Moving Beyond a Suicide Attempt: Moving Beyond a Suicide Attempt: From Surviving to ThrivingFrom Surviving to Thriving

Dr. Dan ReidenbergDr. Dan ReidenbergExecutive Director - SAVEExecutive Director - SAVE

April 28, 2015April 28, 2015

This product is supported by Florida Department of Children and FamiliesSubstance Abuse and Mental Health Program Office funding.

Webinar ObjectivesWebinar ObjectivesParticipants will learn:How to help attempt survivors identify who they can talk about their attempt with and who not to.How to encourage survivors to incorporate the “survivor” identify and move toward a “thriver” identity.How to understand and differentiate between the needs and wants of attempt survivors.The current field’s work in attempt survivor efforts including the National Strategy and National Research Agenda objectives for attempt survivors.Tips for best practices in helping attempt survivors.

““Our best route to understanding suicide is Our best route to understanding suicide is directly through the study of human emotions directly through the study of human emotions described in plain English, in the words of the described in plain English, in the words of the

suicidal person.”suicidal person.”

Ed Shneidman, Ed Shneidman, The Suicidal MindThe Suicidal Mind, 1996, 1996

OutlineOutline DefinitionDefinition Facts at a GlanceFacts at a Glance Why we do and don’t talk about attempt survivorsWhy we do and don’t talk about attempt survivors National StrategyNational Strategy National Research AgendaNational Research Agenda Research on attempt survivorsResearch on attempt survivors Tips: Tips:

from the survivor perspectivefrom the survivor perspective from the provider perspectivefrom the provider perspective

Moving forwardMoving forward

SuicideSuicide

“Death caused by self-directed injurious behavior with any intent to

die as a result of the behavior.”

Source: Centers for Disease Control and Prevention (2013)

Facts at a GlanceFacts at a Glance Suicide is the tenth leading cause of death.Suicide is the tenth leading cause of death. In 2013, there were 41,149 deaths by suicide in the United In 2013, there were 41,149 deaths by suicide in the United

States.States.

Source: Centers for Disease Control and Prevention (2012)Source: Centers for Disease Control and Prevention (2012)

Facts at a GlanceFacts at a Glance Suicide rates decreased from 1990-2000 from 12.5 suicides per

100,000 to 10.4 per 100,000. Over the past decade, the rate has again increased to 12.1 per 100,000.

Every day, approximately 105 Americans die by suicide. There is one death by suicide in the US every 13 minutes. Based on data about suicides in 2009:Based on data about suicides in 2009:

33.3% of suicide decedents tested positive for alcohol;33.3% of suicide decedents tested positive for alcohol; 23% for antidepressants; and 23% for antidepressants; and 20.8% for opiates, including heroin and prescription pain 20.8% for opiates, including heroin and prescription pain

killers.killers. Suicide results in an estimated $34.6 billion in combined Suicide results in an estimated $34.6 billion in combined

medical and work loss costs.medical and work loss costs.

Source: Centers for Disease Control and Prevention (2012)

Suicide AttemptSuicide Attempt

““A non-fatal, self-directed, potentially A non-fatal, self-directed, potentially dangerous behavior with any intent to die as a dangerous behavior with any intent to die as a result of the behavior. A suicide attempt may result of the behavior. A suicide attempt may

or may not result in injury.”or may not result in injury.”

Crosby et al. (2011) Self-directed violence surveillance: Uniform Crosby et al. (2011) Self-directed violence surveillance: Uniform definitionsdefinitions..

Why Talk About Suicide Attempt Survivors?Why Talk About Suicide Attempt Survivors?

There are an estimated 1,028,725 attempts each year There are an estimated 1,028,725 attempts each year (CDC, 2013).(CDC, 2013).

11.5 million seriously considered suicide, 4.8 million made a plan 11.5 million seriously considered suicide, 4.8 million made a plan and 2.5 million attempted suicide (SAMHSA, 2012).and 2.5 million attempted suicide (SAMHSA, 2012).

25 attempts for every 1 suicide (American Association of 25 attempts for every 1 suicide (American Association of Suicidology, 2013).Suicidology, 2013). 1 attempt every 31 seconds: approximately 240 attempts in the next 1 attempt every 31 seconds: approximately 240 attempts in the next

2 hours2 hours 100-200 youth attempts for each death; 4 senior attempts for each 100-200 youth attempts for each death; 4 senior attempts for each

deathdeath

3 female attempts for each male attempt.3 female attempts for each male attempt.

Why Talk About Suicide Attempt Survivors?Why Talk About Suicide Attempt Survivors?

We suspect the true number is under-We suspect the true number is under-estimated, similar to that of actual suicides.estimated, similar to that of actual suicides.

The information they can provide for us could The information they can provide for us could help prevent other suicides.help prevent other suicides. Nonfatal self-harm is the strongest predictor of Nonfatal self-harm is the strongest predictor of

suicide.suicide.

Why Talk About Suicide Attempt Survivors?Why Talk About Suicide Attempt Survivors?

Research and Prevention: Research and Prevention: We need them but as many as 70% of attempters We need them but as many as 70% of attempters

of all ages will never make it to their first of all ages will never make it to their first outpatient appointment outpatient appointment (Knesper, 2010) (Knesper, 2010) and 50% will and 50% will never seek treatment at all never seek treatment at all (De Leo et al, 2005).(De Leo et al, 2005).

Why Don’t We Talk About Attempt Survivors?Why Don’t We Talk About Attempt Survivors?

““For a long time suicide attempt survivors were For a long time suicide attempt survivors were patients and research subjects, misunderstood and patients and research subjects, misunderstood and

anxiety-provoking in their potential deaths, and anxiety-provoking in their potential deaths, and closely associated with possible liability or litigation.” closely associated with possible liability or litigation.”

Why Don’t We Talk About Attempt Survivors?Why Don’t We Talk About Attempt Survivors?

StigmaStigma Fear of going publicFear of going public Public and healthcare providers viewed those who Public and healthcare providers viewed those who

attempt suicide negatively attempt suicide negatively (Lauber et al., 2006)(Lauber et al., 2006)

Perpetuating the attemptPerpetuating the attempt Ongoing struggle with mental illnessOngoing struggle with mental illness Media recommendationsMedia recommendations Part of the pastPart of the past What about the families perspective?What about the families perspective?

National Strategy for Suicide National Strategy for Suicide Prevention (2012)Prevention (2012)

Objective 8.5 Objective 8.5 Encourage health care delivery systems to Encourage health care delivery systems to incorporate suicide prevention and appropriate responses to incorporate suicide prevention and appropriate responses to suicide attempts as indicators of continuous quality improvement suicide attempts as indicators of continuous quality improvement efforts.efforts.

Objective 10.2 Objective 10.2 Provide appropriate clinical care to individuals Provide appropriate clinical care to individuals affected by a suicide attempt or bereaved by suicide, including affected by a suicide attempt or bereaved by suicide, including trauma treatment and care for complicated grief.trauma treatment and care for complicated grief.

Objective 10.3 Objective 10.3 Engage suicide attempt survivors in suicide Engage suicide attempt survivors in suicide prevention planning, including support services, treatment, prevention planning, including support services, treatment, community suicide prevention education, and in the development community suicide prevention education, and in the development of guidelines and protocols for suicide attempt survivor groups.of guidelines and protocols for suicide attempt survivor groups.

Research Agenda (2013)Research Agenda (2013) Aspirational Goal 6 – Aspirational Goal 6 –

Ensure that people who Ensure that people who have attempted suicide have attempted suicide can get effective can get effective interventions to prevent interventions to prevent further attempts. further attempts. (Stakeholder Survey)(Stakeholder Survey)

Became Goal #1 after Became Goal #1 after ranking rounds!ranking rounds! http://actionallianceforsuicideprevention.

org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf

Suicide Attempts in Boundaried Settings: Ways Suicide Attempts in Boundaried Settings: Ways to Reduce 648,000 Attempts by 20%to Reduce 648,000 Attempts by 20%

Logic Model for Aspirational Goal 6Logic Model for Aspirational Goal 6

ResearchResearch Klimes-Dougan, 1998Klimes-Dougan, 1998

Youth who accurately recalled suicidal content were Youth who accurately recalled suicidal content were more likely to report current distress and a history of more likely to report current distress and a history of poor self-concept than were adolescents who failed poor self-concept than were adolescents who failed to accurately recall their previous reports of suicidal to accurately recall their previous reports of suicidal content.content.

Christl et al., 2006Christl et al., 2006 Those who continued to report having attempted Those who continued to report having attempted

suicide in their lifetime were also more likely to have suicide in their lifetime were also more likely to have met DSM-IV criteria for the lifetime experience of met DSM-IV criteria for the lifetime experience of somatoform and depressive disorders.somatoform and depressive disorders.

ResearchResearch

Klimes-Dougan et al., 2007Klimes-Dougan et al., 2007 6 year longitudinal study6 year longitudinal study Replicated earlier and other findingsReplicated earlier and other findings ““For some, a tendency to forget, deny, or For some, a tendency to forget, deny, or

reinterpret suicidal thoughts and behavior may in reinterpret suicidal thoughts and behavior may in fact suggest a resilience or useful protective fact suggest a resilience or useful protective mechanism, in which case clinical efforts may mechanism, in which case clinical efforts may most effectively be directed toward enhancing most effectively be directed toward enhancing these adaptive processes.”these adaptive processes.”

The Benefit of Forgetting Suicidal Ideation The Benefit of Forgetting Suicidal Ideation (Goldney et al., 2009)(Goldney et al., 2009)

Of 302 participants at T1 with at least some degree of suicidal Of 302 participants at T1 with at least some degree of suicidal ideation (SI), 120 were assessed 4 years later (T2).ideation (SI), 120 were assessed 4 years later (T2).

At T2, 52 (43%) acknowledged SI in the past.At T2, 52 (43%) acknowledged SI in the past. Of both those who acknowledged it and those that did not, Of both those who acknowledged it and those that did not,

there were statistically significant differences on all there were statistically significant differences on all psychological measures between the two groups at T2.psychological measures between the two groups at T2.

““The present results add to the small body of literature which The present results add to the small body of literature which reports that there may be benefits to forgetting previous reports that there may be benefits to forgetting previous suicidal ideation, as those who have done so have better suicidal ideation, as those who have done so have better mental health as demonstrated by their significantly better mental health as demonstrated by their significantly better functioning on a range of psychometric measures.” (p. 37)functioning on a range of psychometric measures.” (p. 37)

Other Research FindingsOther Research Findings Hopelessness predicts suicide among psychotic Hopelessness predicts suicide among psychotic

patients more than a prior attempt (Klonsky et al., patients more than a prior attempt (Klonsky et al., 2012).2012).

Substance abuse, in particular cocaine dependence, Substance abuse, in particular cocaine dependence, was a universal predictor of suicide attempts more was a universal predictor of suicide attempts more than ideation. (McCullumsmith et al., 2013).than ideation. (McCullumsmith et al., 2013).

Providing and receiving help from peers counteracts Providing and receiving help from peers counteracts some risk factors for suicidal behaviors (Campbell & some risk factors for suicidal behaviors (Campbell & Leaver, 2003).Leaver, 2003).

Celebrities who have AttemptedCelebrities who have Attempted

Mike WallaceMike Wallace Terry BradshawTerry Bradshaw

Brooke ShieldsBrooke Shields Dorothy HamillDorothy HamillMarie OsmondMarie Osmond

OwenOwen WilsonWilson

More Celebrities who AttemptedMore Celebrities who Attempted Elton JohnElton John Princess DianaPrincess Diana Halle BarryHalle Barry Drew BarrymoreDrew Barrymore Elizabeth TaylorElizabeth Taylor Britney SpearsBritney Spears Walt DisneyWalt Disney Billy JoelBilly Joel Alexa Ray JoelAlexa Ray Joel

Clark GableClark Gable EminemEminem Paris JacksonParis Jackson Sinead O’ConnorSinead O’Connor Drew CareyDrew Carey Ozzy OsbourneOzzy Osbourne Jack OsbourneJack Osbourne

Attempt Survivor StoriesAttempt Survivor Stories

www.Livethroughthis.org: A national portrait www.Livethroughthis.org: A national portrait project of attempt survivors project of attempt survivors

Tips For Helping The Attempt Survivor: Tips For Helping The Attempt Survivor: From From The SurvivorThe Survivor Perspective Perspective

Be more empathetic Be more empathetic with young people who with young people who are dealing with are dealing with depression, show them depression, show them you not only care, but you not only care, but you understand.you understand.

Let them know they can Let them know they can have a future living with have a future living with mental illness.mental illness.

Let clients know right Let clients know right away that a serious away that a serious routine can help them routine can help them get better.get better.

Share with clients that Share with clients that they are not the only they are not the only one, millions live with one, millions live with depression every day depression every day (gets rid of the “I’m the (gets rid of the “I’m the only one” syndrome).only one” syndrome).

More Tips From More Tips From The Survivor The Survivor PerspectivePerspective

Help them understand Help them understand that they had a life that they had a life before their diagnosis before their diagnosis and their attempt, and and their attempt, and they will have a life after they will have a life after the diagnosis and the diagnosis and attempt!attempt!

““Dan treated me like a Dan treated me like a real person and like a real person and like a friend, not as “the bridge friend, not as “the bridge guy.”guy.”

Simple things mean a Simple things mean a lot (cards, notes, calls)lot (cards, notes, calls)

Self-Care: The BasicsSelf-Care: The Basics Effective treatment: qualified, competent, Effective treatment: qualified, competent,

trusted therapisttrusted therapist Talking with others: hotlines, warm lines, specific Talking with others: hotlines, warm lines, specific

friendsfriends Family/social support: time, activities, receiving Family/social support: time, activities, receiving

and giving helpand giving help Positive self-talk: affirmations, belief in oneselfPositive self-talk: affirmations, belief in oneself Distractions: hobbies, music, exerciseDistractions: hobbies, music, exercise Spirituality: prayer, meditationSpirituality: prayer, meditation

Tips For Helping The Attempt Survivor: From Tips For Helping The Attempt Survivor: From the the ProviderProvider Perspective Perspective

Explain that clients live Explain that clients live with a mental illness, they with a mental illness, they are not the mental illness are not the mental illness (their illness is not their (their illness is not their identity).identity).

Likewise, they can live Likewise, they can live knowing they made an knowing they made an attempt, but that is only a attempt, but that is only a small part of their entire small part of their entire life. life.

Help them build a new Help them build a new self-esteem.self-esteem. Advocating for oneself is Advocating for oneself is

the opposite of being self-the opposite of being self-destructivedestructive

Our past is part of us, it Our past is part of us, it is not who we are.is not who we are.

Connect with the Connect with the family. Make sure the family. Make sure the family is comfortable family is comfortable with you and what you with you and what you want the survivor to do.want the survivor to do.

Watch for your own Watch for your own fear: Ideation does not fear: Ideation does not mean hospitalizationmean hospitalization

More Tips From the More Tips From the ProviderProvider Perspective Perspective

We need to help We need to help survivors believe they survivors believe they can move beyond their can move beyond their attempt and help them attempt and help them see the future.see the future.

Make sure others don’t Make sure others don’t take advantage of their take advantage of their celebrity or notoriety.celebrity or notoriety.

Watch out for their best Watch out for their best interest-book offer.interest-book offer.

Be open to reasons for Be open to reasons for living and hearing living and hearing reasons for dying.reasons for dying.

Be supportive of the Be supportive of the struggle attempt struggle attempt survivors experience in survivors experience in their world.their world.

Help them learn when, Help them learn when, where and HOW to where and HOW to speak about it.speak about it.

More Tips From the More Tips From the ProviderProvider Perspective Perspective

Fostering hopeFostering hope Linked to self-esteem, self-efficacy, problem-solvingLinked to self-esteem, self-efficacy, problem-solving

Finding meaningFinding meaning Helps in coping with pain and sufferingHelps in coping with pain and suffering

Finding purpose: a (re)newed oneFinding purpose: a (re)newed one Help them design their own reintegration plansHelp them design their own reintegration plans Attempt survivors as helpers/peer leadersAttempt survivors as helpers/peer leaders

Support groupsSupport groups Mobile crisis responseMobile crisis response Public speakingPublic speaking Serving on boardsServing on boards Testifying in hearingsTestifying in hearings

The Movement Beyond FearThe Movement Beyond Fear

““I am tired of hiding, tired of misspent and I am tired of hiding, tired of misspent and knotted energies, tired of the hypocrisy, and knotted energies, tired of the hypocrisy, and tired of acting as though I have something to tired of acting as though I have something to

hide.”hide.”

Kay Redfield Jamison, Kay Redfield Jamison, An Unquiet MindAn Unquiet Mind, 1997, 1997

Attempt Survivor DivisionAttempt Survivor Division

The Way Forward: Core ValuesThe Way Forward: Core Values Foster hope and help people find meaning in life.Foster hope and help people find meaning in life. Preserve dignity and counter stigma, shame and Preserve dignity and counter stigma, shame and

discrimination.discrimination. Connect people to peer supports.Connect people to peer supports. Promote community connectedness.Promote community connectedness. Engage and support family and friends.Engage and support family and friends. Respect and support cultural, ethnic, and/or Respect and support cultural, ethnic, and/or

spiritual beliefs and traditions.spiritual beliefs and traditions. Promote choice and collaboration in care.Promote choice and collaboration in care. Provide timely access to care and support.Provide timely access to care and support.

Moving ForwardMoving Forward Research tells us we develop a narrative of who we are. Research tells us we develop a narrative of who we are.

Therefore, we need to help attempt survivors build a Therefore, we need to help attempt survivors build a narrative not only around suicide attempt, but new life.narrative not only around suicide attempt, but new life.

The narrative should expand on and include other life The narrative should expand on and include other life tragedies--helps with perspective.tragedies--helps with perspective.

Remember that moving on with work, play, helping others, Remember that moving on with work, play, helping others, keeping the focus off of them and their story has both keeping the focus off of them and their story has both positive and negative aspects.positive and negative aspects.

Help survivors learn how to moderate the attempt, then Help survivors learn how to moderate the attempt, then move on. Don’t deny right away or later.move on. Don’t deny right away or later.

Moving ForwardMoving Forward Follow-up protocolsFollow-up protocols Better training for emergency department Better training for emergency department

physiciansphysicians ListeningListening CompassionCompassion

Better training for First RespondersBetter training for First Responders ResourcesResources

FamilyFamily FriendsFriends Co-workersCo-workers

Moving ForwardMoving Forward

Promote hiring of attempt survivors.Promote hiring of attempt survivors.

Develop policies for work places on suicide Develop policies for work places on suicide prevention – including attempt survivors.prevention – including attempt survivors.

Offer community support programs, space, Offer community support programs, space, training, etc. for attempt survivors.training, etc. for attempt survivors.

Moving ForwardMoving Forward Bibliotherapy: An expressive therapy that uses Bibliotherapy: An expressive therapy that uses

an individual's relationship to the content of an individual's relationship to the content of books and poetry and other written words as books and poetry and other written words as therapy. Often combined with writing therapy. Often combined with writing therapy, it has been shown to be effective in therapy, it has been shown to be effective in the treatment of depression. Other research the treatment of depression. Other research has demonstrated increased resilience, has demonstrated increased resilience, decreased psychological distress and less decreased psychological distress and less suicidal ideation (Songprakun, 2012; Van suicidal ideation (Songprakun, 2012; Van Spijker, 2012).Spijker, 2012).

Thank you!Thank you!

www.save.org

ResourcesResources The Center for Dignity, Recovery and Empowerment The Center for Dignity, Recovery and Empowerment

http://www.dignityandrecoverycenter.org/center-http://www.dignityandrecoverycenter.org/center-programs/transforming-suicide-preventionprograms/transforming-suicide-prevention

Didi Hirsch http://www.didihirsch.org/survivors-of-Didi Hirsch http://www.didihirsch.org/survivors-of-suicide-attempt-support-groupsuicide-attempt-support-group

Continuity of Care for Suicide Prevention and Research Continuity of Care for Suicide Prevention and Research http://www.sprc.org/sites/sprc.org/files/library/continhttp://www.sprc.org/sites/sprc.org/files/library/continuityofcare.pdfuityofcare.pdf

The Way Forward The Way Forward http://actionallianceforsuicideprevention.org/sites/acthttp://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/The-Way-ionallianceforsuicideprevention.org/files/The-Way-Forward-Final-2014-07-01.pdfForward-Final-2014-07-01.pdf

ReferencesReferences Campbell, J. & Leaver, J. Emerging new practices in organized peer support. Report Campbell, J. & Leaver, J. Emerging new practices in organized peer support. Report

from the National Technical Assistance Center National Experts Meeting, from the National Technical Assistance Center National Experts Meeting, Alexandria, VA. 2003:17-18.Alexandria, VA. 2003:17-18.

Christl, B., Wittchen, H.-U., Pfister, H., Leib, R., & Bronisch, T. (2006). The accuracy Christl, B., Wittchen, H.-U., Pfister, H., Leib, R., & Bronisch, T. (2006). The accuracy of prevalence estimations for suicide attempts. How reliably do adolescents and of prevalence estimations for suicide attempts. How reliably do adolescents and young adults report their suicide attempts? young adults report their suicide attempts? Archives of Suicide ResearchArchives of Suicide Research, 10, 253-, 10, 253-263.263.

Crosby, A., Ortega, L, Melanson, C. Self-directed violence surveillance: Uniform Crosby, A., Ortega, L, Melanson, C. Self-directed violence surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta, GA: CDC, definitions and recommended data elements, Version 1.0. Atlanta, GA: CDC, NCIPC, 2011.NCIPC, 2011.

Goldney, R., Winefield, A., Winefield,, H., & Saebel, J. (2009). The benefit of Goldney, R., Winefield, A., Winefield,, H., & Saebel, J. (2009). The benefit of forgetting suicidal ideation. forgetting suicidal ideation. Suicide and Life Threatening BehaviorSuicide and Life Threatening Behavior, 39(1), 33-37., 39(1), 33-37.

Klimes-Dougan, B., Safer, M., Ronnsaville, D., Tinsley, R., & Harris, S. (2007). The Klimes-Dougan, B., Safer, M., Ronnsaville, D., Tinsley, R., & Harris, S. (2007). The value of forgetting suicidal thoughts and behavior. value of forgetting suicidal thoughts and behavior. Suicide and Life Threatening Suicide and Life Threatening BehaviorBehavior, 37(4), 431-438., 37(4), 431-438.

ReferencesReferences Klimes-Dougan, B. (1998). Screening for suicidal ideation in children and Klimes-Dougan, B. (1998). Screening for suicidal ideation in children and

adolescents: Methodological considerations. adolescents: Methodological considerations. Journal of AdolescenceJournal of Adolescence, 21, 435-444., 21, 435-444. Klonsky, E., Kotov, R., Bakst, S., Rabinowitz, J., & Broment, E. Hopelessness as a Klonsky, E., Kotov, R., Bakst, S., Rabinowitz, J., & Broment, E. Hopelessness as a

predictor of attempted suicide among first admission patients with psychosis: a predictor of attempted suicide among first admission patients with psychosis: a 10-year cohort study. 10-year cohort study. Suicide and Life Threatening BehaviorSuicide and Life Threatening Behavior, 42 (1), 1-10., 42 (1), 1-10.

Knesper, D. American Association of Suicidology, Suicide Prevention Resource Knesper, D. American Association of Suicidology, Suicide Prevention Resource Center. Continuity of Care for Suicide Prevention and Research. 2010.Center. Continuity of Care for Suicide Prevention and Research. 2010.

McCullumsmith, C., Clark, C., Perkins, A., Fife, J., & Cropsey, K. Gender and racial McCullumsmith, C., Clark, C., Perkins, A., Fife, J., & Cropsey, K. Gender and racial differences for suicide attempters and ideators in a high risk community differences for suicide attempters and ideators in a high risk community corrections population. corrections population. CrisisCrisis, 34 (1), 50-62., 34 (1), 50-62.

McMenamy, J., Jordan, J., & Mitchell, A. (2008). What do suicide survivors tell us McMenamy, J., Jordan, J., & Mitchell, A. (2008). What do suicide survivors tell us they need? Results of a pilot study. they need? Results of a pilot study. Suicide and Life Threatening BehaviorSuicide and Life Threatening Behavior, 38(4), , 38(4), 375-398.375-398.

ReferencesReferences

Songprakun, W., McCannn, T. Evaluation of a Songprakun, W., McCannn, T. Evaluation of a bibliotherapy manual for reducing psychological bibliotherapy manual for reducing psychological distress in people with depression: A randomized distress in people with depression: A randomized control trial. control trial. J Adv NursJ Adv Nurs. 2012; 68(12):2674-2684.. 2012; 68(12):2674-2684.

van Spijker, B., van Straten, A., & Kerkhof, A. The van Spijker, B., van Straten, A., & Kerkhof, A. The effectiveness of a web-based self-help effectiveness of a web-based self-help intervention to reduce suicidal thoughts: A intervention to reduce suicidal thoughts: A randomized control trial. Dept of Clin Psychology, randomized control trial. Dept of Clin Psychology, VU University of Amsterdam; 2012.VU University of Amsterdam; 2012.