Introduction Effectiveness of psychotherapy for substance use disorder (SUD) in community settings is lower than in controlled trials. We explored whether audio recording sessions for patients to review is an acceptable and feasible approach to improving psychotherapy effectiveness by enhancing engagement, recall, and self-reflection between sessions. We also identified the most meaningful information in therapy sessions from patients’ and therapists’ perspectives.

Methods We recruited therapists in community settings and outpatients with co-occurring SUD and depression or anxiety. We audio recorded two consecutive therapy sessions and re-listened to them with each patient within one week of the session. Patients identified content that was personally meaningful and why; therapists completed the same task independently using transcripts. Patients’ and therapists’ identified meaningful moments were analyzed using a codebook we developed based on Goldfried’s principles of change in psychotherapy. We used inductive analysis to evaluate patients’ and therapists’ reasons for choosing this content. Participants also assessed feasibility, appropriateness, and acceptability of recording.

Results Of five therapists recruited, three were female; one was nonbinary. Four therapists had ≥ five years of clinical experience. Eleven of 15 patients were female, mean 45.8 years (range: 28–71), half had high school education or less. Patients identified 169 meaningful moments (6/session); therapists identified 477 (16/session). ‘Increasing insight’ and ‘validation of strengths/goals/needs’ were most cited as meaningful content and reasons why content was meaningful by both patients and therapists. Participants reported recording was feasible, appropriate, and acceptable.

Discussion In this sample, recording psychotherapy sessions was acceptable and feasible. Therapists and patients identify similar meaningful session content, consistent with other research. However, therapists identify three times more meaningful moments than patients do, indicating there is opportunity for optimizing communication of therapy session information.

Conclusion Recording is an innovative strategy to improve psychotherapy effectiveness in routine care.