Trust and respect declines and recoveries in psychotherapy: Clinical impact of relational feedback.

Abstract

Measurement-based care, also referred to as routine outcome monitoring, has demonstrated modest benefits for psychotherapy outcomes, yet less is known about how feedback on specific relational processes may influence clinical course. The present study examined whether fluctuations in patient-reported trust and respect toward the therapist-conceptualized here as meaningful declines and subsequent recoveries in trust/respect, rather than direct measures of alliance ruptures and repairs-are associated with changes in functioning and whether providing therapists with feedback on these ratings alters these associations. Adult patients receiving treatment in U.S. community mental health settings were randomized for their therapist to receive symptom feedback alone or symptom plus trust/respect feedback. Meaningful declines in trust/respect were defined as within-patient decreases exceeding typical variability, and recoveries were defined as subsequent returns to predecline levels. Weekly functioning was assessed over 11 weeks using time-varying mixed-effects models. Of 233 randomized patients, 185 completed at least one postbaseline assessment, and 162 had postbaseline data sufficient for the current decline/recovery analyses. Meaningful declines in trust/respect across sessions that did not recover to previous levels were associated with lower within-person functioning in the symptom-only feedback condition but was attenuated in the trust/respect feedback condition. Recovery status was not differentially associated with functioning across conditions. These findings suggest that monitoring and providing feedback on patient perceptions of trust and respect may mitigate the impact of unresolved relational strain. Incorporating specific relational process indicators into measurement-based care/routine outcome monitoring may enhance its clinical utility. (PsycInfo Database Record (c) 2026 APA, all rights reserved).