PTSD: National Center for PTSD
Moral Injury and Distress Scale (MIDS)
Moral Injury and Distress Scale (MIDS)
Description
The MIDS is a self-report measure that assesses exposure to potentially morally injurious events (PMIEs) and the possible impacts of moral injury. It is designed to apply to a broad range of populations and types of PMIEs. After identifying the PMIE(s) associated with the greatest amount of current distress, respondents indicate the extent to which problems stemming from the PMIE(s) have impacted them in the past month. The scale comprehensively assesses morally injurious emotional, cognitive, religious/spiritual, social, and behavioral sequelae, ranging from milder moral distress to more severe moral injury.
The initial psychometric testing and validation of the MIDS included populations at high risk of moral injury, including combat Veterans, health care workers, and first responders.
Sample Items
Sample item asking about PMIE exposure (Part One):
Please think about whether you have ever done something, failed to do something, or witnessed an event that went against your own deeply held morals or values. We are focused here on major events that significantly impacted your life rather than smaller-scale experiences, such as hurting someone while telling a white lie. Indicate below how much the following statements are true for you.
- I acted in ways that violated my own morals or values.
- I am bothered by what I did.
- Response: 5-point Likert scale (0="Not at all" to 4="Extremely")
Sample item asking about moral injury symptoms (Part Two):
Keeping the most distressing event(s) and their impact on your life in mind, indicate how true each of the following statements was for you over the last month:
Because of what I did, failed to do, or witnessed that went against my morals and values ...
- Item: I feel guilty.
- Response: 5-point Likert scale (0="Not at all" to 4="Extremely")
Administration and Scoring
The preferred method of administration is for respondents to self-administer the MIDS. It also can be read to respondents by a clinician or researcher in person or over the telephone. The MIDS can be completed in approximately 5-10 minutes.
Part One of the MIDS contains 6 items assessing PMIE exposure in terms of what respondents witnessed or participated in by what they did (commission) or failed to do (omission). Respondents indicate the extent to which they were exposed to and bothered by each PMIE type using a 5-point response format (0 = not at all, 4 = extremely). These items can be scored in 2 ways:
- Continuous scores can be obtained by calculating the sum score for items that assess commission (items 1 and 1a), omission (items 2 and 2a), and witnessing (items 3 and 3a).
- Binary variables can be obtained by collapsing responses into 2 categories: those who denied PMIE exposure ("not at all") and those who endorsed PMIE exposure ("a little bit" to "extremely"). Because no underlying construct is theorized to influence participants' responses to the exposure items, estimates of internal reliability for the 6 PMIE items are not calculated.
Part One also includes open ended questions about the PMIE(s). These are used to determine whether the PMIE(s) meet the criteria included in the directions. These are not explicitly used in scoring beyond verifying the PMIE(s) but can be used qualitatively for clinical or research purposes.
If respondents endorsed one or more of the PMIE items (i.e., greater than not at all for any item), they are prompted to complete Part Two of the MIDS, which includes 18 questions that assess cognitive, emotional, behavioral, social, and religious/spiritual reactions indexed to a specific PMIE. Respondents indicate the extent to which each item is true of them using a 5-point response format (0 = "not at all" to 4 = "extremely"). Item responses are aggregated into a sum score, such that higher scores indicate greater severity of moral distress. Respondents who did not endorse any of the Part One items are scored zero on Part Two of the MIDS. At this point, there is not yet a cut score for the MIDS, although research is underway and scoring will be updated when this information becomes available.
The MIDS is intended to assess moral injury symptoms in the past month. Versions of the MIDS that assess symptoms over a different timeframe (e.g., past day, past week, past 3 months) have not been validated. For various reasons, it may make sense to administer the MIDS more or less frequently than once a month (e.g., multiple measurements in a clinical trial), and in those cases, the timeframe in the instructions may be changed to meet the purpose of the assessment, though providers and researchers should be aware that such changes may alter the psychometric properties of the measure.
References
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 PTSDpubs ID: 1621948
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, 1-12. https://doi.org/10.1002/jts23050 PTSDpubs ID: 1633496
To Obtain Scale
This measure was created by staff at VA's National Center for PTSD.
Download the Moral Injury and Distress Scale:
- MIDS (PDF)
Are you using this measure with U.S. Veterans or Service members?
Our PTSD Consultation Program can answer administration or scoring questions: PTSDconsult@va.gov or 866-948-7880.
Measure availability: We provide information on a variety of measures assessing trauma and PTSD. These measures are intended for use by qualified mental health professionals and researchers. Measures authored by National Center staff are available as direct downloads or by request. Measures developed outside of the National Center can be requested via contact information available on the information page for the specific measure.
