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Moral Injury Outcome Scale


The MIOS is a self-report questionnaire that assesses psychosocial outcomes from exposure to potentially morally injurious events (PMIEs). The MIOS can be used in research and clinical settings as part of a mental health assessment to identify exposure to an index potentially morally injurious experience and to assess the presence and severity of potential moral injury outcomes. Similarly, it can be used to track change in MI symptoms in treatment.

Author/Publisher Details

Litz et al., 2022. Frontiers in Psychiatry.


Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., & 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




MIOS Research version

The first page entails an assessment of

  1. exposure to one or more of three broad types of PMIEs, defined as events that went against the person’s moral code or values (doing something or failing to do something, observing someone else acting or failing to act, or being directly impacted by someone else [or people] acting or failing to act)
  2. whether the worst and most currently distressing event meets the Criterion-A definition of a traumatic event
  3. in those cases when the PMIE is a traumatic event, PTSD symptoms endorsed.

The second page includes the 14 MIOS items, indexed to the PMIE that is the worst and most currently distressing. Respondents are asked to indicate how strongly they agree with each statement in the past month.

The MIOS is followed by the Brief Inventory of Psychosocial Functioning (B-IPF; Kleiman et al., 2020) in which individuals are asked to rate the degree of functional impact of the MIOS symptoms endorsed across 8 domains (romantic relationships, relationships with children, family relationships, friendships or socializing, work, training and education, day to day activities and religious faith/spirituality). The religious faith/spirituality item has been added to the original 7-item B-IPF. Respondents only rate the domains that are relevant to them.

Moral injury “caseness” requires consideration of a combination of symptom severity and substantial functional impairment associated with those symptoms. Future research will investigate the optimal threshold severity score on the MIOS that is associated with functionally impairing MI.

In the Australian sample used in the MIOS validation study, a score of 37 or above on the MIOS (1 standard deviation above the mean) was associated with functional impairment and so this score can be considered to indicate probable MI in this sample. However, the score associated with MI “caseness” may differ across different study populations and further research is required to establish the optimal severity score across populations.

The sharing of de-identified MIOS data with the International Collaboration is strongly encouraged. All available data will contribute to the generation of population norms and the caseness definition.

MIOS brief clinical version
One page long and assesses exposure to PMIEs, moral injury outcomes, and functional impact only.


Scale Structure

  • The first question is a dichotomous yes/no to determine whether an individual should complete the MIOS. Persons who answer no should not complete the MIOS. The next question determines which type of moral injury experience(s) is most currently distressing. These initial questions are not scored
  • The 14-item scale is the MIOS (see below for scoring information)
  • The 8 items following the MIOS are based on the Brief Inventory of Psychosocial Functioning (originally 7 items; we added an item about faith/spirituality).

MIOS Scoring Instructions
The 14-item MIOS is comprised of two subscales, and scale scores are indexed by the sum of item scores as follows

  1. Subscale 1: Shame-related Outcomes – items 1, 3, 7, 8, 12, 13, 14 [range 0-28]
  2. Subscale 2: Trust Violation-related Outcomes – items 2, 4, 5, 6, 9, 10, 11 [range 0-28]
  3. Total Score: all items [range 0-56]

Higher scores indicate greater levels of current moral injury. There are currently no proposed scoring categories or cut offs.

Functional Outcomes Scoring Instructions
The 8-item functional outcome measure is adapted from the Brief Inventory of Psychosocial Functioning. Responses on these items may be considered independently for clinical purposes. Some items may not be applicable for different persons. An overall impression of functional impairment can be obtained by calculating as follows

  1. Sum responses for all answered items.
  2. Divide by the total number of items answered.
  3. Multiply by 100. [range 0-60]

Higher scores indicate more functional impairment. There are currently no proposed scoring categories or cut offs.




There are two versions of MIOS. One is for research purposes and the other is a brief version for most clinical applications, but it can also be used for research.

Key/Core References


  • The Moral Injury Outcome Scale (2021). Litz, B.T., Phelps, A., Frankfurt, S., Murphy, D. Nazarov, A. Houle, S., Levi-Belz, Y., Zerach, G., Dell, L., Hosseiny, F., and the members of the Moral Injury Outcome Scale (MIOS) Consortium.
    • MIOS consortium activities were supported in part by VA Cooperative Studies Program, Office of Research and Development, US Department of Veterans Affairs
  • Department of Veterans’ Affairs Australia, Phoenix Australia - Centre for Posttraumatic Mental Health; and the Canadian Centre of Excellence on PTSD and Related Mental Health Conditions.
  • The Primary Care PTSD Screen for DSM-5 (Prins et al., 2016).
  • The Brief Inventory of Psychosocial Functioning (Kleiman et al., 2020).
  • The Brief Inventory of Psychosocial Functioning (Kleiman et al., 2020).