Veterans Driven Toward Alcohol Abuse by Betrayal, Not Just Combat: New National Trauma Research

Veterans struggling with alcohol dependency after serving in war may not be those who experienced the heaviest combat. For some, the deeper wound may be the sense that someone they trusted betrayed them.

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In a nationally representative study of 1,321 combat-exposed veterans supported by the VA’s National Center for PTSD, perceived betrayal was the strongest predictor of past-year alcohol use disorder among the three types of potentially morally injurious experiences researchers examined.

The association remained statistically significant even after researchers accounted for PTSD. Veterans with a history of PTSD were twice as likely to meet criteria for alcohol use disorder, and three times as likely to meet criteria for drug use disorder as veterans without PTSD, according to separate research cited by the VA’s National Center for PTSD.

A newer wave of the National Health and Resilience in Veterans Study, published in May in the Journal of Clinical Psychiatry, estimated lifetime PTSD prevalence among U.S. veterans at 14.4%, significantly higher than the 8% to 9.4% reported across previous survey waves dating to 2011.

The Wound That You Don’t See

Researchers call it moral injury—the damage done when someone violates their own moral code, watches others do it, or is betrayed by people they trusted.

In the veterans study, published in Psychological Medicine by researchers at the VA, the University of California, San Francisco, and Yale, 24.5% of combat veterans reported betrayal, 23.1% reported witnessing others’ transgressions, and 11.2% reported acts of their own.

Betrayal, as the survey measured it, meant feeling betrayed by leaders a veteran once trusted, by fellow service members or by others outside the military. Betrayal was tied to higher odds of screening positive for past-year alcohol use disorder and accounted for 38.7% of what the models could explain.

Witnessing was tied to higher odds of screening positive for a past-year drug use disorder, accounting for 25.8% of the model’s explained variation. Those associations remained statistically significant after researchers accounted for combat severity, lifetime trauma, depression and PTSD.

For past-year alcohol use disorder, betrayal “explained more variance than the contributions of MDD or PTSD,” the authors wrote, using the clinical shorthand for major depressive disorder.

Each of those odds was only modestly higher. Since the study captured a single moment rather than tracking veterans over time, it cannot show which came first.

However, the authors concluded that moral injury “may be a stronger contributor to SUDs among veterans than previously known.”

They also noted that “not taking exposure to PMIEs into account,” the study’s term for potentially morally injurious events, “may delay recovery or exacerbate symptoms.”

Why the Cycle Feeds Itself

For veterans with both conditions, PTSD often comes first, according to the National Center for PTSD.

People drink or use drugs to relax, to feel comfortable around others, or to avoid unwanted thoughts and feelings, the center says. Alcohol can make falling asleep easier while wreaking havoc on the sleep that follows.

Substance use impairs judgment in ways that raise the risk of accidents and other new traumas, which can produce PTSD of their own, according to the VA.

Trauma, though, is not the same thing as PTSD. Most people who experience trauma never develop the disorder, the VA says. Veterans can also experience substance use problems without PTSD, and their traumatic experiences are not limited to combat.

They can include military sexual trauma, training accidents and events outside military service.

Treating Both at Once

The VA’s answer is to stop treating them separately.

Concurrent treatment, whether two therapies running side by side or one integrated program, works for both conditions, the National Center for PTSD says.

One leading integrated option is COPE, which combines prolonged exposure therapy for trauma with cognitive behavioral therapy for substance use and which the VA calls a gold standard.

In a trial of 81 veterans led by COPE’s developer, 59.3% of those who received it no longer met criteria for PTSD after treatment, compared with 22.2% of those who received relapse prevention therapy alone, researchers reported in the journal Addictive Behaviors in 2019.

Both Groups Cut Their Substance Use by Similar Amounts During Treatment

In August, the VA said Dr. Sudie Back, the Medical University of South Carolina psychologist who led the development of COPE, is building a web-based training program so that more clinicians can deliver it, including in rural clinics “where mental health training is less accessible.”

Separately, the VA in May launched a placebo-controlled trial of MDMA-assisted therapy for about 80 veterans with both PTSD and alcohol use disorder, which Military.com previously reported.

VA and Defense Department guidance also knocks down one persistent myth, that a veteran must get sober before trauma treatment can start. Having one condition is not a reason to withhold care for the other.

Moral injury, though, “is typically not assessed or addressed as part of treatment,” the researchers wrote, warning that overlooking it “may delay recovery or exacerbate symptoms.” They urged clinicians who treat veterans for substance use to ask about morally injurious experiences alongside PTSD.

Each VA medical center has PTSD-substance use disorder specialists trained in treating both conditions, the VA says, and veterans can ask any VA provider for screening.

Veterans who served in a combat zone or experienced military sexual trauma, among other eligibility categories, can get free counseling and substance use assessments at Vet Centers whether they are enrolled in VA health care or not, according to the VA.

Veterans in crisis can reach the Veterans Crisis Line by dialing 988 and pressing 1 or texting 838255, and SAMHSA’s helpline for treatment referrals is 800-662-4357.