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Near-lethal suicide (NLS) attempt survivors are the nearest surrogates we have for completed suicide. In the present study, subjects reporting a recent history of NLS attempt participated in a semistructured interview aimed at reconstructing their state of mind in the hours leading up to their NLS attempt, with the goal of better understanding both situational factors and potential psychological pathways to suicide. Using a mixed methods design, a semistructured interview aimed at evaluating underlying themes of preoccupation, conflict, and defensive processes was developed and completed by participants along with self-report measures assessing demographic, psychiatric, suicide history, and mood. Participants (n = 11) were patients enrolled in residential treatment who had made an NLS attempt in the 2 years prior to participating in the study. The interviews were analyzed using Interpretative phenomenological analysis (IPA). Seven thematic units were identified as being associated with states of mind preceding a near-lethal suicide attempt. Results suggest that mental states and psychological processes preceding an NLS attempt are highly variable and embedded in longer-term developmental and characterological vulnerabilities. Participants reported efforts to conceal their imminent suicidal intent from their treatment providers and other sources of interpersonal support. States of mind preceding NLS attempts were found in this study to evolve in the context of developmental psychopathology, characterized by dimensional aspects that were multi-determined, interactive, and highly individual. Our findings lend support for approaches to treatment of suicidal individuals that emphasize understanding of highly specific elements of personal history and psychological vulnerabilities and the development of personalized interventions for suicide.