Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: https://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 (2020) “It is never okay to talk about suicide”:
Patients’ reasons for concealing suicidal ideation in psychotherapy, Psychotherapy Research, 30:1,
124-136, 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, 2020
Vol. 30, No. 1, 124–136, 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 clients in psychotherapy keep secrets (Baumann &
psychotherapy (e.g., Farber, 2006; Stiles, 1995), it is Hill, 2016; Kelly, 1998) and lie (Farber, Blanchard,
well established that clients are not always honest and & Love, in press; Martin, 2006); they also minimize
forthcoming. Just like people in all types of settings, 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

 Psychotherapy Research 125

Sohn, 2007), hide their negative reactions to therapist In the absence of better tools, most clinical settings
interventions (Hill, Thompson, Cogar, & Denman, rely on self-report questionnaires (e.g., PHQ-9) and,
1993), and sometime mislead therapists about the even more so, the clinical interview. This involves
effectiveness of therapy itself (Blanchard & Farber, asking patients directly about the frequency and
2016). intensity of suicidal thoughts, planning or prep-
The question of honest disclosure is especially arations, desire to die and intent to attempt suicide,
fraught on the subject of suicide. As Jobes and as well as baseline and acute risk factors, protective
Ballard (2011) point out, the life-and-death nature factors, and any warning signs of suicide (e.g.,
of suicidality injects fundamental issues of power Jobes, 2006; Joiner, Van Orden, Witte, & Rudd,
and control into psychotherapy, stirring up strong 2009; Maltsberger, 1986; Mays, 2004; Shea, 1999;
emotions for all involved: “the therapeutic stakes Welton, 2007). Clients who are strongly motivated
are raised to the highest possible level … both to conceal these types of information can usually
parties (clinician and patient) may feel vulnerable, stymie even the most skillful interviewer without
powerful, scared, angry, worried, wary – and some- great difficulty. Indeed, we respect the autonomy of
times all at the same time” (p. 51). all people to disclose only what they wish when speak-
There is evidence that many clients avoid these ing with mental health professionals.
issues by hiding or denying suicidal ideation (SI). Honest disclosure of SI has benefits, however. For
In a sample of 547 adults in individual psychother- those who may go on to attempt suicide, disclosing SI
apy, Blanchard and Farber (2016) found that 31% allows their therapist to conduct a fuller assessment of
recalled having lied to their therapist about suicidal suicide risk, monitor any intensification of suicidality,
thoughts at some time in the past. Similarly, a study provide appropriate psychological treatments, and
of 355 students seeking therapy at a college counsel- intervene in a potentially lifesaving manner. For
ing center found that 13.8% denied SI when asked on those who will never attempt, fostering honest dis-
an intake questionnaire but later admitted it when closure would at the very least mean relief from the
given a full suicide assessment by a counselor (Mor- burden of concealment and a greater opportunity to
rison & Downey, 2000). How many more of these benefit from their mental health treatment. Under-
“hidden ideators” (we will use the term “SI concea- standing clients’ motivations for concealment can
lers” for clarity) continued to conceal during the help clinicians address unspoken concerns about dis-
face-to-face assessment is impossible to know. closure that are acting as roadblocks. Clearing these
Neither study was able to assess the true prevalence impediments, in turn, may increase the likelihood
of SI in their samples. These findings are in keeping that clients will honestly disclose suicidal ideation
with a body of research that suggests concealment of when it is experienced.
suicidal thoughts is common outside of therapy as In theory, identifying these roadblocks to disclos-
well. In a sample of 26,000 college undergraduate ure requires only that researchers ask patients who
and graduate students, 1321 responded in the affirma- are concealing suicidal ideation to voice their con-
tive when asked if they had “seriously considered cerns. Nevertheless, it is rare to find studies in
attempting suicide in the past 12 months”, and 46% which SI concealers are invited to explain their
of this subsample decided to tell no one about these reasons for concealment or provide feedback to the
thoughts (Drum, Brownson, Burton Denmark, & mental health professions who are trying to assess
Smith, 2009). them. One such study, Ganzini and colleagues’
It is very difficult to predict who in the general popu- (2013) research on brief suicide screening in US
lation will attempt suicide, in part because it is a low Department of Veterans Affairs medical centers,
base-rate phenomenon (Murphy, 1984). Even involved interviewing 34 Iraq and Afghanistan War
among those who experience SI, the majority will veterans about their decision to conceal or reveal
never go on to form a suicide plan nor make a suicidal thoughts. These veterans felt that shame
suicide attempt (CDC, 2015; Klonsky & May, 2014; and fear of career repercussions were valid reasons
Nock et al., 2008). While numerous risk factors have not to mention suicidal thoughts. They also noted
been identified (e.g., previous attempts), these do concerns about unwanted hospitalization or medi-
not translate into an ability to predict suicide-related cation recommendations. Veterans stressed trust
behaviors. A recent meta-analysis of the last 50 years and respect as the keys to fostering honesty about a
of research on risk factors suggests there is no category topic they regarded as intimate and shameful. As
of predictors which functions much better than chance one veteran put it: “Those who are nice to me and
at predicting suicide-related outcomes, generating treat me with respect … will get all the information
calls for a more complex algorithms that can account they need from me” (p. 1218). The authors con-
for combinations of perhaps 50 different risk factors cluded that professionals who put aside the standar-
at once (Franklin et al., 2017). dized screener to establish interpersonal trust with
126 M. Blanchard and B. A. Farber

the veterans were deemed to be safe for disclosure. largest proportion of suicides (56%) in 2011, and
These gestures may have helped foster a stronger from 1999 to 2010, the suicide rate among this
therapeutic alliance, which has been found to be posi- group increased by nearly 30% (CDC, 2015). Hom
tively correlated with greater overall disclosure et al. call for research to understand the barriers and
(Farber & Hall, 2002). facilitators to care unique to adults, writing “it is essen-
Hom et al. (2017) looked at why undergraduates tial for this research gap to be addressed” (p. 35).
decide to respond accurately or not when asked Ultimately, the goal of understanding client
about suicidal thoughts by various parties, including motives for suicide concealment is to improve clinical
family members, friends, teachers, religious leaders, treatment. Only one previous study (Ganzini et al.,
and mental health providers. Their sample included 2013) asked SI concealers to provide suggestions
306 undergraduate students who reported some life- about what therapists could do to help them be
time history of suicidal ideation. Of this group, 77 more honest. Thus, in order to learn how psy-
had been asked about suicide by a psychologist, chotherapists can better elicit honest disclosure of
therapist, or counselor, and 49 had been asked by a suicide-related material, the current study directly
psychiatrist, although it was not clear whether they queried SI concealers on their motives for conceal-
were in ongoing psychotherapy. Student motives for ment and their ideas about what could facilitate
not giving accurate information differed slightly their honesty in the context of their psychotherapy.
between psychiatrists and other mental health provi- Specifically, the study’s two research questions were
ders. Fear of hospitalization was most commonly (a) what most commonly motivates clients experien-
reported among those probed by psychiatrists, while cing suicidal ideation to conceal this from their psy-
embarrassment was the most common reason for chotherapist? and (b) what do suicidal ideation
concealment from psychologists or other non- concealers believe their therapist could do to help
medical therapists. Other common motives for con- them be more honest?
cealment included being judged, others finding out,
and not being taken seriously. When these under-
graduates did give accurate accounts of their suicidal Method
thoughts to mental health professionals, it was most
Participants
commonly because they wanted emotional support
or desired help in getting treatment or medications. Of a total of 798 respondents completing an online
These studies suggest there are many possible survey about dishonesty in psychotherapy, 171
reasons for concealment of suicidal ideation, some reported dishonesty specifically about suicidal idea-
of which are universal and some of which vary tion. Among these, 66 elected to answer a series of
across the contexts in which patients are assessed in-depth questions about concealment. These 66
(e.g., military personnel conceal out of worry about constitute the “SI Concealer” sample for this study,
career implications). Expectations regarding confi- defined as those who avoided disclosure of suicidal
dentiality may also affect individuals’ tendencies to thoughts by either actively lying or passively omitting
conceal suicidal thoughts. In this regard, psychother- information on this topic. As Table I indicates, the
apy clients are likely to have higher expectations of average age among these self-acknowledged SI con-
privacy and confidentiality than, for example, under- cealers was 31, ranging in age from 18 to 71. This
graduates being briefly assessed in a hospital emer- sample consisted primarily of women (79%), with
gency room or veterans answering standardized most respondents reporting their ethnicity as White
screening questions during a medical check-up. (77%) or African-American (11%). The majority of
What remains unstudied, though, is how these and this sample (53%) reported having a Bachelors or
other considerations influence the extent to which more advanced degree.
and reasons for which psychotherapy clients conceal Among the 66 SI concealers, 39 were currently in
their suicidal ideation from their therapists. therapy and the remaining 27 had been in therapy
More generally, the literature lacks research on within the previous 12 months. The median
suicide concealment among middle-aged and older number of therapy sessions with their current or
adults. In their comprehensive review of the factors most recent therapist was 35; the mean duration of
affecting help-seeking among suicidal individuals, treatment with this therapist was 22.7 months (SD
Hom et al. (2015) note that the majority of studies = 30.3), with durations ranging from 2 months to
in this area focus on adolescents and young adults, 15 years. The most commonly reported reasons
whose involvement with institutions such as colleges these clients entered therapy were depression
make them relatively easy to study. While suicide is a (58%), stress (32%), and anxiety (30%), with 11%
leading cause of death among young people in the specifically mentioning suicidal ideation. The most
United States, middle-aged adults accounted for the commonly reported therapeutic modalities were
 Psychotherapy Research 127
Table I. Participant demographics, SI concealer sample (N = 66). These respondents first encounter open-text essay
questions, including “What makes it hard to be
n/mean %/SD
honest about this?” and “How could your therapist
Age 31.1 years 13.04 make you feel more comfortable being honest about
Gender this?” Later, respondents encounter multiple-choice
Female 52 79% questions about motives for dishonesty and potential
Male 12 18%
facilitators for honesty, in order to provide corrobora-
Other 2 3%
Race/Ethnicity tion for earlier essay responses.
African-American 7 11%
Asian-American – –
Hispanic/Latino/a 4 6% Procedure
White/Caucasian 51 77%
Biracial 4 6% Participants were recruited through postings to
Other – – Craigslist sites serving 13 large metropolitan areas
Education Level
of the United States, as well as 18 more rural areas.
Grade School 1 2%
High School or GED 13 20% The posting message invited them to participate in
Some college 14 21% a “survey on psychotherapy”, and contained a link
Associate’s Degree 3 5% to the survey. Data were collected between June
Bachelor’s Degree 22 33% 2015 and March 2016. The survey was administered
Master’s Degree 13 20%
online in order to collect the largest and most geo-
PhD/MD/JD – –
graphically diverse sample possible within resource
constraints, and to offer a private, anonymous
format in which respondents would feel most comfor-
CBT (38%), psychodynamic/psychoanalytic (21%), table disclosing what they might not say in a face-to-
and integrative/eclectic (11%), while a number also face interview. All respondents were entered into a
reported “other” (17%). drawing to win one of six $50 Amazon gift cards.
Completers (N = 798) and dropouts (N = 247)
showed no statistically significant differences on any
Measures demographic measure.
The original Difficult Disclosures Survey (Blanchard &
Farber, 2016) is an online, self-report instrument,
Data Analysis
consisting of a total of 107 items developed with the
Qualtrics survey software, and designed to elicit Content analysis was used to identify and themati-
information from psychotherapy clients about the cally categorize reasons (i.e., motives) for partici-
topics they tend to be dishonest about in therapy, pants’ avoidance and dishonesty regarding suicidal
their reasons for doing so, the perceived clinical con- ideation in psychotherapy. Content analysis is the
sequences of their dishonesty, and their sense of what systematic, objective, quantitative analysis of
their therapist could do to facilitate greater honesty. message characteristics (Neuendorf, 2002). The
In order to help respondents access memories of idea of a “theme” in the qualitative analysis has
dishonesty in their therapy, a list of 33 common dis- been variously defined, but in essence, it is “a
closure topics is presented, among them suicidal phrase or sentence that identifies what a unit of data
thoughts; these items were chosen after reviewing is about and/or what it means” (Saldaña, 2009).
prior research on what clients discuss in therapy. For the first research question (“What makes it hard
Respondents are asked to rate their degree of to be honest about this?”), the unit of analysis con-
honesty for each topic they have discussed with sisted of phrases and/or sentences that described or
their current or most recent therapist on a 5-point conveyed a motive for dishonesty. The senior author
Likert scale (1 = “not at all honest”, 5 = “completely examined written responses of all 66 respondents
honest”). For topics they indicated they have not dis- and identified 284 separate statements that appeared
cussed, respondents are asked to provide one of three to describe potential motives for dishonesty. In order
reasons: “It does not apply to me”, “I would discuss to develop the themes, a team consisting of the
this but it has not come up,” and “I purposely avoid senior author and a doctoral student familiar with
this topic”. Respondents who either indicate low the research on disclosure in therapy created the first
levels of honesty (“1” or “2” on the Likert scale) or draft of a codebook, which was then reviewed by the
acknowledge purposeful avoidance about a specific second author, a researcher who has published exten-
topic (e.g., suicidal ideation) are given the opportu- sively in the area of disclosure and non-disclosure in
nity to answer a detailed set of follow-up questions. psychotherapy. Coding was done by a team of three
128 M. Blanchard and B. A. Farber

graduate students in clinical psychology. As described Respondents in the qualitative SI concealer sample
by Neuendorf (2002), coder training was an iterative (N = 66) are those who reported dishonesty and
process in which coders were trained on the codebook, elected to answer in-depth questions about this
attempted to code sample data, and offered feedback topic. Forty respondents reported being either “not
and revisions to the codebook itself. The final code- at all honest” (15 respondents) or only “a little
book contained 21 codes. Coding took place in ten honest” (25 respondents) when speaking about
rounds, each coding roughly 10% of the data, with suicidal thoughts in therapy, while 26 respondents
an average Krippendorf’s alpha of .80, meeting the reported never having spoken of it due to deliberate
generally-accepted standard for intercoder reliability. avoidance of the topic.
Disagreements were resolved through whole-team dis- Three topics of dishonesty were notably more
cussion and consensus. common among the 66 SI concealers than in the
Finally, the team agreed upon four higher-order sample as a whole (N = 798). These were “past
“code groups” to which each of the 21 codes logically suicide attempts” (reported by 30% of SI concealers),
belongs. These higher-order code groups were meant “self-harm” (24%), and “whether therapy is helping
to express overarching domains of motives for lying. me” (24%). Overall, there was no significant differ-
Code groups included reasons related to practical ence in the number of topics respondents reported
impacts, reasons related to emotional impacts, speaking dishonestly about or deliberately avoiding
reasons specific to therapy or the therapist, and between the SI concealer group (M = 5.4, SD = 4.9)
reasons relating to the client’s beliefs about self or and non-SI concealers (M = 4.4, SD = 4.3); t(79) =
suicide. Each is described in greater detail below. 1.57, p = .06. This suggests SI concealers were not
Content analysis for the second research question more dishonest in general.
(“How could your therapist help you be more
honest?”) was conducted by precisely the same
process, with a separate team of three clinical psy-
Motives for Concealment
chology graduate students. The data set for question
two consisted of 85 message-units produced by 66 Open-ended responses to the question. “What makes
respondents. As before, a preliminary codebook was it hard to be honest about this?” ranged in length
produced with 10 thematic coding categories. from four to 271 words, and contained between 1
During coder training, this was reduced to 8 final and 18 separate message units, with the median
codes. Intercoder reliability on the coded data set number of message units being four. Once coded,
was .87, above the accepted standard. As before, 32% of the 66 SI concealers were found to have pro-
the codes for message units on which raters had dis- vided one motive for dishonesty, 26% provided two
agreed were resolved by consensus. motives, 23% provided three motives, and the
remaining 20% provided four or five separate
motives for concealment, with one respondent offer-
ing eight separate motives.
Results
The following sections describe each of the four
The percentage of the overall sample (N = 798) who code groups: unwanted practical impacts; emotional
reported dishonesty or avoidance about suicidal experiences; beliefs about self or about suicide; and
thoughts was 21.4%. This number consists of the reasons specific to therapy. Table II shows the distri-
10.1% who reported speaking dishonestly and bution of reported motives across these four code
11.3% who reported deliberately avoiding the topic. groups. Sample quotations drawn from text entered
Suicidal thoughts was the third most commonly by respondents are also provided for each group.
reported topic of dishonesty or avoidance among 33 Unwanted practical impacts. A majority of SI
topics offered to respondents (after two sex-related concealers (70%) reported one of seven motives for
topics). The remaining participants in the overall dishonesty relating to the practical, real-world conse-
sample fell into three categories: 46%who reported quences of disclosing suicidal ideation. This group of
speaking about suicide in therapy with “moderate” themes includes “hospitalization”, “unwanted medi-
or greater honesty (i.e., had scores of 3 or more on cation”, “others finding out”, “impacts on career or
a 5-point Likert scale), 26% who felt the topic of schooling”, “impacts on others” (such as children),
suicidal thoughts “does not apply to me”, and 7% and in a few cases, “loss of autonomy to attempt
who reported that “I would discuss this, but it suicide”; as well as a category of “other or unspecified
hasn’t come up.” This study did not capture how practical impacts”. All codes in this group reflect the
many of these respondents were experiencing SI, fear that honest disclosure will cause their therapist to
only their degree of honesty when it came up in break confidentiality or make interventions seen as
psychotherapy. leading to practical consequences for their lives
 Psychotherapy Research 129
Table II. Code groups, or general categories of motivation, for concealing suicidal thoughts in psychotherapy (N = 66).

Number Percent of
Categories reporting total sample

Concealment to avoid certain unwanted practical impacts (e.g., hospitalization, medication, 46 70%
career impacts, etc.)

“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 30 45%
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 26 39%
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, 26 39%
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 degree if they realize you are not impulsive and at
would set off a chain of events beyond their control, immediate risk. But still, I don’t know how much
people know that, or what their view of what
they determined that sharing with their therapist
‘immediate risk’ means. A week, a month, a year?
was not worth the risk.
Notably, 52% of these 66 respondents specifically
Others believed that by merely mentioning suicidal
mentioned a fear of being involuntarily admitted to
thoughts they could be subject to forcible hospitaliz-
a hospital psychiatric unit. This was by far the most
ation. One respondent noted that she never came
commonly-endorsed motive for concealing suicidal
close to attempting suicide but was “afraid my
ideation from a therapist. How did they come to
therapist would commit me so I lied and said I
have this fear? Several SI concealers described past
didn’t have thoughts about suicide”. Another
experiences with hospitalization, and appeared to
client wrote: “Talking about suicide … leads to
have knowledge of the reporting requirements for
actions that have to be taken. I feared having to go
clinicians. One client remarked that despite some
to a psychiatric hospital.” Some respondents
familiarity with the rules around hospitalization, she
appeared to believe that any discussion of suicidal
was made anxious by the uncertainty around how
thoughts is risky. They, therefore, concealed it
those rules will be applied:
from everyone in their lives. As one respondent
noted: “I was scared of telling my therapist, or
I am concerned they will force me into a hospital. I
am less concerned about this than I first was as I
anyone, the truth. I was scared that would get me
learned that it [suicide] can be discussed to some placed in some sort of intensive in-patient
130 M. Blanchard and B. A. Farber

therapy.” Or as another respondent succinctly consists of five motives stemming from some belief
explained: “It is never okay to talk about suicide.” the respondent holds about themselves or about
Hospitalization was often seen as the proximal suicide. Codes in this category included “low risk”,
impact that would lead to other impacts, such as “preference to cope alone”, “hard to speak about
“others finding out” cited by 11%, “unwanted medi- suicide”, “disclosure would not help”, and “suicide
cation or medication changes” (9%), “loss of auton- is morally wrong”. The most common among these
omy to commit suicide” (6%), “harming or beliefs was the perception that one is at low risk for
upsetting loved ones” (5%), and “impacts on career actually attempting suicide, reported by 27% of the
or schooling” (3%), as well as an unspecified category sample. These respondents felt their suicidal ideation
(e.g., “lose everything I have”) reported by 12%. was neither intense nor frequent enough to warrant
Thus, hospitalization occupied a special place in the addressing in therapy. Notably, the sense that they
logic of the SI concealers in this sample. It was the were “low risk” did not necessarily alleviate fears of
primary feared outcome from which other feared out- serious consequences should they disclose. Indeed,
comes were thought to flow. 67% of those mentioning low risk also mentioned
Feared emotional impacts. The second-most fear of unwanted practical impacts such as hospitaliz-
common group of motives for concealment of ation and others finding out. For example, a female
suicidal ideation in psychotherapy was the desire to client reported “short-lived suicidal thoughts that I
avoid certain emotional experiences, reported by would never act on” happening only “a few
45% of the 66 respondents providing qualitative moments in a year.” Nonetheless, she hid these
data. This code group includes five codes, including experiences from her therapist believing that “I
“shame, stigma or embarrassment”, “avoidance or would be committed to a psych ward and my family
denial”, “guilt”, “sadness”, an “other or unspecified” would know.” Most respondents who felt they were
category. Among these, the related elements of not at risk for suicide nonetheless worried that clini-
shame, embarrassment, or a fear of being judged con- cians would intervene.
stituted the most common reason for concealment, Smaller numbers of respondents cited other
reported by 30%. While some authors distinguish reasons such as that it is better to cope privately
between shame and embarrassment (e.g., Burton (8%), that suicide is hard to talk about (6%), that dis-
Denmark et al., 2012), our coding team found it closure will not be helpful (5%), and that suicide
was not possible to reliably distinguish “shame” should not be discussed because it is morally wrong
from “embarrassment” or “stigma” or “judgment” (2%).
in the responses analyzed here. Indeed, many respon- Reasons specific to therapy or therapist. The
dents mentioned this theme in the briefest possible fourth and final group of motives for concealment
way, writing only “It’s embarrassing” or “the shame consists of four codes relating to events inside
of it,” a brevity that itself may be motivated by embar- therapy, as distinct from the practical impacts on
rassment. Respondents who elaborated often the respondent’s life outside therapy discussed
acknowledged feeling embarrassed by the simple above. These codes include “to control the agenda
fact that they want to die by suicide. As unwell as of therapy”, “therapist is blamed for concealment”,
they felt, they believed sharing the depth of their “fear that therapist will feel bad at their job”, and
misery would only further compromise their an “other or unspecified therapy-related reason”.
dignity. As one client remarked: “It upsets me Taken together, 29% of SI concealers endorsed one
because I have no control over these thoughts or of these motives.
attempts, so I feel embarrassed that I want to The most common motive in this category was a
attempt suicide.” desire to control the agenda of what is discussed
Avoidance or denial was cited by 12% of respon- (20%), essentially a concern that acknowledging
dents who said concealment in therapy was part of a suicidal thoughts would distract the therapist from
larger effort to keep suicidal thoughts out of aware- the “real reason” the respondent entered therapy.
ness. They felt talking about suicide would force These respondents believed their therapist’s focus
them to realize how bad their condition is, to take on suicide would prevent work on problems such as
action to address the problem, or in one case, to anxiety or relationships. As one respondent noted:
maybe even carry out a suicide attempt. Other, less “Since I only have 45 minutes a week I unfortunately
common emotional experiences included unspecified have to be very selective when it comes to the topics I
emotional impacts (e,g., “It makes me emotional”) discuss.”
reported by 11%, and guilt and sadness, mentioned It was also common to blame therapists for dis-
by 3% of the sample. couraging disclosure (17%), either because they
Beliefs about self or suicide. A third code group failed to ask, did not seem to care enough, or
for concealment, cited by 39% of SI concealers, seemed unsympathetic. Those noting this motive
 Psychotherapy Research 131

implied that they would have disclosed their suicidal would report their disclosure to others, as well as assur-
ideation had it not been for something about their ances about the subsequent consequences of that
therapist. By contrast, one respondent reported con- reporting. Many mentioned hospitalization directly,
cealing in order to “save” the therapist from feeling while others mentioned downstream impacts such as
like she had failed to help. Finally, an unspecified cat- being taken out of school or work.
egory was included for responses in which some event Three sub-themes were identified among those
in therapy was mentioned as a reason for suicide con- seeking assurances about reporting. The most
cealment, but its precise nature was either vaguely common was the belief that concealment would no
worded or not explained (9%). In addition to the longer be necessary if the therapist could simply
open-text item querying respondent’s motives for “promise not to report” the respondent’s suicidal
concealment, the survey later asked respondents to ideation. As one respondent wrote: “If he reassured
complete a multiple-choice item assessing their me that it would stay between us.” Several acknowl-
motivation for non-disclosure of suicidality: “Which edged that this would probably be impossible.
of these describes your reason for not being A second sub-theme involved asking that clinicians
honest?” Both methods of inquiry show that practical “explain the triggers for reporting” so that patients can
consequences such as hospitalization were the most know precisely where the line is and decide for them-
common motive for concealment of suicidal ideation; selves whether to disclose suicidal thoughts. As one
indeed, the same percentage of respondents (70%) respondent put it, “They could explain upon asking
endorsed this motive in both question formats. Simi- about the topic that only very serious thoughts or
larly, while 20% reported a desire to control the active attempts would be considered grounds for invo-
agenda of therapy in the open-text, 24% endorsed a luntary hospitalization.” These respondents were
similar question choice, “I don’t want this to distract seeking transparency from their clinician in order to
from other topics”, in the multiple-choice format. By reduce uncertainty about the likely response to differ-
contrast, SI concealers were more likely to endorse ent levels of suicidal ideation. Before they disclose,
embarrassment or shame as a motive in the mul- they would want to understand the law, and also
tiple-choice format (where 58% did so) than in the how their therapist interprets that law. One respondent
open-text format (where only 30% did so). asked that his therapist prove that she understands
“the difference between ideations and actual inten-
tions”. Another wrote: “Inform me what the protocol
is when I am having these feelings, before it occurs, so
Fostering Greater Honesty
I can decide how comfortable I am sharing.”
Essay responses to the question “How could your The third sub-theme present in this category was a
therapist make you feel more comfortable being desire by clients to be included in the decision of
honest about your suicidal thoughts?” ranged in whether to report. Such a solution would have thera-
length from two to 95 words, and contained pists share decision-making power with clients about
between one and four separate message units, with the best response when suicide is being discussed. As
the median number of message units being one. one respondent wrote, therapists could engender
Once coded, 45 SI concealers (70%) were found to honesty by “allowing me to decide if I needed to be
have provided one idea for how their therapist hospitalized”. Another respondent went so far as to
could help them be more honest about suicidal propose that her therapist “contract” with her not
thoughts, 11 (17%) provided two ideas, and 10 to over-react to her suicide-related disclosures.
(15%) provided no ideas, saying they did not know. These respondents suggested that they would be
Across 66 respondents, 84 message units were more honest about their suicidal ideation if they
coded into one of eight thematic categories, with could gain some control, or at least participate in a
the number of respondents endorsing each provided thorough discussion of next steps or options. As
in Table III. One theme, “provide assurances about one respondent wrote: “Promise to listen to every-
reporting my suicidal ideation,” was found to have thing I say and take into consideration my emotional
three clear subthemes, described below. The struc- state at this time, and his/her opinion about my
ture of the data for research question 2 did not overall emotional state. Then see admitting to a hos-
require the creation of higher-order code groups. pital as a LAST resort.”
Ideas about how clinicians could foster honesty were Other ideas about fostering honesty provided by
heavily weighted toward practical fears. Close to half of respondents included asking direct questions about
SI Concealers (48%) reported that they would feel suicide, normalizing and validating their experience,
more comfortable being honest about suicidal along with unspecified changes in clinical technique.
thoughts if they received some form of assurance, A few imagined that if they had more time in therapy,
explanation, or control over whether the therapist or a more trusting relationship with the therapist,
132 M. Blanchard and B. A. Farber
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).

Individuals Percent of
Themes reporting sample

Provide assurances about reporting my suicidal ideation 32 48%

“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
13 20%
“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 10 15%

“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 6 9%

“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 5 8%

“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 1 2%

“Considering the costs involved … Maybe if it wasn’t so expensive and I had more time to work
with.”
Unspecified change of technique 1 2%

“If his technique/approach was different.”

Don’t know/no response 10 15%
“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 sig- responses to the question “Under what circumstances
nificant subset expressed very little hope of ever being would you be more honest about this topic?”. Notably,
honest, either having no idea what could change the most commonly-endorsed item choice, “If I knew
(15%) or believing there was really nothing their my therapist would not over-react” (selected by 52%),
therapist could do (20%). Respondents in these cat- appears to corroborate the open-text finding that 48%
egories cited a wide range of motives for concealment sought assurances about how their therapist would
(shame, hospitalization fear, sense of being low risk, react to their disclosure. Other commonly-selected
desire to deny the problem, etc.) with no clear choices included “If my therapist asked me about it
pattern emerging. directly” (38%), “If I felt like this was blocking my pro-
After providing the open-text responses discussed gress in therapy” (29%), and “If I trusted my therapist
above, respondents provided multiple-choice more” (26%).
 Psychotherapy Research 133

Discussion factors” (Klonsky & May, 2015; see also O’Connor,

2011). Some respondents worried their clinicians
Since suicide assessment relies almost entirely on the
would not recognize this separateness, treating all
client’s willingness to disclose, understanding why
ideation as prelude to action.
clients make the decision to conceal is key to improv-
Taken together, these findings strongly suggest
ing such assessment. Finding ways to foster greater
that if clients with suicidal thoughts are calculating
honesty from suicidal ideation concealers is likely to
their chances of triggering unwanted interventions,
improve the quality and usefulness of psychotherapy
it is imperative for clinicians to take seriously their
for clients who experience suicidal ideation. This
fears about hospitalization and their uncertainty
study directly queried concealers to learn how psy-
about the limits of confidentiality. Surprisingly,
chotherapists can better elicit honest disclosure of
though, this dynamic is rarely or only cursorily
suicidal material. The findings illuminate how clash-
addressed in the literature. Many texts about mana-
ing desires for certainty and control by both therapist
ging suicidal risk (e.g., Jobes, 2006; Maltsberger,
and patient can result in patients resisting efforts to
1986) start from the point in time after a patient has
accurately report their suicide risk.
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
Practical Concerns Often Motivate
how to encourage new disclosures rarely mention
Concealment
the practical concerns raised by clients in this study.
The most common motivation for concealing suicidal For example, Shea’s (1999) Practical Art of Suicide
ideation in psychotherapy is a fear of practical, real- Assessment contains three insightful chapters about
world consequences of disclosure. Most often, this uncovering suicidal ideation, yet includes only one
fear focuses on the possibility of hospitalization, of brief mention that clients may have fears about
being involuntarily admitted to an inpatient psychia- being “locked up” for revealing suicidal ideation to
tric unit. Expressions of this fear were not limited to a clinician (p. 112). Hospitalization fear may be con-
clients experiencing severe or imminent suicidality; sidered too obvious to mention and yet the results of
a substantial proportion of those saying they were a this study and recent others suggest that it is decisive
low risk for actually making an attempt reported a for many clients.
fear of being hospitalized. These findings regarding
fears of hospitalization as the primary factor in
client non-disclosure of suicidal ideation are consist-
Shame as a Motive for Concealment
ent with the results of Ganzini et al. (2013) in their
study of veterans and of Hom et al. (2017) in their Strategies for interviewing potentially-suicidal clients
study of college students. Consistent too with obser- are often based on the assumption that such individ-
vations made by Hom et al. (2015), many clients in uals are highly sensitive to shame; interviewers are
the current sample appeared to lack clarity about urged to move gradually into the topic and normalize
the triggers for hospitalization. Without a clear the experience (e.g., the “hierarchical approach”;
sense for where the line was, they described staying Bryan & Rudd, 2006; Shea’s “shame attenuation”,
well back of the border by concealing even mild 1999). However, in the present study, when given
suicidal symptoms. an opportunity to provide reasons for their conceal-
A related finding is that a large percentage of SI- ment, less than 1/3 of the sample mentioned embar-
concealing clients said they would be more honest if rassment, shame, stigma, or fear of being judged.
the threat of hospitalization was somehow reduced or Again, they were more likely to mention fear of hos-
controlled. These respondents wanted some form of pitalization, and almost as likely to cite a desire to
assurance, explanation, or certainty about the set their agenda for their therapy. Why was shame
chances of being hospitalized as a result of disclosure. not mentioned more often? It may be that some
Some wanted a frank promise not to report the idea- amount of embarrassment is assumed by clients,
tion. Others wanted to be educated about the triggers such that they did not see fit to mention it. Alter-
for hospitalization so as to control their disclosure stra- nately, respondents may have shied away from volun-
tegically. And still others wanted to be included in a teering shame as a motive because, after all,
collaborative decision about hospitalization and other acknowledging that one is experiencing shame can
treatment interventions. These requests resonate feel shameful. It is notable that shame was more com-
with recent models of suicidality that strongly differen- monly endorsed when provided in a list of multiple-
tiate between suicidal ideation and suicidal action, in choice options.
which the two are seen as “separate processes that Whatever the case, it does not appear that reducing
come with separate sets of explanations and risk shame was seen by SI concealers as a way to foster
134 M. Blanchard and B. A. Farber

greater honesty. When asked what could help them psychiatrists interviewing patients about suicidal
be more honest, few respondents mentioned ideation found that they tended to ask patients to
shame-reducing interventions such as normalizing confirm that they are not suicidal (“You don’t have
or validating. For SI concealers in this sample, at thoughts of harming yourself?”), to which patients
least, it appears that efforts to de-stigmatize suicidal were more likely to deny being suicidal (McCabe,
ideation would have little effect on their willingness Sterno, Priebe, Barnes, & Byng, 2017). Avoidance
to disclose to a clinician. 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,
Clinical Implications
1999). Among psychotherapists, there is evidence
Clients who believe—correctly or not—that they will (e.g., Farber, 1983) that suicidal statements are felt
be involuntarily hospitalized or experience other to be the most stress-inducing client behaviors,
unwanted interventions if they disclose suicidal more so even than aggression and hostility. Anxious
thoughts may feel strongly motivated to conceal no therapists may shy away from providing more than
matter what method of assessment is used, and no cursory explanations of the rules around confidential-
matter how much clinicians attempt to reduce ity. Explanations may also be avoided by clinicians
shame. For this reason, achieving the goal of who do not want to alarm new patients, or who are
honest disclosure may require finding ways for thera- themselves unsure of the specifics, or who perhaps
pists to better educate about the basic rules of con- worry that “giving away” the precise triggers for hos-
fidentiality, reporting, and hospitalization, in such a pitalization might make it easy for suicidal clients to
way that clients feel some measure of control or escape detection.
predictability. A fuller approach to discussing suicide, confidenti-
Ethical and professional responsibilities to respond ality, and interventions is in keeping with the colla-
when patients are at imminent risk are not negotiable; borative approach to suicide risk management
however, nothing is lost by, for example, clarifying favored by recent scholarship in the field. Jobes
circumstances under which one would certainly not (2006), for example, urges clinicians to ensure that
be hospitalized. In the majority of cases, doing so the “patient – who is the expert of his or her own
will likely alleviate unrealistic fears held by the experience – is engaged as an active collaborator in
client, and potentially remove or mitigate this major clinical care” (p. 41). Similarly, our findings can be
barrier to disclosure. In fact, our findings provide seen as an endorsement of some of the 24 “core com-
some clues for what this conversation should look petencies” in suicide assessment promulgated by the
like. Respondents suggest that clinicians can: (a) Suicide Prevention Resource Center (2006). Specifi-
explain the rules about mandated reporting, (b) cally, the third competency calls for clinicians to
explain the level of suicide risk that might trigger hos- maintain a collaborative, non-adversarial stance,
pitalization at the facility where the client is being including “obtaining informed consent to protect
seen, (c) express their personal awareness of the client rights and promote client participation in
difference between severe and non-severe suicidal making decisions regarding care and treatment
ideation, (d) describe what typically happens when options”. Our findings suggest that mastery of this
suicide risk rises to the level of being reported, and competency might be especially valuable for those
(e) acknowledge and validate the anxiety that clients clients concealing suicidal thoughts out of fear of
often have about unwanted interventions. Due to practical repercussions.
the significant number of our respondents who
doubted whether fleeting or low-intensity SI was
worth discussing, clinicians might also (f) educate
Limitations and Future Directions
clients about the evolving understanding of SI as
often involving rapid fluctuations in intensity (see It is important to note that the original study from
Kleiman & Nock, 2018). which this data set was drawn was not primarily
But doesn’t every therapy start with an explanation about suicide. Responses make it evident that the
of the limits of confidentiality? While clinics often sample includes a wide range of frequency and sever-
require clients to sign consent documents, it is not ity of client suicidal ideation; however, the study did
clear how often clients receive detailed explanations not include measures that could have captured this
about the triggers for hospitalization in a style and information. Thus, our sample includes an
format that they will remember. Indeed, there is evi- unknown proportion of mild versus serious ideators,
dence that many clinicians are inclined to gloss over and we cannot conclude that this sample is represen-
this material. A recent observational study of British tative of the symptom severity among the general
 Psychotherapy Research 135

population of suicidal ideators, or one that a clinician in modeling the disclosure dilemma regarding SI in
might encounter in a given clinical setting. conditions of varying uncertainty about the clinical
Furthermore, the relatively small sample size, the response. This study has demonstrated that clients
absence of clients from countries outside the United make risk-benefit calculations about whether disclos-
States, and the absence of random sampling ing suicidal ideation will have serious impacts on their
methods means we cannot claim that this sample is daily life. Our ability to help as psychotherapists may
representative of the therapy-using population, nor depend, in part, on helping them making that calcu-
of the population experiencing suicidal thoughts. In lation more accurately.
addition, while the sample has an extensive age
range, it is heavily skewed toward female and white
clients; men and minorities are underrepresented in Acknowledgements
the sample. If there are unique features of the male
and/or minority experience around disclosing suicid- Our thanks to Melanie N. Love for her help shaping
ality, these may not be fully represented by the and conducting this research.
present analysis. In fact, the small size sample here
precluded analyses of motives for concealment as a
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