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This naturalistic long-term follow-up study explored psychosocial and suicide-related outcomes among high-risk adult psychiatric patients treated within a psychoanalytically oriented residential program. Longitudinal outcomes pertaining to suicide mortality rate and changes in risk and protective factors for suicide were examined approximately 7 years following completion of the baseline study, which evaluated states of mind preceding near-lethal suicidal behavior. The original baseline cohort consisted of 131 participants; however, one participant subsequently withdrew consent and was excluded from the current analyses, resulting in an analytic baseline sample of 130 participants. Of the original analytic baseline sample (N = 130) who participated in the baseline study, the suicide mortality rate was 7.7%. Participants who provided follow-up data (n = 44) reported significant improvements in protective factors, including resilience (d = 0.89) and reasons for living (d = 0.72), and a significant reduction in psychic pain (d = 0.68) compared with baseline levels. However, psychic pain scores at follow-up remained elevated compared with cutoff scores associated with suicide risk, suggesting continued elevations in risk and impairment despite improvements in other areas. These findings underscore both the persistence of vulnerability to experiences of emotional pain and the considerable potential for positive long-term psychosocial adaptation and growth in individuals at elevated risk for suicide.