Date of Award

5-2026

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Applied Health Research and Evaluation

Committee Chair/Advisor

Amanda Stover, PhD

Committee Member

Sarah Griffin, PhD

Committee Member

Qiping Fan, DrPH

Committee Member

Kelsey White, PhD

Abstract

PLAIN LANGUAGE ABSTRACT

This dissertation explores how moral struggles, spiritual distress, and mental health challenges affect veterans and how they influence care-seeking support within the Department of Veterans Affairs (VA). Across three studies, the research examines how these experiences shape veterans’ well-being, their decisions to seek counseling, and the diverse role of clinical chaplains in supporting veteran mental health.

The first study examined the relationships between moral injury, spiritual injury, and religious coping in veterans who served after September 11, 2001. A survey of 625 veterans found that harmful forms of religious coping, such as feeling abandoned or punished by God, were strongly linked to greater moral injury. Other spiritual factors did not show the same relationship. These findings suggest different forms of spiritual struggle affect veterans in different ways and should not be treated as the same experience. The second study examined the factors influencing veterans’ decisions to seek counseling through the VA. Using a large dataset, a study found that veterans with higher levels of depression and moral injury were more likely to use VA counseling services. This shows moral injury plays an important role in mental health care-seeking, beyond depression, and should be considered in how services are designed and delivered. The third study explored the lived experiences of VA chaplains who support veterans’ mental health. Through interviews with chaplains, the study found that chaplains perceive they play a unique role at the intersection of spiritual and mental health. While they are deeply committed to supporting veterans, gaps exist in training, collaboration, and the use of mental health interventions.

Together, these studies highlight the importance of addressing moral, spiritual, and psychological needs together in veteran care. The findings support more integrated approaches to mental health services that combine clinical treatment, spiritual care, and collaborative support systems to better serve veterans’ complex needs.

ABSTRACT

Study 1 explored the relationships between moral injury, spiritual injury, and religious coping in post-9/11 veterans with combat exposure. Although conceptually overlapping and widely discussed in the literature, these scales have not been directly compared. Secondary data obtained from a retrospective cross-sectional study of 625 veterans were analyzed to further investigate these relationships.  Negative religious coping was significantly related to Moral Injury (r = .246, p < .01), yet spiritual injury and positive religious coping did not show meaningful associations. Negative religious coping was a significant positive predictor of moral injury severity (B = 0.661, β = 0.290, t = 7.60, p < .001). Future research would benefit from measuring the assumed relationships between conceptually overlapping scales and further distinguishing the potentially distinct components of these related psychometric measures.

Study 2 examined the associations between depressive symptoms, moral injury, and the utilization of counseling services for veterans within the Veterans Administration (VA), while accounting for demographic, military, and enabling factors. A retrospective cross-sectional analysis was conducted using survey data from a large sample of veterans in the Transitioning Veterans Metrics Initiative (TVMI). Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), and moral injury was measured using the Moral Injury Events Scale (MIES). Logistic regression models were used to estimate the odds of receiving counseling at a VA facility. Sensitivity analyses included a theory-driven adjusted model to assess the robustness of primary associations. Higher levels of depressive symptoms (OR = 1.16, 95% CI [1.14, 1.17], p < .001) and moral injury (OR = 1.02, 95% CI [1.01, 1.03], p < .001) were independently associated with increased odds of VA counseling utilization. These associations remained significant after sensitivity adjustments. Findings support the relevance of moral injury as a distinct factor in mental health service engagement among veterans and highlight the importance of considering collaborative care models to address the anticipated increase in veteran mental health needs.

Study 3 explored VA chaplains’ lived experiences regarding their support of veterans’ mental health. Using a phenomenological qualitative approach, the study explored their motivations, perceptions of mental health patterns, collaborative practices, and assessments of training adequacy. Semi-structured interviews were conducted with a purposive sample of 11 VA Chaplains. Interviews were transcribed and analyzed using thematic coding to identify themes reflecting chaplains' lived experiences. Five primary themes emerged: (1) values and purpose underpinning veteran care; (2) veteran mental health patterns; (3) chaplain interventions; (4) collaboration with mental health professionals; and (5) education and training. The study supports the chaplains’ unique role at the intersection of spiritual and mental health care within the VA. While chaplains demonstrate increased awareness of veterans’ psychological and spiritual needs, gaps persist in the application of interventions. Future research would benefit from mixed-methods approaches that could yield more comprehensive insights into the implementation of mental health initiatives.

Author ORCID Identifier

https://orcid.org/0000-0002-8499-4801

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