How Do Morally Injurious Events Affect Substance Use in Combat Veterans?

What you need to know

• Different types of morally injurious experiences are linked to alcohol and drug use disorders in combat veterans
• Witnessing morally injurious events was associated with current drug use problems
• Moral injury caused by betrayal was strongly linked to current alcohol use problems
• Assessing for moral injury may be important when treating veterans for substance use disorders

Understanding moral injury in veterans

Military service, especially in combat zones, can expose veterans to extremely challenging situations that conflict with their moral beliefs and values. These experiences are known as “potentially morally injurious events” or PMIEs. Examples include:

• Being ordered to do things that violate one’s personal ethics
• Witnessing acts of cruelty or failing to prevent harm to others
• Feeling betrayed by leaders or peers

Exposure to these morally difficult situations can lead to profound psychological distress known as moral injury. Symptoms of moral injury may include:

• Intense feelings of guilt, shame, or self-condemnation
• Loss of trust in oneself, others, or previously held moral beliefs
• A sense of betrayal or being morally tainted
• Difficulty forgiving oneself or others

Prior research has found moral injury to be associated with mental health issues like depression, post-traumatic stress disorder (PTSD), and suicidal thoughts in veterans. However, less was known about how moral injury relates to substance use problems. This study aimed to examine those connections in more detail.

The link between moral injury and substance use

Researchers analyzed data from a nationally representative survey of 1,321 U.S. combat veterans. They looked at three types of morally injurious experiences:

1. Perpetration - directly engaging in acts that violated one’s moral code
2. Witnessing - observing actions by others that were morally wrong
3. Betrayal - feeling let down by leaders or trusted others

The study examined how these different moral injury experiences related to both current and lifetime substance use disorders, including:

• Alcohol use disorder (problematic drinking)
• Drug use disorder (problematic use of illicit drugs or misuse of prescription medications)
• Any substance use disorder (either alcohol or drug problems)

Some key findings emerged:

• Veterans who reported more experiences of perpetrating morally injurious acts had higher rates of lifetime alcohol problems and substance use disorders. This suggests directly violating one’s values may lead to long-term struggles with substance use.

• Those who witnessed more morally injurious events were more likely to have current drug use disorders and substance use problems. Observing unethical actions by others appears linked to ongoing substance issues.

• Feeling betrayed by leaders or peers was strongly associated with current alcohol use disorders. This implies broken trust may drive some veterans to cope through drinking.

Importantly, these connections remained significant even after accounting for other risk factors like combat exposure, past trauma, PTSD, and depression. This indicates moral injury has a unique relationship with substance use beyond these other common issues.

Why moral injury may lead to substance use

There are several reasons why veterans who experience moral injury may be at higher risk for developing substance use problems:

Coping with guilt and shame: Moral injury often involves intense feelings of guilt, shame, and self-condemnation. Veterans may turn to alcohol or drugs to numb these painful emotions or escape from distressing memories.

Punishing oneself: Some veterans may use substances as a form of self-punishment, feeling they don’t deserve to be happy or healthy after what they’ve experienced or done.

Loss of meaning: Moral injury can shatter previously held beliefs and values, leaving veterans struggling to find purpose. Substance use may fill this void or provide temporary relief from existential distress.

Damaged relationships: The betrayal and loss of trust involved in moral injury can strain relationships. Substances may be used to cope with loneliness or difficulties connecting with others.

Avoidance: Using alcohol or drugs may help veterans avoid confronting the moral implications of their experiences or processing difficult emotions.

Impaired decision-making: Moral injury may damage one’s sense of right and wrong, potentially leading to more risk-taking behaviors like substance use.

Understanding these potential pathways can help inform treatment approaches for veterans struggling with both moral injury and substance use issues.

Implications for assessment and treatment

The study’s findings have important implications for how substance use disorders are assessed and treated in combat veterans:

Screening for moral injury: When veterans seek help for substance use problems, it may be valuable to screen for exposure to morally injurious events. This could help identify an underlying driver of their substance use.

Tailored interventions: Different types of moral injury experiences (perpetration, witnessing, betrayal) were linked to different substance use patterns. Treatment may need to be tailored based on the specific moral injuries a veteran has experienced.

Addressing moral injury in addiction treatment: Substance use treatments for veterans may be more effective if they incorporate strategies for processing moral injury, such as:

• Exploring feelings of guilt, shame, and betrayal
• Examining and potentially adjusting moral beliefs
• Practicing self-forgiveness and self-compassion
• Rebuilding a sense of meaning and purpose
• Restoring damaged relationships and social connections

Substance use awareness in moral injury treatment: When treating veterans for moral injury, clinicians should be aware of the potential for co-occurring substance use issues and screen/treat accordingly.

Family involvement: Since moral injury can strain relationships, involving family members in treatment may be beneficial for addressing both moral injury and substance use.

Long-term perspective: The study found links between moral injury and lifetime substance use disorders, highlighting the potential long-term impacts. This suggests the need for ongoing support and relapse prevention strategies.

Conclusions

• Exposure to morally injurious events is linked to both current and lifetime substance use disorders in combat veterans
• Different types of moral injury experiences (perpetration, witnessing, betrayal) may contribute to different patterns of substance use
• Assessing for moral injury may be important when treating veterans for substance use disorders
• Integrating moral injury treatment into addiction programs for veterans could potentially improve outcomes

While more research is needed, this study highlights the complex relationship between moral injury and substance use in veterans. By better understanding these connections, healthcare providers can offer more comprehensive and effective care to veterans struggling with the psychological wounds of war.