United States veterans suffer from an array of mental health and substance related problems. Traditionally, these problems have been conceptualized through fear-based models of threats to life and safety and traumatic losses. However, mounting clinical wisdom and theory suggests that posttraumatic stress disorder, depression, suicidal ideation, and substance use may not be adequately captured by current conceptualizations. Moral injury is an emerging concept that includes the more intricate spiritual, emotional, and psychological wounds that stem from ethical and moral challenges of military service. A group of veterans that may especially prone to the harmful effects of moral injury are justice-involved veterans, as they tend to report a high prevalence of traumatic event exposure, mental illness, and substance related problems. The purpose of this study is to examine the unique impact of moral injury as a contributor to the frequent problems reported by justice-involved veterans and to further understand this construct among the justice-involved veteran population.

Eighty-two veterans who presented to a central California veterans' treatment court participated in semi-structured interviews consisting of measures of moral injury, combat and non-combat trauma exposure, posttraumatic stress disorder symptoms, depressive symptoms, substances use, and suicidal ideation. The court was a jail diversion psychological and substance abuse treatment program for veterans in the local criminal justice system. Results from hierarchical multiple regression analyses indicated that moral injury contributed to the prediction of posttraumatic stress disorder symptoms, depressive symptoms, alcohol use, and drug use, even after controlling for predeployment trauma, combat exposure, and postdeployment trauma. As predicted, moral injury played a unique role in both mental health and substance use among the justice-involved veteran population, many who were never deployed and never experienced combat. Qualitative analysis examined the types of events that justice-involved veterans reported as morally injurious, revealing that unconventional traumatic events, such as perceived personal and systemic betrayals, were more frequently reported than conventional events, such as combat violence. The results were similar for both deployed and nondeployed veterans. Implications for treatment and future directions for research are discussed.