrayed by his military boss, we fleshed out that moral injury was a salient part of his clinical picture.
Currently, there is no consensus in the field on the exact definition of moral injury, but one I like refers to it as “enduring psychosocial and spiritual harms following exposures to high-stakes events that involve transgressions of one’s deeply held moral convictions or beliefs of right and wrong through one’s own or others’ action or inaction, or perceived betrayal by those in positions of authority or trust” (Phelps et al., 2022).
A new self-report measure called the Moral Injury Distress Scale-MIDS (Norman, Griffin, Pietrzak, McLean, Hamblen, & Maguen, 2024) helped me and my patient identify his moral injury. This measure and other moral injury resources from the National Center for PTSD website (https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp) definitely enhanced our work together and were educational and validating to him.
In this blog, I want to focus on several strengths of the MIDS and encourage mental health professionals to use it as part of their routine intake paperwork with patients at risk for exposure to possible morally conflicting events. One strength of this instrument is that it has demonstrated strong psychometric properties with veterans, first responders and health care providers, broadening the populations with whom it can be used. Some older moral injury measures were designed only for use with military-connected patients.
Another benefit of the MIDS is that it opens the door to the topic of morally injurious events by providing patients with examples of experiences that may defy a person’s beliefs, values or ethics (e.g., health care workers or first responders who may have to make decisions that affect the well-being or survival of others, military service members who may cause harm or fail to protect others during war, border patrol or police officers who may receive orders that contradict their morals/values). Then it asks them whether they have (1) acted in ways that violated their own moral or values; (2) violated their own moral values by failing to do something they should have done and/or (3) saw things that violated their values or morals. If patients endorse any of these experiences, they rate how bothered they are by what happened on a 5-point Likert scale ranging from not at all to extremely. If patients don’t report any of these experiences, they stop filling out the measure..
Furthermore, a nice feature of the MIDS is that it has patients who have endorsed experiencing morally injurious events (based on questions 1-3 above) identify the incident that is most troubling to them or that they think about the most and share qualitative information about it. This includes: (a) briefly describing that event or series of events; (b) indicating what is most upsetting about it to them; (c) discussing what they would have done differently; and (d) indicating how often and how long ago the event or series of events occurred. Answers to these questions give the clinician greater understanding and context about the transgressive experience the patient is struggling with; it also may be affirming for the patient to share this information.
Next, the MIDS has patients think about the most distressing morally injurious event they have just identified and consider its impact on their life by indicating how true 18 statements about moral injury symptoms and moral distress are. Specifically, they indicate the degree to which each of the problems has affected them during the past month on a 5-point Likert scale ranging from not at all to extremely. This instruction directly connects their exposure to the morally injurious event with their moral injury symptoms and moral distress, which is an important link that some other moral injury instruments lack. There are self-reports that ask only about exposure to morally injurious events or only about moral injury symptoms in general, which can lead to erroneous assumptions or conclusions. For example, just because a patient indicates they have been exposed to several morally conflicting events does not mean they have moral injury.
An additional plus of the MIDS is that these 18 statements – linked to what a patient did, failed to do, or witnessed that went against their morals and values — reflect a fairly comprehensive set of emotional, cognitive, spiritual, social, and behavioral consequences or problems. These items get at the range of psychosocial and spiritual harms described in the definition above. Sample symptoms or problems that patients rate include the following:
- I have withdrawn from others more often.
- I feel guilty.
- I do not feel like I deserve to be happy.
- I feel helpless.
- I do not seek support because I feel like I do not deserve it.
- I feel betrayed by leaders or institutions.
- I should not be forgiven.
- My spirituality/faith is no longer a source of comfort.
- I do not take good care of myself.
At this time, researchers are recommending a cutoff of 27 based on a unidimensional sum. This cut score seems to differentiate those with milder moral distress from those with impairing moral injury or more severe moral injury (Maguen, Griffin, Pietrzak, McLean, Hamblen, & Norman, 2024).
Download the MIDS or learn more about it here: https://ptsd.va.gov/professional/assessment/te-measures/mids.asp. This fillable measure is straightforward, easy for patients to complete, and illuminating. I hope you will consider using the MIDS in your clinic practice. It has certainly enhanced my case formulations and treatment decisions.
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.
Maguen, S., Griffin, B. J., Pietrzak, R. H., McLean, C. P., Hamblen, J. L., & Norman, S. B. (2024).
Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury. Journal of
Traumatic Stress, 37(4), 685-696. https://doi.org/10.1002/jts.23050
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. Psychological Trauma: Theory, Research, Practice, and Policy, 16(2), 280-291.
https://doi.org/10.1037/tra0001533
Phelps, A. J., Adler, A. B., Belanger, S. A. H., Bennett, 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., & Members of the Five Eyes
Mental Health Research and Innovation Collaborative (2022). Addressing moral injury in the
military. BMJ Military Health, 170(1), 51–55. https://doi.org/10.1136/bmjmilitary-2022-002128