Introduction
Self-harm refers to intentional self-poisoning or self-injury, regardless of suicidal motive or level of suicidal intent [1], which is often used as a coping mechanism to resolve a difficult situation and can have functions such as emotion regulation, pain level regulation, or self-punishment [2]. Self-harm is a broader concept that includes some degrees of intentionality and ranges from suicidal attempts to non-suicidal self-injury (NSSI) [3]. Adolescent self-harm is a leading public health problem. The results of a study that was conducted on the high schools of the north of Iran show that the prevalence of self-harm was 54.9% (20.3% in females and 79.7% in males) [5]. Currently, dialectical behavior therapy (DBT) is the only format of psychotherapy that has been confirmed to decrease self-harm in adolescents [9]. However, in a study conducted in Norway, the mean number of self-harm behaviors during a 19-week treatment and the one-year follow-up period was 9 and 5.5, respectively, indicating that some participants continued to self-harm even when they were receiving treatment [7, 11]. Therefore, it seems that there is a need to increase the effectiveness of DBT for adolescents. 
The results of the studies indicate that parenting styles play a major role in the formation and continuation of psychological problems of children and adolescents [12]. Since DBT is a treatment with strong evidence for improving emotion regulation, researchers have begun to examine how it can not only enhance psychopathology in adult patients but also improve parenting skills toward the goal of reducing psychopathology of adolescents [15]. In this regard, Berk et al. designed a parent-only DBT-based parenting intervention using the “walking the middle path skills” module from the DBT Skills Manual for Adolescents. This intervention is used as individual sessions for parents to provide the possibility of in-depth training of skills as well as implementation according to the special needs of each family [6].

Methods 
The present study is a randomized clinical trial. The study inclusion criteria were as follows: Being 11-18 years old for adolescents and 30-50 years old for primary caregivers, the adolescent has attempted suicide or NSSI at least once in the past 3 months, having at least a high school diploma for the primary caregiver and not receiving any simultaneous treatment (psychological and pharmaceutical) by caregivers and adolescents. According to the inclusion criteria, 32 pairs (primary caregiver and adolescent) referred by a psychiatrist at Luqman Hospital through convenience sampling were randomly assigned to the experimental and control groups. Adolescents did not receive any treatment as part of the study. The caregivers in the experimental group received an 8-session parenting intervention by a PhD student in clinical psychology under supervision. 
The participants who were in the control group were placed on the waiting list and received DBT-based parenting intervention from another therapist after completing the study. Both parents were encouraged to attend the sessions. However, if both parents could not attend, one parent was allowed to participate. The data were collected from both caregivers and adolescents at the baseline and post-test phases using the difficulty in emotion regulation scale (DERS); parenting style and dimensions questionnaire (PSDQ); depression, anxiety, and stress scale-21 (DASS-21); five-facet mindfulness questionnaire (FFMQ); conflict behavior questionnaire (CBQ); and caregiver strain questionnaire-short form 11 (CGSQ-SF11). Then the obtained data were analyzed at descriptive and inferential levels. In the descriptive section, indicators such as mean and standard deviation were reported. Also, the assumptions of the covariance test (homogeneity of variances) were examined to analyze the main relationships between groups. However, the relevant tests were all significant in the present study, so the quade nonparametric analysis of covariance (ANCOVA) was used to analyze the dependent variables. The significance level in all the above cases is 0.05, and all analyses were performed using SPSS software, version 27.

Results
The results related to the demographic characteristics of the participants showed that the average age in the experimental group was 15.31 in adolescents and 41.43 in primary caregivers. Also, the average age in the adolescent control group was 15.43 and 41.75 in the primary caregivers. About 50% of adolescents in both experimental and control groups had a history of NSSI. Also, 100% of adolescents in the control and experimental groups attempted suicide, but 23.5% of participants in the experimental group and 31.3% of the control group reported previous suicide attempts. 
Participants of the experimental group reported no suicide attempt or NSSI, and only one uncompleted attempt and three NNSI cases were reported in the control group of adolescents. The results of quade nonparametric ANCOVA for the parent group showed that the observed differences in the averages of parenting styles (increasing the scores of authoritative parenting style and decreasing the scores of authoritarian parenting style), mindfulness (total score and components of observation, acting with awareness, non-judgment and non-reaction), DASS-21 (depression, stress) and caregiver strain between the two experimental and control groups are statistically significant. Also, the mentioned test was statistically significant for the DASS-21 variables (depression and anxiety, stress), SIDAS (suicide risk), and conflict behavior with the parent for the adolescent group. Still, there were no significant differences in the components of DERS of adolescents and permissive parenting style and anxiety score of primary caregivers compared to control groups (Tables 1 and 2).







Conclusion
The present study aimed to investigate the effectiveness of a DBT-based parenting intervention on primary caregivers of adolescents with self-harm behaviors. The results showed that the current parenting intervention was associated with reducing the stress and depression symptoms of primary caregivers, increasing the score related to authoritative parenting, and reducing the burden of strain on caregivers. Also, even though adolescents did not receive any intervention, their CBQ, SIDAS, and DASS-21 scores decreased significantly from the baseline to the end of the intervention. Reducing the symptoms of depression and stress, as well as increasing the mindfulness of parents in this study, are completely aligned with the skills and rules that are included in this intervention. For example, learning to have a dialectical and non-judgmental position towards themselves and their adolescents and using behavioral management skills to reduce behavioral problems can explain the observed changes. Also, learning how to make decisions using a wise mind versus an emotional mind, practicing mindfulness, and increasing the validation of themselves and their adolescents causes them to have more control over their responses to their adolescents. 
The present study is the first to investigate the effectiveness of a DBT-based parenting intervention therapy with a control group. However, the findings of each research study should be considered, along with its limitations. Among the limitations of the current research, we can mention the small size of the sample and the selection of participants from Tehran Province, making it difficult to generalize the findings to larger populations. The other limitation is the participation of one parent in the study. Therefore, it is recommended that future research overcome the limitations of the current study by increasing the size and diversity of the sample and implementing the intervention for both parents. Also, in the field of statistical analysis, future studies are suggested to identify the exact mediating mechanisms and paths through which the DBT-based parenting intervention has led to the mentioned changes in adolescents using the mediation analysis method.

Ethical Considerations

Compliance with ethical guidelines
Before the study, a written informed consent was obtained from the parents. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.MSP.REC.1402.007), and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20201009048974N6). 

Funding
This article was extracted from the PhD thesis of Fatemeh Nazari at the Department of Clinical Psychology, Shahid Beheshti University of Medical Sciences. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors contributions
Conceptualization, writing, validation, and investigation, validation: Fatemeh Nazari; Supervision, review & editing: Maryam Bakhtiyari, Amir Sam Kianimoghadam, Banafshe Mohajerin, and Mahdieh Golestanifard; Methodology: Hojatollah Farahani.

Conflicts of interest
The authors declared no conflict of interest. 

Acknowledgments
The authors would like to thank the Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences for their support, and all participants for their cooperation in the study.




 

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