Psychotherapy Research
ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20
“It is never okay to talk about suicide”: Patients’
reasons for concealing suicidal ideation in
psychotherapy
Matt Blanchard & Barry A. Farber
To cite this article: Matt Blanchard & Barry A. Farber (2018): “It is never okay to talk about
suicide”: Patients’ reasons for concealing suicidal ideation in psychotherapy, Psychotherapy
Research, DOI: 10.1080/10503307.2018.1543977
To link to this article: https://doi.org/10.1080/10503307.2018.1543977
Published online: 08 Nov 2018.
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Psychotherapy Research, 2018
https://doi.org/10.1080/10503307.2018.1543977
EMPIRICAL PAPER
“It is never okay to talk about suicide”: Patients’ reasons for concealing
suicidal ideation in psychotherapy
MATT BLANCHARD∗ & BARRY A. FARBER
Teachers College, Columbia University, New York, NY, USA
(Received 22 April 2018; revised 16 September 2018; accepted 22 October 2018)
Abstract
Objective: To identify psychotherapy clients’ motives for concealing suicidal ideation from their therapist, and their
perceptions of how their therapists could better elicit honest disclosure. Method: A sample of 66 psychotherapy clients
who reported concealing suicidal ideation from their therapist provided short essay responses explaining their motives for
doing so and what their therapist could do to help them be more honest. Content analysis was used to identify major
motives and themes in these responses. Results: Seventy percent of suicidal ideation concealers cited fear of unwanted
practical impacts outside therapy as the reason they did not disclose. Chief among these unwanted impacts was
involuntary hospitalization, a perceived outcome of disclosing even mild suicidal thoughts. Less concrete motives for
concealment, such as shame or embarrassment, were significant but secondary concerns. Nearly half of suicide-concealing
clients said they would be more honest only if the threat of hospitalization was somehow reduced or controlled.
Conclusion: Fostering disclosure of suicidal ideation in therapy may require renewed attention to providing transparent,
comprehensive, and easy-to-understand psychoeducation about the triggers for hospitalization and other interventions.
Clients make risk-benefit calculations about whether to disclose suicidal ideation, but may operate with exaggerated or
inaccurate ideas about the consequences of disclosure.
Keywords: Suicide; psychotherapy; disclosure; lying
Clinical or methodological significance of this article: This study’s online and anonymous design allowed for SI
concealers to describe in their own words the most important factors motivating their concealment. In this way, the study
serves as a type of “customer feedback”, offering a constructive critique of suicide risk assessment as it is presently
practiced in psychotherapy, from the point of view of patients who conceal their suicidal thoughts.
The findings suggest concealment is most often driven by practical concerns such as a fear of being hospitalized. This, in
turn, suggests renewed attention to aspects of informed consent that do not get much attention in the research.
Clients who believe—often incorrectly—that they will be involuntarily hospitalized or experience other unwanted
interventions if they disclose suicidal thoughts may feel strongly motivated to conceal no matter what method of
assessment is used, and no matter how skillful the clinician is at normalizing or reducing client shame around being suicidal.
For this reason, achieving the goal of honest disclosure may require finding ways for therapists to psycho-educate about the
basic rules of confidentiality, reporting, and hospitalization, in such a way that clients feel some measure of control or
predictability. In the majority of cases, doing so will likely alleviate unrealistic fears held by the client, and potentially
remove or at least mitigate this major barrier to disclosure.
This study adds to recent findings on suicide concealment by Hom, Stanley, Podlogar, and Joiner (2017) and Ganzini et al.
(2013), and helps to answer a call made by Hom, Stanley, and Joiner (2015) for more research with middle-aged and older
adults in a field that is dominated by studies using college undergraduates.
Although honest disclosure is central to the process of
psychotherapy (e.g., Farber, 2006; Stiles, 1995), it is
well established that clients are not always honest and
forthcoming. Just like people in all types of settings,
∗
clients in psychotherapy keep secrets (Baumann &
Hill, 2016; Kelly, 1998) and lie (Farber, Blanchard,
& Love, in press; Martin, 2006); they also minimize
discussion of personally salient topics (Farber &
Matt Blanchard is now at New York University.
Matt Blanchard, Teachers College, Columbia University, New York, NY, USA. Email: mpb2160@tc.columbia.edu; matt.blanchard@nyu.
edu
© 2018 Society for Psychotherapy Research
2
M. Blanchard and B. A. Farber
Sohn, 2007), hide their negative reactions to therapist
interventions (Hill, Thompson, Cogar, & Denman,
1993), and sometime mislead therapists about the
effectiveness of therapy itself (Blanchard & Farber,
2016).
The question of honest disclosure is especially
fraught on the subject of suicide. As Jobes and
Ballard (2011) point out, the life-and-death nature
of suicidality injects fundamental issues of power
and control into psychotherapy, stirring up strong
emotions for all involved: “the therapeutic stakes
are raised to the highest possible level … both
parties (clinician and patient) may feel vulnerable,
powerful, scared, angry, worried, wary – and sometimes all at the same time” (p. 51).
There is evidence that many clients avoid these
issues by hiding or denying suicidal ideation (SI).
In a sample of 547 adults in individual psychotherapy, Blanchard and Farber (2016) found that 31%
recalled having lied to their therapist about suicidal
thoughts at some time in the past. Similarly, a study
of 355 students seeking therapy at a college counseling center found that 13.8% denied SI when asked on
an intake questionnaire but later admitted it when
given a full suicide assessment by a counselor (Morrison & Downey, 2000). How many more of these
“hidden ideators” (we will use the term “SI concealers” for clarity) continued to conceal during the
face-to-face assessment is impossible to know.
Neither study was able to assess the true prevalence
of SI in their samples. These findings are in keeping
with a body of research that suggests concealment of
suicidal thoughts is common outside of therapy as
well. In a sample of 26,000 college undergraduate
and graduate students, 1321 responded in the affirmative when asked if they had “seriously considered
attempting suicide in the past 12 months”, and 46%
of this subsample decided to tell no one about these
thoughts (Drum, Brownson, Burton Denmark, &
Smith, 2009).
It is very difficult to predict who in the general population will attempt suicide, in part because it is a low
base-rate phenomenon (Murphy, 1984). Even
among those who experience SI, the majority will
never go on to form a suicide plan nor make a
suicide attempt (CDC, 2015; Klonsky & May, 2014;
Nock et al., 2008). While numerous risk factors have
been identified (e.g., previous attempts), these do
not translate into an ability to predict suicide-related
behaviors. A recent meta-analysis of the last 50 years
of research on risk factors suggests there is no category
of predictors which functions much better than chance
at predicting suicide-related outcomes, generating
calls for a more complex algorithms that can account
for combinations of perhaps 50 different risk factors
at once (Franklin et al., 2017).
In the absence of better tools, most clinical settings
rely on self-report questionnaires (e.g., PHQ-9) and,
even more so, the clinical interview. This involves
asking patients directly about the frequency and
intensity of suicidal thoughts, planning or preparations, desire to die and intent to attempt suicide,
as well as baseline and acute risk factors, protective
factors, and any warning signs of suicide (e.g.,
Jobes, 2006; Joiner, Van Orden, Witte, & Rudd,
2009; Maltsberger, 1986; Mays, 2004; Shea, 1999;
Welton, 2007). Clients who are strongly motivated
to conceal these types of information can usually
stymie even the most skillful interviewer without
great difficulty. Indeed, we respect the autonomy of
all people to disclose only what they wish when speaking with mental health professionals.
Honest disclosure of SI has benefits, however. For
those who may go on to attempt suicide, disclosing SI
allows their therapist to conduct a fuller assessment of
suicide risk, monitor any intensification of suicidality,
provide appropriate psychological treatments, and
intervene in a potentially lifesaving manner. For
those who will never attempt, fostering honest disclosure would at the very least mean relief from the
burden of concealment and a greater opportunity to
benefit from their mental health treatment. Understanding clients’ motivations for concealment can
help clinicians address unspoken concerns about disclosure that are acting as roadblocks. Clearing these
impediments, in turn, may increase the likelihood
that clients will honestly disclose suicidal ideation
when it is experienced.
In theory, identifying these roadblocks to disclosure requires only that researchers ask patients who
are concealing suicidal ideation to voice their concerns. Nevertheless, it is rare to find studies in
which SI concealers are invited to explain their
reasons for concealment or provide feedback to the
mental health professions who are trying to assess
them. One such study, Ganzini and colleagues’
(2013) research on brief suicide screening in US
Department of Veterans Affairs medical centers,
involved interviewing 34 Iraq and Afghanistan War
veterans about their decision to conceal or reveal
suicidal thoughts. These veterans felt that shame
and fear of career repercussions were valid reasons
not to mention suicidal thoughts. They also noted
concerns about unwanted hospitalization or medication recommendations. Veterans stressed trust
and respect as the keys to fostering honesty about a
topic they regarded as intimate and shameful. As
one veteran put it: “Those who are nice to me and
treat me with respect … will get all the information
they need from me” (p. 1218). The authors concluded that professionals who put aside the standardized screener to establish interpersonal trust with
Psychotherapy Research 3
the veterans were deemed to be safe for disclosure.
These gestures may have helped foster a stronger
therapeutic alliance, which has been found to be positively correlated with greater overall disclosure
(Farber & Hall, 2002).
Hom et al. (2017) looked at why undergraduates
decide to respond accurately or not when asked
about suicidal thoughts by various parties, including
family members, friends, teachers, religious leaders,
and mental health providers. Their sample included
306 undergraduate students who reported some lifetime history of suicidal ideation. Of this group, 77
had been asked about suicide by a psychologist,
therapist, or counselor, and 49 had been asked by a
psychiatrist, although it was not clear whether they
were in ongoing psychotherapy. Student motives for
not giving accurate information differed slightly
between psychiatrists and other mental health providers. Fear of hospitalization was most commonly
reported among those probed by psychiatrists, while
embarrassment was the most common reason for
concealment from psychologists or other nonmedical therapists. Other common motives for concealment included being judged, others finding out,
and not being taken seriously. When these undergraduates did give accurate accounts of their suicidal
thoughts to mental health professionals, it was most
commonly because they wanted emotional support
or desired help in getting treatment or medications.
These studies suggest there are many possible
reasons for concealment of suicidal ideation, some
of which are universal and some of which vary
across the contexts in which patients are assessed
(e.g., military personnel conceal out of worry about
career implications). Expectations regarding confidentiality may also affect individuals’ tendencies to
conceal suicidal thoughts. In this regard, psychotherapy clients are likely to have higher expectations of
privacy and confidentiality than, for example, undergraduates being briefly assessed in a hospital emergency room or veterans answering standardized
screening questions during a medical check-up.
What remains unstudied, though, is how these and
other considerations influence the extent to which
and reasons for which psychotherapy clients conceal
their suicidal ideation from their therapists.
More generally, the literature lacks research on
suicide concealment among middle-aged and older
adults. In their comprehensive review of the factors
affecting help-seeking among suicidal individuals,
Hom et al. (2015) note that the majority of studies
in this area focus on adolescents and young adults,
whose involvement with institutions such as colleges
make them relatively easy to study. While suicide is a
leading cause of death among young people in the
United States, middle-aged adults accounted for the
largest proportion of suicides (56%) in 2011, and
from 1999 to 2010, the suicide rate among this
group increased by nearly 30% (CDC, 2015). Hom
et al. call for research to understand the barriers and
facilitators to care unique to adults, writing “it is essential for this research gap to be addressed” (p. 35).
Ultimately, the goal of understanding client
motives for suicide concealment is to improve clinical
treatment. Only one previous study (Ganzini et al.,
2013) asked SI concealers to provide suggestions
about what therapists could do to help them be
more honest. Thus, in order to learn how psychotherapists can better elicit honest disclosure of
suicide-related material, the current study directly
queried SI concealers on their motives for concealment and their ideas about what could facilitate
their honesty in the context of their psychotherapy.
Specifically, the study’s two research questions were
(a) what most commonly motivates clients experiencing suicidal ideation to conceal this from their psychotherapist? and (b) what do suicidal ideation
concealers believe their therapist could do to help
them be more honest?
Method
Participants
Of a total of 798 respondents completing an online
survey about dishonesty in psychotherapy, 171
reported dishonesty specifically about suicidal ideation. Among these, 66 elected to answer a series of
in-depth questions about concealment. These 66
constitute the “SI Concealer” sample for this study,
defined as those who avoided disclosure of suicidal
thoughts by either actively lying or passively omitting
information on this topic. As Table I indicates, the
average age among these self-acknowledged SI concealers was 31, ranging in age from 18 to 71. This
sample consisted primarily of women (79%), with
most respondents reporting their ethnicity as White
(77%) or African-American (11%). The majority of
this sample (53%) reported having a Bachelors or
more advanced degree.
Among the 66 SI concealers, 39 were currently in
therapy and the remaining 27 had been in therapy
within the previous 12 months. The median
number of therapy sessions with their current or
most recent therapist was 35; the mean duration of
treatment with this therapist was 22.7 months (SD
= 30.3), with durations ranging from 2 months to
15 years. The most commonly reported reasons
these clients entered therapy were depression
(58%), stress (32%), and anxiety (30%), with 11%
specifically mentioning suicidal ideation. The most
commonly reported therapeutic modalities were
4
M. Blanchard and B. A. Farber
Table I. Participant demographics, SI concealer sample (N = 66).
Age
Gender
Female
Male
Other
Race/Ethnicity
African-American
Asian-American
Hispanic/Latino/a
White/Caucasian
Biracial
Other
Education Level
Grade School
High School or GED
Some college
Associate’s Degree
Bachelor’s Degree
Master’s Degree
PhD/MD/JD
n/mean
%/SD
31.1 years
13.04
52
12
2
79%
18%
3%
7
–
4
51
4
–
11%
–
6%
77%
6%
–
1
13
14
3
22
13
–
2%
20%
21%
5%
33%
20%
–
CBT (38%), psychodynamic/psychoanalytic (21%),
and integrative/eclectic (11%), while a number also
reported “other” (17%).
Measures
The original Difficult Disclosures Survey (Blanchard &
Farber, 2016) is an online, self-report instrument,
consisting of a total of 107 items developed with the
Qualtrics survey software, and designed to elicit
information from psychotherapy clients about the
topics they tend to be dishonest about in therapy,
their reasons for doing so, the perceived clinical consequences of their dishonesty, and their sense of what
their therapist could do to facilitate greater honesty.
In order to help respondents access memories of
dishonesty in their therapy, a list of 33 common disclosure topics is presented, among them suicidal
thoughts; these items were chosen after reviewing
prior research on what clients discuss in therapy.
Respondents are asked to rate their degree of
honesty for each topic they have discussed with
their current or most recent therapist on a 5-point
Likert scale (1 = “not at all honest”, 5 = “completely
honest”). For topics they indicated they have not discussed, respondents are asked to provide one of three
reasons: “It does not apply to me”, “I would discuss
this but it has not come up,” and “I purposely avoid
this topic”. Respondents who either indicate low
levels of honesty (“1” or “2” on the Likert scale) or
acknowledge purposeful avoidance about a specific
topic (e.g., suicidal ideation) are given the opportunity to answer a detailed set of follow-up questions.
These respondents first encounter open-text essay
questions, including “What makes it hard to be
honest about this?” and “How could your therapist
make you feel more comfortable being honest about
this?” Later, respondents encounter multiple-choice
questions about motives for dishonesty and potential
facilitators for honesty, in order to provide corroboration for earlier essay responses.
Procedure
Participants were recruited through postings to
Craigslist sites serving 13 large metropolitan areas
of the United States, as well as 18 more rural areas.
The posting message invited them to participate in
a “survey on psychotherapy”, and contained a link
to the survey. Data were collected between June
2015 and March 2016. The survey was administered
online in order to collect the largest and most geographically diverse sample possible within resource
constraints, and to offer a private, anonymous
format in which respondents would feel most comfortable disclosing what they might not say in a face-toface interview. All respondents were entered into a
drawing to win one of six $50 Amazon gift cards.
Completers (N = 798) and dropouts (N = 247)
showed no statistically significant differences on any
demographic measure.
Data Analysis
Content analysis was used to identify and thematically categorize reasons (i.e., motives) for participants’ avoidance and dishonesty regarding suicidal
ideation in psychotherapy. Content analysis is the
systematic, objective, quantitative analysis of
message characteristics (Neuendorf, 2002). The
idea of a “theme” in the qualitative analysis has
been variously defined, but in essence, it is “a
phrase or sentence that identifies what a unit of data
is about and/or what it means” (Saldaña, 2009).
For the first research question (“What makes it hard
to be honest about this?”), the unit of analysis consisted of phrases and/or sentences that described or
conveyed a motive for dishonesty. The senior author
examined written responses of all 66 respondents
and identified 284 separate statements that appeared
to describe potential motives for dishonesty. In order
to develop the themes, a team consisting of the
senior author and a doctoral student familiar with
the research on disclosure in therapy created the first
draft of a codebook, which was then reviewed by the
second author, a researcher who has published extensively in the area of disclosure and non-disclosure in
psychotherapy. Coding was done by a team of three
Psychotherapy Research 5
graduate students in clinical psychology. As described
by Neuendorf (2002), coder training was an iterative
process in which coders were trained on the codebook,
attempted to code sample data, and offered feedback
and revisions to the codebook itself. The final codebook contained 21 codes. Coding took place in ten
rounds, each coding roughly 10% of the data, with
an average Krippendorf’s alpha of .80, meeting the
generally-accepted standard for intercoder reliability.
Disagreements were resolved through whole-team discussion and consensus.
Finally, the team agreed upon four higher-order
“code groups” to which each of the 21 codes logically
belongs. These higher-order code groups were meant
to express overarching domains of motives for lying.
Code groups included reasons related to practical
impacts, reasons related to emotional impacts,
reasons specific to therapy or the therapist, and
reasons relating to the client’s beliefs about self or
suicide. Each is described in greater detail below.
Content analysis for the second research question
(“How could your therapist help you be more
honest?”) was conducted by precisely the same
process, with a separate team of three clinical psychology graduate students. The data set for question
two consisted of 85 message-units produced by 66
respondents. As before, a preliminary codebook was
produced with 10 thematic coding categories.
During coder training, this was reduced to 8 final
codes. Intercoder reliability on the coded data set
was .87, above the accepted standard. As before,
the codes for message units on which raters had disagreed were resolved by consensus.
Results
The percentage of the overall sample (N = 798) who
reported dishonesty or avoidance about suicidal
thoughts was 21.4%. This number consists of the
10.1% who reported speaking dishonestly and
11.3% who reported deliberately avoiding the topic.
Suicidal thoughts was the third most commonly
reported topic of dishonesty or avoidance among 33
topics offered to respondents (after two sex-related
topics). The remaining participants in the overall
sample fell into three categories: 46%who reported
speaking about suicide in therapy with “moderate”
or greater honesty (i.e., had scores of 3 or more on
a 5-point Likert scale), 26% who felt the topic of
suicidal thoughts “does not apply to me”, and 7%
who reported that “I would discuss this, but it
hasn’t come up.” This study did not capture how
many of these respondents were experiencing SI,
only their degree of honesty when it came up in
psychotherapy.
Respondents in the qualitative SI concealer sample
(N = 66) are those who reported dishonesty and
elected to answer in-depth questions about this
topic. Forty respondents reported being either “not
at all honest” (15 respondents) or only “a little
honest” (25 respondents) when speaking about
suicidal thoughts in therapy, while 26 respondents
reported never having spoken of it due to deliberate
avoidance of the topic.
Three topics of dishonesty were notably more
common among the 66 SI concealers than in the
sample as a whole (N = 798). These were “past
suicide attempts” (reported by 30% of SI concealers),
“self-harm” (24%), and “whether therapy is helping
me” (24%). Overall, there was no significant difference in the number of topics respondents reported
speaking dishonestly about or deliberately avoiding
between the SI concealer group (M = 5.4, SD = 4.9)
and non-SI concealers (M = 4.4, SD = 4.3); t(79) =
1.57, p = .06. This suggests SI concealers were not
more dishonest in general.
Motives for Concealment
Open-ended responses to the question. “What makes
it hard to be honest about this?” ranged in length
from four to 271 words, and contained between 1
and 18 separate message units, with the median
number of message units being four. Once coded,
32% of the 66 SI concealers were found to have provided one motive for dishonesty, 26% provided two
motives, 23% provided three motives, and the
remaining 20% provided four or five separate
motives for concealment, with one respondent offering eight separate motives.
The following sections describe each of the four
code groups: unwanted practical impacts; emotional
experiences; beliefs about self or about suicide; and
reasons specific to therapy. Table II shows the distribution of reported motives across these four code
groups. Sample quotations drawn from text entered
by respondents are also provided for each group.
Unwanted practical impacts. A majority of SI
concealers (70%) reported one of seven motives for
dishonesty relating to the practical, real-world consequences of disclosing suicidal ideation. This group of
themes includes “hospitalization”, “unwanted medication”, “others finding out”, “impacts on career or
schooling”, “impacts on others” (such as children),
and in a few cases, “loss of autonomy to attempt
suicide”; as well as a category of “other or unspecified
practical impacts”. All codes in this group reflect the
fear that honest disclosure will cause their therapist to
break confidentiality or make interventions seen as
leading to practical consequences for their lives
6
M. Blanchard and B. A. Farber
Table II. Code groups, or general categories of motivation, for concealing suicidal thoughts in psychotherapy (N = 66).
Categories
Concealment to avoid certain unwanted practical impacts (e.g., hospitalization, medication,
career impacts, etc.)
Number
reporting
Percent of
total sample
46
70%
30
45%
26
39%
26
39%
“I would say I wasn’t suicidal, even though I was, just to make sure I wasn’t hospitalized.”
“Involuntary commitment is far more traumatic than just dealing with such feelings on my own.”
“It would out me to my friends, family, and coworkers.”
“I do not want to ever be sedated”
“I am afraid to open up and lose everything I have.”
Concealment to avoid certain emotional experiences (e.g., shame, guilt, or to continue denial of
the problem, etc.)
“I feel embarrassed that I want to attempt suicide.”
“I know it’s supposed to protect me from myself, but it adds more shame and self-loathing that
exasperates everything.”
“It’s hard to be honest because it means admitting that the trauma of the sexual assault had such an
impact on me.”
Concealment due to beliefs about self or about suicide (e.g., belief that one is a low risk, that no
one can help, or a preference to cope alone)
“Since I wouldn’t really do it, I don’t want to talk about it.”
“There are only a few moments a year when I feel suicidal.”
“I feel I am fine coping on my own.”
“Discussing it with people has never had any positive effect on my feelings.”
Concealment for reasons specific to therapy or therapist (e.g., to control agenda of therapy,
because of something therapist has done, etc.)
“I think the topics we discuss would change greatly.”
“Since it is my money and time, I want to choose what topics we will talk about … suicidal ideation is
not one of them.”
“It seemed he was concerned about his liability more than how I felt.”
Note: Example quotations taken from survey responses, represent different codes within the code group.
outside of therapy. Predicting that their disclosure
would set off a chain of events beyond their control,
they determined that sharing with their therapist
was not worth the risk.
Notably, 52% of these 66 respondents specifically
mentioned a fear of being involuntarily admitted to
a hospital psychiatric unit. This was by far the most
commonly-endorsed motive for concealing suicidal
ideation from a therapist. How did they come to
have this fear? Several SI concealers described past
experiences with hospitalization, and appeared to
have knowledge of the reporting requirements for
clinicians. One client remarked that despite some
familiarity with the rules around hospitalization, she
was made anxious by the uncertainty around how
those rules will be applied:
I am concerned they will force me into a hospital. I
am less concerned about this than I first was as I
learned that it [suicide] can be discussed to some
degree if they realize you are not impulsive and at
immediate risk. But still, I don’t know how much
people know that, or what their view of what
‘immediate risk’ means. A week, a month, a year?
Others believed that by merely mentioning suicidal
thoughts they could be subject to forcible hospitalization. One respondent noted that she never came
close to attempting suicide but was “afraid my
therapist would commit me so I lied and said I
didn’t have thoughts about suicide”. Another
client wrote: “Talking about suicide … leads to
actions that have to be taken. I feared having to go
to a psychiatric hospital.” Some respondents
appeared to believe that any discussion of suicidal
thoughts is risky. They, therefore, concealed it
from everyone in their lives. As one respondent
noted: “I was scared of telling my therapist, or
anyone, the truth. I was scared that would get me
placed in some sort of intensive in-patient
Psychotherapy Research 7
therapy.” Or as another respondent succinctly
explained: “It is never okay to talk about suicide.”
Hospitalization was often seen as the proximal
impact that would lead to other impacts, such as
“others finding out” cited by 11%, “unwanted medication or medication changes” (9%), “loss of autonomy to commit suicide” (6%), “harming or
upsetting loved ones” (5%), and “impacts on career
or schooling” (3%), as well as an unspecified category
(e.g., “lose everything I have”) reported by 12%.
Thus, hospitalization occupied a special place in the
logic of the SI concealers in this sample. It was the
primary feared outcome from which other feared outcomes were thought to flow.
Feared emotional impacts. The second-most
common group of motives for concealment of
suicidal ideation in psychotherapy was the desire to
avoid certain emotional experiences, reported by
45% of the 66 respondents providing qualitative
data. This code group includes five codes, including
“shame, stigma or embarrassment”, “avoidance or
denial”, “guilt”, “sadness”, an “other or unspecified”
category. Among these, the related elements of
shame, embarrassment, or a fear of being judged constituted the most common reason for concealment,
reported by 30%. While some authors distinguish
between shame and embarrassment (e.g., Burton
Denmark et al., 2012), our coding team found it
was not possible to reliably distinguish “shame”
from “embarrassment” or “stigma” or “judgment”
in the responses analyzed here. Indeed, many respondents mentioned this theme in the briefest possible
way, writing only “It’s embarrassing” or “the shame
of it,” a brevity that itself may be motivated by embarrassment. Respondents who elaborated often
acknowledged feeling embarrassed by the simple
fact that they want to die by suicide. As unwell as
they felt, they believed sharing the depth of their
misery would only further compromise their
dignity. As one client remarked: “It upsets me
because I have no control over these thoughts or
attempts, so I feel embarrassed that I want to
attempt suicide.”
Avoidance or denial was cited by 12% of respondents who said concealment in therapy was part of a
larger effort to keep suicidal thoughts out of awareness. They felt talking about suicide would force
them to realize how bad their condition is, to take
action to address the problem, or in one case, to
maybe even carry out a suicide attempt. Other, less
common emotional experiences included unspecified
emotional impacts (e,g., “It makes me emotional”)
reported by 11%, and guilt and sadness, mentioned
by 3% of the sample.
Beliefs about self or suicide. A third code group
for concealment, cited by 39% of SI concealers,
consists of five motives stemming from some belief
the respondent holds about themselves or about
suicide. Codes in this category included “low risk”,
“preference to cope alone”, “hard to speak about
suicide”, “disclosure would not help”, and “suicide
is morally wrong”. The most common among these
beliefs was the perception that one is at low risk for
actually attempting suicide, reported by 27% of the
sample. These respondents felt their suicidal ideation
was neither intense nor frequent enough to warrant
addressing in therapy. Notably, the sense that they
were “low risk” did not necessarily alleviate fears of
serious consequences should they disclose. Indeed,
67% of those mentioning low risk also mentioned
fear of unwanted practical impacts such as hospitalization and others finding out. For example, a female
client reported “short-lived suicidal thoughts that I
would never act on” happening only “a few
moments in a year.” Nonetheless, she hid these
experiences from her therapist believing that “I
would be committed to a psych ward and my family
would know.” Most respondents who felt they were
not at risk for suicide nonetheless worried that clinicians would intervene.
Smaller numbers of respondents cited other
reasons such as that it is better to cope privately
(8%), that suicide is hard to talk about (6%), that disclosure will not be helpful (5%), and that suicide
should not be discussed because it is morally wrong
(2%).
Reasons specific to therapy or therapist. The
fourth and final group of motives for concealment
consists of four codes relating to events inside
therapy, as distinct from the practical impacts on
the respondent’s life outside therapy discussed
above. These codes include “to control the agenda
of therapy”, “therapist is blamed for concealment”,
“fear that therapist will feel bad at their job”, and
an “other or unspecified therapy-related reason”.
Taken together, 29% of SI concealers endorsed one
of these motives.
The most common motive in this category was a
desire to control the agenda of what is discussed
(20%), essentially a concern that acknowledging
suicidal thoughts would distract the therapist from
the “real reason” the respondent entered therapy.
These respondents believed their therapist’s focus
on suicide would prevent work on problems such as
anxiety or relationships. As one respondent noted:
“Since I only have 45 minutes a week I unfortunately
have to be very selective when it comes to the topics I
discuss.”
It was also common to blame therapists for discouraging disclosure (17%), either because they
failed to ask, did not seem to care enough, or
seemed unsympathetic. Those noting this motive
8
M. Blanchard and B. A. Farber
implied that they would have disclosed their suicidal
ideation had it not been for something about their
therapist. By contrast, one respondent reported concealing in order to “save” the therapist from feeling
like she had failed to help. Finally, an unspecified category was included for responses in which some event
in therapy was mentioned as a reason for suicide concealment, but its precise nature was either vaguely
worded or not explained (9%). In addition to the
open-text item querying respondent’s motives for
concealment, the survey later asked respondents to
complete a multiple-choice item assessing their
motivation for non-disclosure of suicidality: “Which
of these describes your reason for not being
honest?” Both methods of inquiry show that practical
consequences such as hospitalization were the most
common motive for concealment of suicidal ideation;
indeed, the same percentage of respondents (70%)
endorsed this motive in both question formats. Similarly, while 20% reported a desire to control the
agenda of therapy in the open-text, 24% endorsed a
similar question choice, “I don’t want this to distract
from other topics”, in the multiple-choice format. By
contrast, SI concealers were more likely to endorse
embarrassment or shame as a motive in the multiple-choice format (where 58% did so) than in the
open-text format (where only 30% did so).
Fostering Greater Honesty
Essay responses to the question “How could your
therapist make you feel more comfortable being
honest about your suicidal thoughts?” ranged in
length from two to 95 words, and contained
between one and four separate message units, with
the median number of message units being one.
Once coded, 45 SI concealers (70%) were found to
have provided one idea for how their therapist
could help them be more honest about suicidal
thoughts, 11 (17%) provided two ideas, and 10
(15%) provided no ideas, saying they did not know.
Across 66 respondents, 84 message units were
coded into one of eight thematic categories, with
the number of respondents endorsing each provided
in Table III. One theme, “provide assurances about
reporting my suicidal ideation,” was found to have
three clear subthemes, described below. The structure of the data for research question 2 did not
require the creation of higher-order code groups.
Ideas about how clinicians could foster honesty were
heavily weighted toward practical fears. Close to half of
SI Concealers (48%) reported that they would feel
more comfortable being honest about suicidal
thoughts if they received some form of assurance,
explanation, or control over whether the therapist
would report their disclosure to others, as well as assurances about the subsequent consequences of that
reporting. Many mentioned hospitalization directly,
while others mentioned downstream impacts such as
being taken out of school or work.
Three sub-themes were identified among those
seeking assurances about reporting. The most
common was the belief that concealment would no
longer be necessary if the therapist could simply
“promise not to report” the respondent’s suicidal
ideation. As one respondent wrote: “If he reassured
me that it would stay between us.” Several acknowledged that this would probably be impossible.
A second sub-theme involved asking that clinicians
“explain the triggers for reporting” so that patients can
know precisely where the line is and decide for themselves whether to disclose suicidal thoughts. As one
respondent put it, “They could explain upon asking
about the topic that only very serious thoughts or
active attempts would be considered grounds for involuntary hospitalization.” These respondents were
seeking transparency from their clinician in order to
reduce uncertainty about the likely response to different levels of suicidal ideation. Before they disclose,
they would want to understand the law, and also
how their therapist interprets that law. One respondent
asked that his therapist prove that she understands
“the difference between ideations and actual intentions”. Another wrote: “Inform me what the protocol
is when I am having these feelings, before it occurs, so
I can decide how comfortable I am sharing.”
The third sub-theme present in this category was a
desire by clients to be included in the decision of
whether to report. Such a solution would have therapists share decision-making power with clients about
the best response when suicide is being discussed. As
one respondent wrote, therapists could engender
honesty by “allowing me to decide if I needed to be
hospitalized”. Another respondent went so far as to
propose that her therapist “contract” with her not
to over-react to her suicide-related disclosures.
These respondents suggested that they would be
more honest about their suicidal ideation if they
could gain some control, or at least participate in a
thorough discussion of next steps or options. As
one respondent wrote: “Promise to listen to everything I say and take into consideration my emotional
state at this time, and his/her opinion about my
overall emotional state. Then see admitting to a hospital as a LAST resort.”
Other ideas about fostering honesty provided by
respondents included asking direct questions about
suicide, normalizing and validating their experience,
along with unspecified changes in clinical technique.
A few imagined that if they had more time in therapy,
or a more trusting relationship with the therapist,
Psychotherapy Research 9
Table III. Themes in open-text responses to “How could your therapist make you feel more comfortable being honest about your suicidal
thoughts?” (N = 66).
Themes
Provide assurances about reporting my suicidal ideation
Individuals
reporting
Percent of
sample
32
48%
13
20%
10
15%
6
9%
5
8%
1
2%
1
2%
10
15%
“If hospitalization wasn’t a consequence of talking about suicide”
“Saying they won’t take me out of school”
“Explain what would happen if I talked about my suicidal thoughts”
“Allow me to decide if I needed to be hospitalized”
“Offering to work with me through my suicidal thoughts without inpatient care.”
There is nothing my therapist can do
“I honestly would not share it with a therapist. As much help that they may be giving me, I trust my
friends and family a whole lot more.”
Ask me direct questions about my suicidal thoughts
“If my therapist asked me frankly about it, I think that could make me finally open up about it.”
“If she asked about specific time frames for example, I would
probably tell her directly.”
Normalize my suicidal thoughts or validate my experience
“If he assured me very clearly … that I am normal for having these feelings, and that they can co-exist
with healthier feelings, then I might discuss them.”
If my therapist and I had a closer, more trusting relationship
“I would have to be more comfortable with them.”
“I guess maybe just over time as I observe if she understands things I say and my general thoughts
more.”
If I had more time in therapy
“Considering the costs involved … Maybe if it wasn’t so expensive and I had more time to work
with.”
Unspecified change of technique
“If his technique/approach was different.”
Don’t know/no response
“I honestly don’t know.”
Note. Example quotations taken from survey responses. Sample percentages refer to proportion of 66 SI concealers who reported each theme.
then disclosure might become possible. Finally, a significant subset expressed very little hope of ever being
honest, either having no idea what could change
(15%) or believing there was really nothing their
therapist could do (20%). Respondents in these categories cited a wide range of motives for concealment
(shame, hospitalization fear, sense of being low risk,
desire to deny the problem, etc.) with no clear
pattern emerging.
After providing the open-text responses discussed
above, respondents provided multiple-choice
responses to the question “Under what circumstances
would you be more honest about this topic?”. Notably,
the most commonly-endorsed item choice, “If I knew
my therapist would not over-react” (selected by 52%),
appears to corroborate the open-text finding that 48%
sought assurances about how their therapist would
react to their disclosure. Other commonly-selected
choices included “If my therapist asked me about it
directly” (38%), “If I felt like this was blocking my progress in therapy” (29%), and “If I trusted my therapist
more” (26%).
10
M. Blanchard and B. A. Farber
Discussion
Since suicide assessment relies almost entirely on the
client’s willingness to disclose, understanding why
clients make the decision to conceal is key to improving such assessment. Finding ways to foster greater
honesty from suicidal ideation concealers is likely to
improve the quality and usefulness of psychotherapy
for clients who experience suicidal ideation. This
study directly queried concealers to learn how psychotherapists can better elicit honest disclosure of
suicidal material. The findings illuminate how clashing desires for certainty and control by both therapist
and patient can result in patients resisting efforts to
accurately report their suicide risk.
Practical Concerns Often Motivate
Concealment
The most common motivation for concealing suicidal
ideation in psychotherapy is a fear of practical, realworld consequences of disclosure. Most often, this
fear focuses on the possibility of hospitalization, of
being involuntarily admitted to an inpatient psychiatric unit. Expressions of this fear were not limited to
clients experiencing severe or imminent suicidality;
a substantial proportion of those saying they were a
low risk for actually making an attempt reported a
fear of being hospitalized. These findings regarding
fears of hospitalization as the primary factor in
client non-disclosure of suicidal ideation are consistent with the results of Ganzini et al. (2013) in their
study of veterans and of Hom et al. (2017) in their
study of college students. Consistent too with observations made by Hom et al. (2015), many clients in
the current sample appeared to lack clarity about
the triggers for hospitalization. Without a clear
sense for where the line was, they described staying
well back of the border by concealing even mild
suicidal symptoms.
A related finding is that a large percentage of SIconcealing clients said they would be more honest if
the threat of hospitalization was somehow reduced or
controlled. These respondents wanted some form of
assurance, explanation, or certainty about the
chances of being hospitalized as a result of disclosure.
Some wanted a frank promise not to report the ideation. Others wanted to be educated about the triggers
for hospitalization so as to control their disclosure strategically. And still others wanted to be included in a
collaborative decision about hospitalization and other
treatment interventions. These requests resonate
with recent models of suicidality that strongly differentiate between suicidal ideation and suicidal action, in
which the two are seen as “separate processes that
come with separate sets of explanations and risk
factors” (Klonsky & May, 2015; see also O’Connor,
2011). Some respondents worried their clinicians
would not recognize this separateness, treating all
ideation as prelude to action.
Taken together, these findings strongly suggest
that if clients with suicidal thoughts are calculating
their chances of triggering unwanted interventions,
it is imperative for clinicians to take seriously their
fears about hospitalization and their uncertainty
about the limits of confidentiality. Surprisingly,
though, this dynamic is rarely or only cursorily
addressed in the literature. Many texts about managing suicidal risk (e.g., Jobes, 2006; Maltsberger,
1986) start from the point in time after a patient has
been identified as a suicide risk, for example, by
showing up in an emergency room after a suicide
attempt. Texts that address the earlier challenge of
how to encourage new disclosures rarely mention
the practical concerns raised by clients in this study.
For example, Shea’s (1999) Practical Art of Suicide
Assessment contains three insightful chapters about
uncovering suicidal ideation, yet includes only one
brief mention that clients may have fears about
being “locked up” for revealing suicidal ideation to
a clinician (p. 112). Hospitalization fear may be considered too obvious to mention and yet the results of
this study and recent others suggest that it is decisive
for many clients.
Shame as a Motive for Concealment
Strategies for interviewing potentially-suicidal clients
are often based on the assumption that such individuals are highly sensitive to shame; interviewers are
urged to move gradually into the topic and normalize
the experience (e.g., the “hierarchical approach”;
Bryan & Rudd, 2006; Shea’s “shame attenuation”,
1999). However, in the present study, when given
an opportunity to provide reasons for their concealment, less than 1/3 of the sample mentioned embarrassment, shame, stigma, or fear of being judged.
Again, they were more likely to mention fear of hospitalization, and almost as likely to cite a desire to
set their agenda for their therapy. Why was shame
not mentioned more often? It may be that some
amount of embarrassment is assumed by clients,
such that they did not see fit to mention it. Alternately, respondents may have shied away from volunteering shame as a motive because, after all,
acknowledging that one is experiencing shame can
feel shameful. It is notable that shame was more commonly endorsed when provided in a list of multiplechoice options.
Whatever the case, it does not appear that reducing
shame was seen by SI concealers as a way to foster
Psychotherapy Research
greater honesty. When asked what could help them
be more honest, few respondents mentioned
shame-reducing interventions such as normalizing
or validating. For SI concealers in this sample, at
least, it appears that efforts to de-stigmatize suicidal
ideation would have little effect on their willingness
to disclose to a clinician.
Clinical Implications
Clients who believe—correctly or not—that they will
be involuntarily hospitalized or experience other
unwanted interventions if they disclose suicidal
thoughts may feel strongly motivated to conceal no
matter what method of assessment is used, and no
matter how much clinicians attempt to reduce
shame. For this reason, achieving the goal of
honest disclosure may require finding ways for therapists to better educate about the basic rules of confidentiality, reporting, and hospitalization, in such a
way that clients feel some measure of control or
predictability.
Ethical and professional responsibilities to respond
when patients are at imminent risk are not negotiable;
however, nothing is lost by, for example, clarifying
circumstances under which one would certainly not
be hospitalized. In the majority of cases, doing so
will likely alleviate unrealistic fears held by the
client, and potentially remove or mitigate this major
barrier to disclosure. In fact, our findings provide
some clues for what this conversation should look
like. Respondents suggest that clinicians can: (a)
explain the rules about mandated reporting, (b)
explain the level of suicide risk that might trigger hospitalization at the facility where the client is being
seen, (c) express their personal awareness of the
difference between severe and non-severe suicidal
ideation, (d) describe what typically happens when
suicide risk rises to the level of being reported, and
(e) acknowledge and validate the anxiety that clients
often have about unwanted interventions. Due to
the significant number of our respondents who
doubted whether fleeting or low-intensity SI was
worth discussing, clinicians might also (f) educate
clients about the evolving understanding of SI as
often involving rapid fluctuations in intensity (see
Kleiman & Nock, 2018).
But doesn’t every therapy start with an explanation
of the limits of confidentiality? While clinics often
require clients to sign consent documents, it is not
clear how often clients receive detailed explanations
about the triggers for hospitalization in a style and
format that they will remember. Indeed, there is evidence that many clinicians are inclined to gloss over
this material. A recent observational study of British
11
psychiatrists interviewing patients about suicidal
ideation found that they tended to ask patients to
confirm that they are not suicidal (“You don’t have
thoughts of harming yourself?”), to which patients
were more likely to deny being suicidal (McCabe,
Sterno, Priebe, Barnes, & Byng, 2017). Avoidance
of in-depth suicide assessment has been observed in
psychiatric nurse practitioners (O’Reilly, Kiyimba,
& Karim, 2016) and primary care physicians
(Stoppe, Sandholzer, Huppertz, Duwe, & Staedt,
1999). Among psychotherapists, there is evidence
(e.g., Farber, 1983) that suicidal statements are felt
to be the most stress-inducing client behaviors,
more so even than aggression and hostility. Anxious
therapists may shy away from providing more than
cursory explanations of the rules around confidentiality. Explanations may also be avoided by clinicians
who do not want to alarm new patients, or who are
themselves unsure of the specifics, or who perhaps
worry that “giving away” the precise triggers for hospitalization might make it easy for suicidal clients to
escape detection.
A fuller approach to discussing suicide, confidentiality, and interventions is in keeping with the collaborative approach to suicide risk management
favored by recent scholarship in the field. Jobes
(2006), for example, urges clinicians to ensure that
the “patient – who is the expert of his or her own
experience – is engaged as an active collaborator in
clinical care” (p. 41). Similarly, our findings can be
seen as an endorsement of some of the 24 “core competencies” in suicide assessment promulgated by the
Suicide Prevention Resource Center (2006). Specifically, the third competency calls for clinicians to
maintain a collaborative, non-adversarial stance,
including “obtaining informed consent to protect
client rights and promote client participation in
making decisions regarding care and treatment
options”. Our findings suggest that mastery of this
competency might be especially valuable for those
clients concealing suicidal thoughts out of fear of
practical repercussions.
Limitations and Future Directions
It is important to note that the original study from
which this data set was drawn was not primarily
about suicide. Responses make it evident that the
sample includes a wide range of frequency and severity of client suicidal ideation; however, the study did
not include measures that could have captured this
information. Thus, our sample includes an
unknown proportion of mild versus serious ideators,
and we cannot conclude that this sample is representative of the symptom severity among the general
12
M. Blanchard and B. A. Farber
population of suicidal ideators, or one that a clinician
might encounter in a given clinical setting.
Furthermore, the relatively small sample size, the
absence of clients from countries outside the United
States, and the absence of random sampling
methods means we cannot claim that this sample is
representative of the therapy-using population, nor
of the population experiencing suicidal thoughts. In
addition, while the sample has an extensive age
range, it is heavily skewed toward female and white
clients; men and minorities are underrepresented in
the sample. If there are unique features of the male
and/or minority experience around disclosing suicidality, these may not be fully represented by the
present analysis. In fact, the small size sample here
precluded analyses of motives for concealment as a
function of multiple demographic (e.g., age, relationship status) and diagnostic (e.g., type of disorder,
chronicity of disorder, previous suicide attempts)
variables. Further, the practice of content analysis,
like all qualitative methods, involves fallible coders.
It is possible that different groups of coders would
have arrived at different conclusions using the same
data set. A final limitation arises from the respondents’ own insight into their motives and behaviors.
There is no guarantee that what our respondents
believe will help them disclose SI would, in actual
practice, foster greater honesty.
Important avenues of future research are suggested
by the prevalence of hospitalization fear in this
sample. What are clients actually told about the triggers for hospitalization? How much of this information do they retain? What do they believe about
the types of disclosures that would mandate a therapist to break confidentiality? Research with psychotherapists could gauge the diversity of attitudes
and practices regarding hospitalization across the
profession, and potentially reveal the need to standardize or otherwise advance practice on this matter.
Finally, we agree with the general point made by
Hom et al. (2017), that “further research is needed
to better understand how to enhance accuracy of
reporting when individuals are probed about
thoughts of suicide” (p. 2). We hypothesize that clarifying triggers for hospitalization empowers clients to
make more informed decisions about whether to disclose suicidal ideation in therapy. Would this actually
increase rates of disclosure? SI concealers in the
present study certainly believed it would for them,
but controlled experiments directly studying
suicide-related disclosure may be impossible due to
ethical concerns. Future research to test this proposition could instead employ proxy measures to
study risk-taking under conditions of greater or
lesser uncertainty (e.g., Balloon-Analogue Risk
Task; Lejuez et al., 2002), which may prove useful
in modeling the disclosure dilemma regarding SI in
conditions of varying uncertainty about the clinical
response. This study has demonstrated that clients
make risk-benefit calculations about whether disclosing suicidal ideation will have serious impacts on their
daily life. Our ability to help as psychotherapists may
depend, in part, on helping them making that calculation more accurately.
Acknowledgements
Our thanks to Melanie N. Love for her help shaping
and conducting this research.
References
Baumann, E. C., & Hill, C. E. (2016). Client concealment and disclosure of secrets in outpatient psychotherapy. Counselling
Psychology Quarterly, 29, 53–75.
Blanchard, M., & Farber, B. A. (2016). Lying in psychotherapy:
Why and what clients don’t tell their therapist about therapy
and their relationship. Counselling Psychology Quarterly, 29, 90–
112.
Bryan, C. J., & Rudd, M. D. (2006). Advances in the assessment of
suicide risk. Journal of Clinical Psychology, 62(2), 185–200.
Burton Denmark, A., Hess, E., & Becker, M. S. (2012). College
students’ reasons for concealing suicidal ideation. Journal of
College Student Psychotherapy, 26(2), 83–98.
Centers for Disease Control and Prevention. (2015). Facts at a
Glance: Web-based Injury Statistics Query and Reporting
System (WISQARS) [Online]. National Center for Injury
Prevention and Control. Retrieved from www.cdc.gov/injury/
wisqars/inde.html.
Drum, D. J., Brownson, C., Burton Denmark, A., & Smith, S. E.
(2009). New data on the nature of suicidal crises in college students: Shifting the paradigm. Professional Psychology: Research
and Practice, 40(3), 213–222.
Farber, B. A. (2006). Self-disclosure in psychotherapy. New York:
Guilford Press.
Farber, B. A. (1983). Psychotherapists’ perceptions of stressful
patient behavior. Professional Psychology: Research and Practice,
14(5), 697–705.
Farber, B. A., Blanchard, M., & Love, M. (in press). Secrets and lies
in psychotherapy. Washington, DC: APA Publications.
Farber, B. A., & Hall, D. (2002). Disclosure to therapists: What is
and is not discussed in psychotherapy. Journal of Clinical
Psychology, 58(4), 359–370.
Farber, B. A., & Sohn, A. E. (2007). Patterns of self-disclosure in
psychotherapy and marriage. Psychotherapy: Theory, Research,
Practice, Training, 44(2), 226–231.
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman,
E. M., Huang, X., … Nock, M. K. (2017). Risk factors for
suicidal thoughts and behaviors: A meta-analysis of 50 years
of research. Psychological Bulletin, 143(2), 187–232.
Ganzini, L., Denneson, L. M., Press, N., Bair, M. J., Helmer, D.
A., Poat, J., & Dobscha, S. K. (2013). Trust is the basis for
effective suicide risk screening and assessment in veterans.
Journal of General Internal Medicine, 28(9), 1215–1221.
Hill, C. E., Thompson, B. J., Cogar, M. C., & Denman, D. W.
(1993). Beneath the surface of long-term therapy: Therapist
and client report of their own and each other’s covert processes.
Journal of Counseling Psychology, 40, 278–287.
Psychotherapy Research
Hom, M. A., Stanley, I. H., & Joiner, T. E. (2015). Evaluating
factors and interventions that influence help-seeking and
mental health service utilization among suicidal individuals: A
review of the literature. Clinical Psychology Review, 40, 28–39.
Hom, M. A., Stanley, I. H., Podlogar, M. C., & Joiner, T. E.
(2017). “Are you having thoughts of suicide?” Examining
experiences with disclosing and denying suicidal ideation.
Journal of Clinical Psychology, 73(10), 1382–1392.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative
approach. New York: Guilford Press.
Jobes, D. A., & Ballard, E. (2011). The therapist and the suicidal
patient. In K. Michel, & D. A. Jobes (Eds.), Building a therapeutic alliance with the suicidal patient (pp. 51–61). Washington,
DC: American Psychological Association.
Joiner, T. E., Jr, Van Orden, K. A., Witte, T. K., & Rudd, M. D.
(2009). The interpersonal theory of suicide: Guidance for working
with suicidal clients. Washington, DC, US: American
Psychological Association.
Kelly, A. E. (1998). Clients’ secret keeping in outpatient therapy.
Journal of Counseling Psychology, 45(1), 50–57.
Kleiman, E. M., & Nock, M. K. (2018). Real-time assessment of
suicidal thoughts and behaviors. Current Opinion in Psychology,
22, 33–37.
Klonsky, E. D., & May, A. M. (2014). Differentiating suicide
attempters from suicide ideators: A critical frontier for suicidology research. Suicide and Life-Threatening Behavior, 44, 1–5.
Klonsky, E. D., & May, A. M. (2015). The three-step theory
(3ST): A new theory of suicide rooted in the “ideation-toaction” framework. International Journal of Cognitive Therapy,
8(2), 114–129.
Lejuez, C. W., Read, J. P., Kahler, C. W., Richards, J. B., Ramsey,
S. E., Stuart, G. L. … Strong, D. R. (2002). Evaluation of a behavioral measure of risk taking: The Balloon Analogue Risk
Task (BART). Journal of Experimental Psychology: Applied, 8
(2), 75.
Maltsberger, J. T. (1986). Suicide risk: The formulation of clinical
judgment. New York: New York University Press.
Martin, L. E. (2006). Lying in psychotherapy: Results of an exploratory study (Doctoral dissertation). Retrieved from ProQuest
dissertations and Theses database. (UMI No. 3253137).
13
Mays, D. (2004). Structured assessment methods may improve
suicide prevention. Psychiatric Annals, 34(5), 366–372.
McCabe, R., Sterno, I., Priebe, S., Barnes, R., & Byng, R. (2017).
How do healthcare professionals interview patients to assess
suicide risk? BMC Psychiatry, 17(1), 122.
Morrison, L. L., & Downey, D. L. (2000). Racial differences in
self-disclosure of suicidal ideation and reasons for living:
Implications for training. Cultural Diversity and Ethnic Minority
Psychology, 6(4), 374–386.
Murphy, G. E. (1984). The prediction of suicide: Why is it so difficult? American Journal of Psychotherapy, 38(3), 341–349.
Neuendorf, K. A. (2002). The content analysis guidebook. Thousand
Oaks, CA: Sage Publications.
Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer,
M., Beautrais, A., … Williams, D. (2008). Cross-national
prevalence and risk factors for suicidal ideation, plans and
attempts. British Journal of Psychiatry, 192(2), 98–105.
O’Connor, R. C. (2011). The integrated motivational-volitional
model of suicidal behavior. Crisis: The Journal of Crisis
Intervention and Suicide Prevention, 32, 295–298.
O’Reilly, M., Kiyimba, N., & Karim, K. (2016). “This is a question
we have to ask everyone”: asking young people about self-harm
and suicide. Journal of Psychiatric and Mental Health Nursing, 23
(8), 479–488.
Saldaña, J. (2009). The coding manual for qualitative researchers.
London: Sage.
Shea, S. C. (1999). The practical art of suicide assessment: A guide for
mental health professionals and substance abuse counselors.
New York: John Wiley & Sons Inc.
Stiles, W. B. (1995). Disclosure as a speech act: Is it psychotherapeutic to disclose? In J. W. Pennebaker (Ed.), Emotion, disclosure, and health (pp. 71–91). Washington, DC: American
Psychological Association.
Stoppe, G., Sandholzer, H., Huppertz, C., Duwe, H., & Staedt, J.
(1999). Family physicians and the risk of suicide in the depressed
elderly. Journal of Affective Disorders, 54(1), 193–198.
Suicide Prevention Resource Center. (2006). Core competencies in the
assessment and management of suicidality. Newton, MA: SPRC.
Welton, R. S. (2007). The management of suicidality: Assessment
and intervention. Psychiatry, 4(5), 24–34.