Associations Among Exposure to Potentially Morally Injurious Experiences, Spiritual Injury, and Alcohol Use Among Combat Veterans

Abstract

Potentially morally injurious experiences (PMIEs) are events that may violate deeply held values or belief systems. Combat engagement places service members at a heightened risk for PMIE exposure. Exposure to PMIEs may elicit internal conflict between moral beliefs and experiences and, if unresolved, conflict may manifest as feelings of guilt, shame, and spiritual or existential crisis. Further, distress caused by these experiences may promote harmful behaviors (e.g., excessive alcohol use), which may serve as attempts to cope with PMIEs veterans have witnessed or participated in. The present study examined a sequential mediation model in which combat exposure was associated with alcohol use (i.e., alcohol consumption, dependence symptoms, and alcohol‐related problems) via PMIE exposure and spiritual injury (e.g., alienation from and/or anger towards respective higher power) in a community sample of 380 recent‐era combat veterans. Multiple‐group sequential mediation was then used to examine whether the model fit similarly across men and women. Exposure to PMIEs and spiritual injury sequentially mediated the association between combat and alcohol; higher levels of PMIE exposure and spiritual injury were associated with increased alcohol use, R2 = .17, f2 = 0.07. The multiple‐group model showed that these associations significantly varied between genders such that the mediation was only significant among men. The results indicated that PMIEs and spiritual injury were associated with increased alcohol use, but these associations differed as a function of gender. Future research is needed to refine our understanding of moral and spiritual injury and explore possible risk and protective factors.

Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications

“…Tellingly, these were veterans for whom spirituality or religion was an important personal value, thus suggesting the need for further investigations to take into account the wide diversity of belief systems that might shape the meaning given and the consequences accruing from morally injurious events. The subsequent paper continues this theme, with Battles, Kelley, Jinkerson, Hamrick, & Hollis’ () investigation of the associations among PMIEs, spiritual injury (defined as alienation from or anger at one's deity), and the specific outcome of problematic alcohol use among combat veterans. Intriguingly, spiritual injury mediated the effects of MI on alcohol use for men but not for women in the sample, suggesting the importance for future research to examine potentially gender‐specific forms of maladaptive coping with the negative aftermath of MI.…”

Commentary on the Special Issue on Moral Injury: Advances, Gaps in Literature, and Future Directions

“…Whereas earlier reports emphasized the detrimental effects of MI on previously held beliefs about morality, goodness of people, and self (Jinkerson, ; Litz et al., ), recent work has suggested that exposure to PMIEs may further impact spiritual and religious foundations (Battles et al., ; Yeterian et al., [this issue]). Battles and colleagues () reported that spiritual injury, together with exposure to PMIEs, mediates the association between combat exposure and alcohol use among male veterans. In another study, Currier, Foster, et al.…”

The Relationship between of Moral Injury and Radicalisation: A Systematic Review

“…Previous research 48 has found that military reserve or active service status to be protective of psychological wellbeing due to higher levels of social support compared to military veterans who have left service. However, two studies did not find a consistently significant association between active or reserve status 49 and fewer PMIEs or moral injury-related mental health symptoms as compared to military veterans (see Table 6). Taken together, our result found the role of social support in moral injury development is not entirely clear and, as all of these studies included military samples, how social support influences moral injury in other contexts remains unknown.…”

“…Ames et al 37 further clarified this relationship by observing a significant positive association for religious struggles and loss of religious faith or hope and suicidality following PMIEs in U.S. military veterans. Battles et al 38 demonstrated that both higher levels of exposure to PMIEs and experiences of spiritual injury were significantly associated with increased alcohol use after combat exposure (see Table 5). However, this relationship was only significant for male veterans (data not shown in table) and could represent a gender-specific maladaptive coping mechanism to manage the negative emotions caused by spiritual injuries.…”