Moral Injury and Distress Scale (MIDS)
The MIDS is a self-report measure that assesses exposure to potentially morally injurious events (PMIEs) and the possible psychosocial and functional 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.
Author/publisher details
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
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
Sonya Norman, PhD: snorman@ucsd.edu Shira Maguen, PhD: shira.maguen@va.gov Brandon Griffin, PhD: brandon.griffin2@va.gov
Date
2024
Description
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). 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.
The MIDS is intended to be used with any population with moral injury from any type of morally injurious event (e.g., civilian, military, healthcare, other). The initial psychometric testing and validation of the MIDS included U.S. adult populations at high risk of moral injury, including combat Veterans, health care workers, and first responders.
The MIDS has been translated into Portuguese and additional translations are underway
Scoring
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 exposure 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 given the unidimensional factor structure of the MIDS, 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.
Interpretation
The MIDS can be used to identify those with clinically meaningful and impairing moral injury. A cut score of 27 on the MIDS is optimally efficient for detecting clinically significant posttraumatic stress and depression symptom severity, trauma-related guilt, and functional impairment. At a cut score of 27 roughly 70% of people screening positive on the MIDS report clinically significant mental health symptoms and 50% report severe trauma-related guilt and/or functional impairment. The MIDS is one of the only moral injury measures where data-driven methods have been used to establish a cut score for clinically meaningful and impairing moral injury.
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.
Measuring Change
Good clinical care requires that clinicians monitor patient progress. Evidence for the PCL for DSM-IV suggests that a 5-10 point change represents reliable change (i.e., change not due to chance) and a 10-20 point change represents clinically significant change. Therefore, it was recommended to use 5 points as a minimum threshold for determining whether an individual has responded to treatment and 10 points as a minimum threshold for determining whether the improvement is clinically meaningful using the PCL for DSM-IV.
Change scores for PCL-5 are currently being determined. It is expected that reliable and clinically meaningful change will be in a similar range.
Sample Item
- Item: In the past month, how much were you been bothered by: "Repeated, disturbing, and unwanted memories of the stressful experience?"
- Response: 5-point Likert (0 = "Not at all" to 4 = "Extremely")
Psychometrics
Tests of the psychometric properties of the MIDS have focused on the 18 items in Part Two of the measure, which assesses cognitive, emotional, social, and spiritual problems attributed to moral injury. Because items in Part One assess PMIE exposure and no single construct is theorized to underly the various types of exposure (i.e., exposure by witnessing or participating in a PMIE are potentially co-occurring but distinct experiences), responses to the 6 Part One items are analyzed at the item-level only.
Tests of Dimensionality
Exploratory and Confirmatory Factor Analyses support a unidimensional factor structure for the MIDS Part Two. Specifically, a one-factor solution was extracted and replicated in initial validation studies, with item loadings ranging between .56 and .84. In a series of Multigroup Confirmatory Factor Analyses, the factor configuration, item loadings, and item intercepts also were generally similar across military Veterans, healthcare workers, and first responders. Taken together, these findings suggest that responses to the MIDS Part Two items may be aggregated into a total score indicative of a single syndrome and meaningful comparisons on total scores can be made between groups the aforementioned high-risk groups.
Tests of Reliability and Stability
Internal reliability estimates are in the excellent range for MIDS Part Two scores in military Veterans (Cronbach’s α = .94), healthcare workers (α = .95), and first responders (α = .94). Stability of scores over a two-week interval (r = .68, p < .001) is similar to other scales designed to assess fluctuations in mental health symptom severity over time (e.g., PTSD Checklist for DSM-5).
Tests of Convergent Validity
Positive and large associations have been observed between MIDS Part Two scores and measures of constructs theorized to be core components of moral injury, including trauma-related shame (r = .68, p < .001) and guilt (r = .69, p < .001). MIDS scores also were positively related to scores on measures of posttraumatic stress (r = .67, p < .001), depression (r = .60, p < .001), insomnia (r = .51, p < .001), hazardous alcohol use (r = .18, p < .001), and functional impairment (r = .56, p < .001). Notably, MIDS scores predicted functional impairment more strongly than scores on commonly used PMIE exposure measures, explaining up to 7x greater unique variance (9% vs. 1-1.3% variance explained).
Tests of Clinical Utility
Because no formalized criterion for case identification with moral injury exists, the recommended cut score on the MIDS (scores ≥ 27) was determined by identifying the optimal score for detecting clinically significant mental health symptoms, trauma-related guilt, and functional impairment. At this threshold, about 70% of those who screened positive on the MIDS reported clinically significant symptoms of posttraumatic stress (Positive Predictive Value [PPV] = .76) and/or depression (PPV = .68). About 50% of respondents who screened positive on the MIDS Part Two at this threshold also endorsed severe trauma-related guilt (PPV = .54) and/or impaired psychosocial functioning (PPV = .46).
Key/Core 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
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
Translation in Brazil: https://www.global-psychotrauma.net/moral-injury
Access
The measure is also currently available at https://www.ptsd.va.gov/professional/assessment/te-measures/mids.asp#obtain
There is no cost to use the measure.
There is no manual. Scoring information is above and can be found here: https://www.ptsd.va.gov/professional/assessment/te-measures/mids.asp
Further Information
For further information, please contact the primary developers of the MIDS.
Sonya Norman, PhD: snorman@ucsd.edu
Shira Maguen, PhD: shira.maguen@va.gov
Brandon Griffin, PhD: brandon.griffin2@va.gov