Please note that VA’s submission of these technical
comments does not reflect the views of VA or the
Administration, and does not indicate that the
Administration is taking a position on the bill.
Response on posttraumatic growth
It is proposed that the VA partner with one or more nonprofit organizations to conduct a
two-year pilot study of the effectiveness of posttraumatic growth programs for veterans
at risk for suicide. Under this proposal, 24 groups of no more than six veterans would be
established at more than one location around the US. At least one rural location must be
established, and at least four of the groups must include only women. To be included, a
veteran must be at risk for suicide and not receiving traditional mental health treatment.
The nonprofit partner must have staff with expertise in evidence-based care, experience
working with veterans, experience in the science of posttraumatic growth, and must use
a “standardized, evaluated and comprehensive curriculum.”
Conducting a pilot program to evaluate non-profit posttraumatic growth programs has
key challenges that would prevent VA from obtaining valid, actionable information:
1. It would be inappropriate to assign suicidal Veterans who are not receiving
mental health care to an intervention of unknown effectiveness. Veterans known
to be suicidal should be immediately referred into VA or non-VA evidence-based
mental health care and other supportive services.
2. There is insufficient information to inform decisions about which posttraumatic
growth program(s) to study. Although there are some programs based on the
posttraumatic growth literature, there is no specific evidence-based posttraumatic
growth treatment protocol. A study of this size would typically be conducted only
after there was better information about which program(s) to study and their initial
effectiveness.
3. This lack of preliminary information about program(s) efficacy prevents
determination of the adequacy of the proposal study size, which may be too
small to detect meaningful effects or unnecessarily large.
4. It is not clear what standards to use to determine whether an appropriate
nonprofit partner exists as defined in the proposal. Furthermore, it is not clear
how it will be determined whether the nonprofit partner’s posttraumatic growth
curriculum is “standardized, evaluated and comprehensive.”
5. The proposal appears to presume that the intervention would be a group
intervention with up to six participants per group, but it is premature to
predetermine group size.
6. The outcome measures are not stated, which is important for determining the
adequacy of the sample size.
7. The 2-year study timeline is not feasible for the scope of what is expected,
particularly if the duration of the intervention(s) is unknown. Assuming that the
intervention is 3 months in duration, and that follow-up of at least 6 months would
be performed in order to determine the durability of any effects, it would take 9
months for a group to be treated and evaluated. Identifying participants for the
group would add to this timeframe. With unknown capacity at sites, it is possible
that a site could run only 1 or 2 groups at a time. For this study to be completed

 Please note that VA’s submission of these technical
comments does not reflect the views of VA or the
Administration, and does not indicate that the
Administration is taking a position on the bill.
within two years, recruitment would need to occur over the first few months of the
study. This rate of recruitment of veterans not currently receiving traditional
mental health treatment may not be feasible.
8. In order to interpret findings in contrast to traditional models of mental health care
(lines 12-13), it would be necessary to include a comparison group, which would
further challenge the feasibility of completing the study within two years. The
study as proposed does not adequately control for placebo effects, which might
be expected for a novel intervention like a posttraumatic growth program.
Recommendations:
1. Conduct literature review to summarize existing knowledge about posttraumatic
growth programs
2. Determine which programs might be sufficiently structured to support more
formal evaluation
3. Conduct a small pilot feasibility study to inform the design of any larger study if
pilot findings suggest a larger study would be warranted
4. Exclude participants at known risk of suicide