Reframing adolescent self-harm as a functional continuum

The clinical and research fields have long relied on a dichotomous classification of adolescent self-harm, rigidly separating non-suicidal self-injury (NSSI) from suicide attempts (SA) based on intent. While operationally convenient for acute risk assessment, this framework oversimplifies the complex clinical reality of mixed and fluctuating intent and obscures the profound developmental and functional links between these behaviors. This perspective article argues for a conceptual shift away from this dichotomy toward a functional continuum model (FCM). The FCM posits that all self-harm behaviors exist on a multidimensional spectrum and are selected from a shared pool of psychological functions-primarily to regulate overwhelming emotional pain (psychache). We reinterpret epidemiological, psychological, and neurobiological evidence to demonstrate that NSSI and SA are not disparate phenomena but rather evolving expressions of the same underlying pathological process. Specifically, NSSI can act as a behavioral training ground that builds the acquired capability for suicide. This model reframes clinical intervention, shifting the focus from mere behavioral cessation to functional rehabilitation-equipping adolescents with adaptive skills to replace the maladaptive functions of self-harm. Finally, we outline future directions for research, including the use of ecological momentary assessment (EMA) and the development of function-specific assessment tools to translate this model into a more precise, dynamic, and compassionate standard of care.