As we honor the efforts and sacrifices of our soldiers on distant battlefields, Americans should keep in mind the enduring debt we owe to our country’s military veterans. News and witness accounts remind us daily of the dangers soldiers confront in combat, but we don’t often hear about another threat they frequently face when they return home: substance abuse.

Much has been researched and reported about PTSD and how it can lead to self-medication.  A less commonly discussed but equally powerful condition is moral injury.

Moral injury is a psychological trauma that describes extreme and unprecedented life experience including the aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations” Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.

Moral injury in war

  • In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations. The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.


  • Unintentional Errors: Military personnel are well trained in the rules of engagement and do a remarkable job making life or death decisions in war; however, sometimes unintentional error leads to the loss of life of non-combatants, setting the stage for moral injury.
  • Transgressive Acts of Others: Service members can be morally injured by the transgression of peers and leaders who betray expectations in egregious ways.Moral injury may result in highly aversive and haunting state of inner conflict and turmoil.

Emotional responses may include:

  • Shame,  “I am an evil terrible person; I am unforgivable”
  • Guilt
  • Anxiety about possible consequences
  • Anger about betrayal-based moral injuries

Behavioral manifestations of moral injury may include:

  • Withdrawal and self-condemnation
  • Self-harming (for example suicidal ideation or attempts)
  • Self-handicapping behaviors (for example alcohol or drug use, self-sabotaging relationships, etc.)

Mental Health and Substance Abuse Statistics

There are an estimated 23.4 million veterans in the United States, and about 2.2 million military service members and 3.1 million immediate family members.

  • Approximately 50% of returning service members who need treatment for mental health conditions seek it, but only slightly more than half who receive treatment receive adequate care.
  • Between 2004 and 2006, 7.1% of U.S. veterans met the criteria for a substance use disorder.
  • The Army suicide rate reached an all-time high in 2012.
  • In the 5 years from 2005 to 2009, more than 1,100 members of the Armed Forces took their own lives, an average of 1 suicide every 36 hours.
  • Mental and substance use disorders caused more hospitalizations among U.S. troops in 2009 than any other cause.
  • Prescription drug abuse doubled among U.S. military personnel from 2002 to 2005 and almost tripled between 2005 and 2008.
  • An internal Army investigation report released Tuesday revealed that 25% to 35% of about 10,000 soldiers assigned to special units for the wounded, ill or injured are addicted to or dependent on drugs, according to their nurses and case managers.
  • In an attempt to respond to the needs of the men and women of our active duty military and returning veterans, “military doctors wrote almost 3.8 million prescriptions for pain relief medication for service members in 2009- four times more than the 866,773 doses handed out in 2001, according to data from the Pentagon health office.”
    (USA Today, March 17, 2010)
  • From 2005 to 2009, the number of troops diagnosed each year with substance abuse disorders jumped 50% to nearly 40,000, the Pentagon says.  And substance abuse hospitalizations increased from 100 troops per month in 2003 to more than 250 per month in 2009. Our soldiers are coming back from combat wounded, injured and in need of rehab.