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Background on Moral Injury

Moral injury is the emotional pain and functional impairment people can experience after participating in, failing to prevent, or witnessing highly stressful events that transgress their beliefs about right and wrong. In recent years, there has been an explosion of interest in moral injury and its impacts. We now know that exposure to potentially
morally injurious events is common among many groups at high risk for trauma (e.g., veterans, healthcare professionals, first responders) and that moral injury is associated with greater risk of functional impairment, posttraumatic stress, depression, suicidal thoughts and behaviors, and problematic substance use.

Identifying Moral Injury

It is important for mental health professionals to know how to identify people with moral injury and to be able to assess if novel and existing interventions targeting moral injury and related problems are helpful to them. Yet, until recently, we have not had the tools to do so. The Moral Injury and Distress Scale (MIDS) was developed to address these gaps.

Significance of New Study

The first study of the MIDS showed that it has strong psychometric properties to measure exposure to potentially morally injurious events and related moral injury symptoms in three high-risk populations. This new study just published in the Journal of Traumatic Stress shows that the MIDS can be used to identify those with clinically meaningful and impairing moral injury. The authors examined data from 645 military veterans, healthcare workers, and first responders who endorsed exposure to potentially morally injurious events. Using signal detection methods, the authors identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depression symptom severity, trauma-related guilt, and functional impairment. A cut score of 27 was recommended because roughly 70% of participants screening positive on the MIDS at this threshold reported clinically significant mental health symptoms and 50% reported severe trauma-related guilt and/or functional impairment. This is the first study to use data-driven methods that establish a cut score for clinically meaningful and impairing moral injury. Having this cut score can help clinicians to conduct measurement-based moral injury care, identify individuals at risk of negative outcomes because of moral injury, and to better understand risk and protective factors for moral injury. The MIDS can be downloaded at this link.

Discussion Questions


About the Authors

Sonya B. Norman, PhD is director of the PTSD Consultation Program for the National Center for PTSD and a Professor of Psychiatry at the University of California, San Diego School of Medicine. Dr. Norman is a clinical psychologist and a researcher in the treatment of PTSD and addictions, and in novel treatments to address trauma-related guilt, shame, and moral injury. She serves on the board of the International Society of
Traumatic Stress. Dr. Norman can be followed on X: @sonyabn, Instagram: @sonyab100, Threads: @sonyab100, and LinkedIn.

Shira Maguen, PhD is the Mental Health Director of the Post-9/11 Integrated Care Clinic, Staff Psychologist on the PTSD Clinical Team, and a PTSD Researcher at the San Francisco Veterans Affairs Healthcare System (SFVAHCS). She is also Professor and Interim Vice Chair for SFVAHCS in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco (UCSF) School of Medicine. She also serves as the Director of the MIRECC VA Advanced Fellowship in PTSD Research and Treatment at the SFVAHCS. Dr. Maguen can be followed on LinkedIn.

Brandon J. Griffin, PhD is a research psychologist with the Central Arkansas Veterans Healthcare System (CAVHS) and South Central Mental Illness Research, Education, and Clinical Center (SCMIRECC) in Little Rock, Arkansas. He also is an Assistant Professor in the Department of Psychiatry at the University of Arkansas for Medical Sciences. Dr. Griffin studies the effectiveness and implementation of treatments designed to promote health and prevent suicide in military veterans, healthcare workers, and first responders seeking care for PTSD and moral injury. Dr. Griffin can be followed on X @BrandonJGriffin.

For more information, follow @VA_PTSD_Info, @vaptsdinfo, and @SCMIRECC.