Date of Award

Summer 8-2020

Document Type


Degree Name

Doctor of Philosophy (PhD)




Virginia Consortium Program in Clinical Psychology

Committee Director

Michelle L. Kelley

Committee Member

Cathy Lau-Barraco

Committee Member

Ernestine Duncan

Committee Member

Andrew Franklin

Committee Member

Anthony Perez


Exposure to morally injurious experiences (MIEs), or stressors that transgress deeply held moral beliefs, are risk factors for hazardous alcohol use and drug abuse among combat veterans. Guilt following a traumatic event also has a negative impact on veteran’s mental health and is conceptualized as a core symptom of moral injury that may elicit secondary outcomes, including substance use. Significant gaps remain in our understanding of the way MIEs and trauma-related guilt relate to hazardous alcohol use and drug abuse symptoms. Most prior research on MIEs and substance use have been limited to veterans sampled from the general population and further the role of both MIEs and trauma-related guilt in hazardous alcohol use and drug abuse symptoms has not been examined. Consequently, the present study used data collected by the Department of Veterans Affairs (VA): (1) to investigate the relationships between combat, MIEs, hazardous alcohol use, and drug abuse symptoms; (2) to explore the effects of combat and MIEs on drug abuse symptoms; (3) to examine the potential mediating role of MIEs on the association between combat and hazardous alcohol use; (4) to evaluate the effects of trauma-related guilt on combat, MIEs, and drug abuse symptoms; and (5) to examine both the individual mediating role of trauma-related guilt and the sequential mediating role of MIEs and trauma-related guilt on the combat-alcohol abuse association. The sample consisted of 285 Iraq and Afghanistan combat veterans; the majority were receiving VA benefits for service-connected disabilities. Participants completed questionnaires on combat experiences, MIEs, trauma-related guilt, hazardous alcohol use, and drug abuse symptoms. Correlational findings revealed that MIEs were positively associated with trauma-related guilt, hazardous alcohol use, and drug abuse symptoms. Hierarchical logistic regression results demonstrated that MIEs have a significant, positive effect on drug abuse symptoms. However, trauma-related guilt did not have a significant effect on drug abuse symptoms. Structural equation modeling revealed that MIEs mediated the association between combat exposure and hazardous alcohol use. However, trauma-related guilt did not mediate the associations between combat exposure, MIEs, and hazardous alcohol use. Study findings partially supported the model that substance abuse symptoms are related to MIE exposure and that MIEs are a pathway through which combat may be related to hazardous alcohol use. However, no evidence was found to support trauma-related guilt’s role in combat veterans’ alcohol use or drug abuse symptoms. Given increasing rates of substance use among recent-era veterans, it is imperative that future research explore additional mechanisms that may be associated with alcohol use and drug abuse symptoms.


The VIRGINIA CONSORTIUM PROGRAM IN CLINICAL PSYCHOLOGY is a joint program of Eastern Virginia Medical School, Norfolk State University, and Old Dominion University.


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