Clinical psychiatrist Dr. Jonathan Shay first coined the term "moral injury" in the 1990s, characterizing it as the "undoing of the soul." He wrote that "Moral injury is present when (1) there has been a betrayal of what is morally correct; (2) by someone who holds legitimate authority; and (3) in a high-stakes situation."

Chaplain (Col.) Thomas Waynick, Pentagon Chaplain, led a workshop on "Moral Injury in the Military Context" at the American Association of Pastoral Counselors annual conference in St. Louis, Missouri in April 2014. With many civilian pastoral counselors and psychotherapists who work with Reserve and Guard Veterans in attendance, the event helped extend the reach of military ministry and expand the understanding of Veteran needs.

The Chaplain Corps is in the process of creating new training on moral injury for all Family Life Chaplains, but it is not a new concern. Caregivers including clergy have always helped service members manage moral injury as they continue to fight personal battles after returning home from war. But as more and more Veterans begin to reintegrate back into civilian life after tours in Iraq and Afghanistan, there is continued interest in moral injury within the medical and religious fields -- the "healing communities," as Waynick refers to them.

"Moral injury is that serious transgression that leads to a mortal conflict of the soul when one's experience is at odds with one's core ethical or moral beliefs," Waynick said in his presentation. "The transgression stands in opposition to the values of the soul and thus splits the self into a battle of competing parts which destroys a sense of wholeness and being. Soldiers have often reported 'my soul has fled.'"

Moral injury varies from person to person, but can result in feelings of shame, guilt, and self-handicapping behaviors. There is a distinction between post-traumatic stress and moral injury. A person can have one without the other, or they can be interrelated.

One way to explain how the concept may occur, is "doing what you think is right in the situation, but this action, in turn violates a core moral value that you have," Chaplain Waynick said.

A moral injury does not simply occur when somebody does something they consider amoral, though. Soldiers are trained to overcome a natural aversion to killing enemies in combat situations to safeguard their own lives and the lives of others. In the heat of battle, though, lines can be blurred and split second decisions must be made on limited information.

A person doesn't have to be present at the event to experience moral injury, either. Commanders may experience moral injury in the form of guilt for leading Soldiers into combat, for example. In his presentation, Waynick referred to commanders who carry cards with them at all times representing the Soldiers they have lost. Chaplains, who are non-combatants, may also be witness to or hear the story of tragedies, which can elicit powerful emotional responses.

In the past, warfare was relatively clear. People knew they had to fight to save their village from outside enemies, for example.

"Warfare is far more complex today," Waynick said. "It is not always as easy to make sense of the violence witnessed or engaged in, which makes our moral reasoning more difficult."

The violence and lethality that coincides with the emergence of modern weapons, combined with having to make quick decisions in the moment during combat also lends itself to more opportunities for moral injury. "VUCA" is an acronym used to describe the volatility, uncertainty, complexity and ambiguity that comprise the nature of modern warfare.

Though moral injury may be more prevalent in today's wars, there is an irony within the cultural beliefs of the society to which service members return, Waynick says.

"We live in a post-modern world without absolutes and without a lot of moral authority," Waynick said. "We believe that we can fix everything through technology, education, medicine -- and when we are talking about moral injury, we are talking about a fix that requires time, a relationship, and a search of the soul. It involves forgiveness and guilt. It involves a lot of the concepts that people's religions have always promoted -- but the cultural beliefs of our current society put less emphasis on and give less credence to matters of the soul."

Waynick spoke of a Native American tradition in which the tribe would symbolically take on the transgressions of warriors when they returned from battle. Within American culture, combat Veterans are typically lauded as heroes whose service helps keep America free. A dichotomy may exist for service members if they carry guilt for actions, which may be in opposition to the appreciation their communities show for their service.

"Religious traditions provide a framework to work through moral injury and moral dilemmas," Waynick says. "There are also non-religious ways to approach the issue, but it is predominately a spiritual, existential issue."

Adaptive Disclosure Therapy (ADT) is one approach to treat moral injury. ADT is a six week process designed by psychologist Brett Litz and his team in which "Soldiers close their eyes and imagine they are speaking to an unconditionally-loving and non-judging person."

This process models a common religious ritual, Waynick says -- prayer. In prayer, people can speak with God as a source of unconditional love without judgment. Chaplains and clergy can support service members by facilitating conversations with God to work through guilt and find forgiveness.

"Combat comes at a cost -- it comes at a moral cost," Waynick said. "The good news is that in the safety of safe, caring relationships, to both human beings and to our God, people can find forgiveness and healing for moral wounds. They don't have to be mortal wounds."