Suicide and self-harm behavior are a global concern and a priority for the World Health Organization (2000). Health care clinicians assess the extent of the wish-to-die in patients who engage in suicidal behavior and plan evidence based interventions. Yet, the assessment is challenging and often uncertain. The theoretical literature has not resolved whether suicide and self-harm are different or the same phenomenon (Walsh & Rosen,1998); nor have intervention reviews demonstrated empirical evidence of efficacy (Hawton et al., 1998). Is the patient engaging in non-suicidal, self-harm behavior or attempting to terminate his or her life? Historically, international researchers and clinicians, across professions, have conceptualized the constellation of self-injurious behaviors from the perspective of the extreme event: death (Fuse, 1997). Recently, trauma theorists articulate contrasting theories that purport an event which sustains life (Herman, 1992). In a clinical, trans-disciplinary study, a series of questionnaires, which measure intent based upon the major concepts from the suicide and self-harm literature, were given to 83 patients in an emergency population who engaged in self-harm/ suicidal behavior. Their mean scores on the Beck Depression Inventory (Beck, Steer & Garbin, 1988), the Beck Hopelessness Scale (Beck, Weissman, Lester & Trexler, 1974) the Beck Suicide Intent Scale (Beck, Weissman, Lester & Trexler, 1976), and the Self-Injury Questionnaire (Alexander, 1999) suggest that numerous reasons: affect regulation, dissociation management, coping and the wish to die, coalesce rather than diverge. The analysis of the data supports the re-conceptualization of self-injurious and suicidal behavior. This paper presents an alternative, comprehensive conceptualization of intention in self-harm behavior. A complex, multifaceted phenomenon arises from the data which challenges the traditional spotlight on the intent-to-die and requires assessments that are holistic, and simultaneously inclusive of strategies to stay alive. Implications for evidence based interventions and future research are discussed.