Exploring the relationship between Adverse Childhood Experiences and Moral Injury in UK Treatment-Seeking Veterans

Background: Veterans report higher rates of common mental health difficulties (CMD),
post-traumatic stress disorder (PTSD) and alcohol misuse. Increased exposure to adverse
childhood experiences (ACEs) is reported by military personnel and veterans, which is a
known risk factor for poorer physical and mental health outcomes in adulthood. Veterans
face unique occupational stressors during military service, and in transitioning back into
civilian life and are at increased risk of exposure to potentially morally injurious
experiences (PMIE) and Moral Injury (MI). This study aimed to examine the relationship
between ACEs and MI in UK veterans.
Method: A secondary analysis of cross-sectional survey data was used to analyse 428
responses to a routine patient survey, carried out by specialist veteran mental health
service Combat Stress. The relationship between ACEs and MI was explored using linear
regression analysis. Further correlational analysis explored other possible associations
within this relationship.
Results: The majority of respondents experienced ACEs (74.6%) and over half (57.1%)
reported exposure to a PMIE. The mean Moral Injury Outcome Scale (MIOS) score was
33.48. High rates of CMD (80.7%), PTSD (68.7%), and problematic alcohol use (81.1%) were
reported within the sample, with 72.2% of respondents reporting low social support. ACEs
were found to be associated with MI, with Personal Abuse ACEs explaining 4.4% of the
variance in MIOS scores. Social support negatively correlated with both ACEs and MI
symptoms.
Conclusions: ACEs may be a vulnerability factor increasing the risk of MI following
experience of PMIEs during adult military service. Personal Abuse ACEs have been
associated with MI particularly in the experience of Shame-related MI symptoms, amongst
this sample of treatment-seeking UK veterans. Correlational analysis indicated a
potentially beneficial role of social support. Further research is needed to better
understand mediating factors in the relationship between ACEs and MI, with clinical
implications for supporting veterans who are at risk of, or suffering with, MI.