Every person is unique, and any post-suicide-attempt situation is complicated, so what my client and I will end up talking about will vary greatly. That said, here's my answer.
Having a client attempt and/or commit suicide is something that almost every therapist will have to deal with sometime during his or her career, unfortunately. It's always difficult. No, saying it like that is too clinical. It's more than difficult; it is extremely painful and scary and sad and horrible to find out that someone you have been treating and caring for has tried to kill himself. And just like anyone who cares about this person, you as a therapist are going to wonder what you did or didn't do that might have contributed to his decision, whether you had anything to do with it or not. In spite of all of this, being able to talk to someone who has just survived an attempt can sometimes be an opportunity to move therapy forward, and I believe it is always something that both the therapist and the client can learn from.
When a client makes an attempt to kill himself, survives, and comes back to therapy, I want to talk about what happened. I want to know if I missed something I should have caught, from his perspective. Sometimes I was being given warnings and I didn't know that's what they were. If I missed something, I apologize, sincerely, for not understanding what was going on and explain what I thought was going on. I say what I would have done if I had known. Sometimes I will be told there was no forewarning for anyone, and we can talk about what that means to make such a final decision without any input from people he trusts. Sometimes I will be told that the reason he gave me no warning was because he knew I would have to try to stop him. We can talk about everything that led to his decision, and that may help both of us understand what happened and help prevent it from happening again. It's important that by the end of the session I feel like I understand why he did this and that I understand why he thinks he did this.
I ask my client to be completely honest with me, as I will be with him. We can talk about what led up to the attempt, what his thought process was, what actions he took to avert it (if any) before resorting to suicide. I want to talk about his thoughts, his feelings, and how he is doing now and where do we go from here. I want to talk about our suicide prevention plan, how and where it failed, and what we need to do differently if there ever is a "next time." I want to talk about if he hopes there will never be a next time or if he hopes next time he will be "successful." I will want to know how he is looking at the attempt: as a failure or a blessing that he was not successful. I will need to be assessing what my client's current risk for suicide is and what we need to put into place depending on his current risk.
I want to talk about what the reactions were to the attempt from significant people—everyone from his friends, family, co-workers, and hospital emergency room or inpatient treatment staff members. I want to know what he thinks and feels about those people's reactions to his attempt. Then I will want to gently explore what he thinks my feelings are about his attempt. While this has to be addressed carefully and respectfully, I tell my clients how I felt when I learned about their attempts and how I would feel if they had died. I disclose honestly, as a human being who cares about another human being, how I would be affected if he died from suicide. This is not an attempt to "guilt" or manipulate, and I am sensitive to what he has just been through. I just want him to know how I feel and explore what this means to him.
I tell my client how thankful I am that he survived, that he is here now, and that I hope he never attempts again. We can talk about what each of us will do so that he never finds himself in that situation again, and what each of us will do if he does find himself in that situation again.
All of the questions, answers to the questions, and my client's participation in this process of debriefing the attempt will hopefully give me a better sense of what happened, how it happened, and how I need to modify my treatment plan in order to be more helpful. My hope is that this session will clarify and bring to light some important thoughts and feelings for my client, without creating any additional stress or overwhelming him. My intent is not to shame or retraumatize my client, but to allow him the freedom to express honestly what happened and to instill hope, no matter how small, that things can be different and can get better from here. It can be an incredibly powerful session, with the potential to have a positive impact on both of us.
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