Emotions Observed During Sessions of Dialectical Behavior Therapy Predict Outcome for Borderline Personality Disorder

Objective: We examined whether the emotions that clients experience within session are associated with treatment outcome in dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Method: Participants were 52 adults who met criteria for BPD and were enrolled in a 12-month DBT treatment. The Classification of Affective-Meaning States, an observer-rated measure of discrete emotions, was used to code videos of individual DBT sessions. Raters coded three psychotherapy sessions for each participant: one session from each of the early, working, and late phases of psychotherapy. Self-report measures of BPD symptoms were used to assess treatment outcome. Results: More emotional experience overall during the early phase predicted fewer BPD symptoms at 12-month treatment outcome, explaining 19% of the variance in symptoms. However, increases across treatment in global distress predicted higher levels of BPD (24% of the variance explained) and depression symptoms (15% explained) at termination. Increases in emotional flexibility (i.e., variation between states) from the early to working phase predicted fewer depressive symptoms at termination (14% explained). Self-compassion coded during the working phase also predicted a better treatment outcome (explaining 19%-34%). Conclusions: Clients' in-session emotional experiences predict treatment outcome 8-10 months later. Clients with BPD may benefit from more overall exploration of their emotional experiences early in DBT, as well as expression of self-compassion. Increases in nonspecific, intense negative affect anticipates poor prognosis, whereas increases in emotional flexibility during early treatment anticipates better prognosis. What is the public health significance of this article? This study highlights the importance of discrete emotional experiences in dialectical behavior therapy for borderline personality disorder. Specific kinds of emotional experience in individual dialectical behavior therapy sessions anticipate treatment outcome.