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Despite advances in theory and research surrounding self-injurious behavior (SIB), rates of SIB in adolescents continue to increase. The Interpersonal Theory of Suicide (IPTS) proposes that suicidality results from incorrect mental calculations of perceived burdensomeness and thwarted belongingness, but does not consider how these negative interpersonal cognitions are developed. We argue that existing theoretical models for understanding the development and treatment of SIB in youth can be improved by including the role of self and self-function, using mentalization-based theory and practice as a guide. By providing an overview of mentalization-based theory, we illustrate how the development of mentalization can go awry in the early caregiving environment and lead to incoherence in the sense of self. A continuous and reciprocal relationship between an incoherent sense of self and poor mentalization then develops and sustains negative interpersonal cognitions, and subsequent SIB. We build an evidence base for this argument by demonstrating the role of personality, the early caregiving environment, mentalizing, and the sense of self in the development of SIB. Finally, we conclude with clinical implications of how mentalization can be integrated to the treatment of SIB.