Concealment of Suicidal Ideation in Psychotherapy

Purpose: Assessment and management of suicidal risk often relies on the client’s willingness to disclose suicidal thoughts or behaviors. Understanding why clients make the decision to conceal these symptoms is key to improving techniques of assessment. This study directly queried suicide concealers to learn how psychotherapists can better elicit honest disclosure of suicidal material. Method: A sample of 107 suicide concealers provided both short essay responses and multiple choice responses explaining why they concealed suicidal thoughts from their therapist. In addition, a sub-sample of 64 suicide concealers provided short essay responses describing what they thought their therapist could do differently to help them disclose, and answered multiple-choice questions explaining how they felt about concealment, and whether concealment impacted their therapy. Content analysis was used to identify motives and themes in short essay responses. Results: Nearly three-fourths of suicide concealers cited fear of practical consequences as the reason they did not disclose. Chief among these fears was involuntary hospitalization, which respondents viewed as the likely outcome of telling a therapist about their 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. Many asked for some form of assurance or explanations about the chances of being hospitalized as a result of their disclosure. Concealers most commonly felt conflicted about their decision to conceal, with significant numbers feeling frustrated or guilty as well as safe or in control. While a quarter of concealers believed concealment hurt their progress in therapy, the majority reported no effect. Limitations: While responses suggest a range of symptom severity, the sample includes an unknown proportion of mild versus severe suicide risk, reducing generalizability to the general or clinical population. Male and minority clients are under-represented in the sample. Conclusions: The concerns expressed by the suicide concealers in this sample suggest that improving techniques of suicide risk assessment may require renewed attention to providing transparent, complete, and easy-to-understand psychoeducation about the triggers for hospitalization and other possible outcomes of disclosure. Clients ultimately control their level of disclosure, and the results of this study suggest they desire sufficient knowledge to make an informed decision