Supporting engagement in psychological therapy: A guide for GPs and health professionals

Introduction

In primary care settings, GPs are often the first to identify individuals experiencing anxiety, depression, adjustment disorders, psychosomatic symptoms or chronic illness complications with secondary mental‐health consequences.

Yet, while a referral to a psychologist is a clinically sound step, many practitioners observe that referral alone does not guarantee sustained engagement in therapy.

Disengagement – whether through premature drop-out, missed sessions, or gradual disengagement – remains a major barrier to effective treatment. Research shows that 30-75% of young people in Australia will stop therapy early. Although fewer studies focus on adults, international estimates suggest that between 20-40% will terminate treatment earlier than recommended.

This article explores the common reasons for disengagement from psychological therapy and outlines practical, evidence-based strategies that GPs and other health professionals can use to strengthen engagement, support continuity, and improve outcomes for their patients.

The benefits of psychological therapy

When discussing mental health treatment pathways with patients, ensuring your recommendations are grounded in evidence can help build confidence and allow you to frame your recommendation convincingly, priming your patient to perceive the referral as a positive step towards recovery.

The following points summarise what research shows about the value and effectiveness of psychological therapy, addressing some common barriers and misconceptions.

1. Strong clinical evidence of benefit

• A large body of systematic reviews demonstrates that psychotherapy (talk-therapy) is effective for a wide range of mental health concerns, and demonstrates positive, lasting outcomes from both short-term and long-term interventions.
• More specifically, an overview of systematic reviews on Cognitive Behavioural Therapy (CBT) confirms extensive evidence for CBT’s efficacy across multiple health conditions.
• A recent qualitative meta-analysis in The Lancet Psychiatry found that psychotherapy clients experience outcomes extending beyond symptom relief – such as deeper self-understanding, improved relationships, increased agency, and greater engagement with life.
• In treatment of depression, psychotherapy achieves clinically significant effect sizes. While these effect sizes are sometimes smaller than pharmacotherapy, psychotherapy often proves more effective than medication in the long-term — and may have fewer side-effects.

2. Broad applicability and durability

• Therapy supports not only those with defined psychiatric diagnoses but also people adjusting to chronic illness, managing comorbid physical and mental health concerns, or seeking behavioural change for better wellbeing.
• Evidence from the UK Council for Psychotherapy shows that long-term therapy can yield stronger effects in some cases than brief interventions.
• The therapeutic relationship (Clinician‐client alliance) consistently emerges as a key ‘active ingredient’ in therapeutic longevity and a major factor in achieving positive outcomes. This systematic review identifies this relationship as a mediator of change in psychotherapy.

3. Cost-effectiveness, health system relevance

• From a system standpoint, effective therapy contributes to reduced GP consultations, lower medication use, and fewer hospital admissions.
• For individuals, this translates to not just feeling “less depressed and/or anxious” but also improvements in productivity, relationships, physical health, and better overall functioning.
• As many people first present in primary care, early referral to therapy can prevent symptom escalation, reduce chronicity, and improve long-term outcomes.

In summary, you can confidently reassure your patient that psychological therapy is a powerful, evidence-based intervention that goes far beyond reducing symptoms — it helps people lead fuller, more connected, and more meaningful lives. Your endorsement matters: presenting therapy as a positive and proactive step can strongly influence engagement and outcomes.

What influences disengagement from psychological therapy?

Before exploring strategies to improve engagement, it’s important to understand the factors that commonly undermine engagement with therapy. Awareness of these influences allows clinicians to anticipate barriers and implement preventive strategies.

1. Sociocultural and individual context

Many aspects of an individual’s background and life context shape their likelihood of engagement with therapy.

• Gender norms:

Men and boys may view therapy as a threat to self-reliance, while women (especially those in caregiving roles) may experience guilt for prioritising their own wellbeing.

• Cultural beliefs:

In some cultures, mental health challenges are framed through moral or spiritual lenses. This can create feelings of shame or reluctance to seek professional help.

• Aboriginal and/or Torres Strait Islander perspectives:

Attitudes towards mental health are often framed through the holistic concept of social and emotional wellbeing (SEWB), which is connected to culture, land, spirituality, family, and community. This view contrasts with the Western biomedical focus on the individual, and lack of cultural alignment can contribute to disengagement.

2. Attitudinal and motivational factors

Low readiness for change, poor self-efficacy, self-stigma, avoidance behaviours, or scepticism about therapy’s effectiveness can all affect commitment. Some individuals may not believe that therapy can help, or may fear being judged for seeking support.

3. Practical and structural barriers

External constraints can significantly affect engagement:

• Scheduling difficulties or inconsistent session times.
• Transportation issues and distance to clinic.
• Cost or financial stress.
• Competing demands from work or family life.
• Lack of available childcare.

4. Therapy delivery factors

How therapy is delivered can also impact whether individuals remain engaged. Common issues include:

• Poor therapeutic alliance or lack of rapport.
• Mismatch between client expectations and the therapeutic approach.
• Unclear session goals or treatment purpose.
• Insufficient explanation of what therapy involves.

5. Lack of choice or involvement

Individuals who feel they have had no say in their treatment are more likely to drop out. One meta-analysis found that when individuals had treatment choice (versus being “assigned”), they were 1.5 times more likely to complete treatment than those who were not given a choice.

6. Comorbidity, complexity, and severity

Individuals with more severe or multiple conditions are at greater risk of disengagement and may require more intensive engagement strategies and tailored support.

7. Clinician/service quality:

Service delivery quality may also influence engagement, including factors such as:

• Long wait times.
• Limited therapist competence or poor client–clinician fit.
• Inadequate tailoring of therapy to the client’s cultural or personal context.

8. Unclear expectations:

When individuals are unsure about what therapy entails – how many sessions, what is expected between sessions, or what outcomes to anticipate – they can lose motivation and prematurely discontinue.

You can learn more about factors in engagement from these articles: ‘Therapeutic Adherence of People with Mental Disorders: An Evolutionary Concept Analysis’, and ‘Understanding and preventing nonadherence and treatment dropout in adolescents and young adults with anxiety and depressive disorders’.

Strategies to improve therapy engagement

Listed below are practical, evidence-based strategies GPs can use to maximise the “stick-rate” of psychological therapy referrals. Many require minimal effort but yield meaningful improvements in engagement.

1. Shared decision-making and aligning referral with preference

Evidence suggests individuals who have at least some choice are more likely to attend and persist with therapy. Take the time to ask them about their preferences:

• Would you rather try therapy or medication first?
• Would you prefer face-to-face or online support?
• Here are three local clinics; which do you prefer?

It can also be helpful to frame therapy as a partnership rather than a passive process: “Try a few sessions with this Clinician. If it doesn’t feel right, we can revisit the referral.” This approach reinforces agency, reduces anxiety about “failing therapy” and emphasises the importance of finding the right therapeutic fit.

2. Orientation and expectation-setting

Briefly explain what therapy usually involves – typical duration (e.g., 8–12 sessions), homework between sessions, possible discomfort (e.g., “you’ll be asked to think about what you avoid”), and the idea of progress being sometimes non-linear.

Studies show that “therapy orientation” (i.e. preparing patients for what to expect) is one of the most effective interventions in improving engagement. In a systematic review of engagement-improving interventions, efforts such as orientation, motivational interviewing and reminders were beneficial.

Combine this with gentle check-ins: “How do you feel about starting therapy?” or “Is there anything that worries you about therapy?” to prime readiness and surface concerns before they become barriers.

3. Address practical and structural barriers

For many individuals, practical and structural barriers are some of the hardest obstacles to overcome.

When discussing referrals, ask: “What might make it hard to attend therapy twice a month for 3 months?”. Common issues include transport, work hours, child-care, and finances.

Discuss solutions – after-hours or telehealth options, support with transport or childcare, or use of reminder systems. Encourage individuals to set reminders or ask a family member to help them keep appointments. Reminders and between-session engagement (such as text messages) have been shown to improve attendance.

4. Link therapy to their values and goals

Reinforce why you are recommending therapy for them. For example, “You said you want to feel more confident at work/stop the cycle of rumination/repair your relationship. Therapy can help you move towards those goals.”

Individuals are more likely to persist when they view the therapy as relevant to their personally meaningful goals. An explicit connection between therapy and outcome helps combat ambivalence and improve motivation.

5. Monitor early engagement and support follow-up

After you refer, schedule a brief check-in at your next appointment or over the phone. At the check-in, ask how the first session/s went, how helpful it was, and whether or not the Clinician was a good fit. If the individual has attended only one or two sessions, it can be helpful to temper expectations of overnight progress or instant connection.

If, at the check-in, the therapy has not started, you can explore barriers and help troubleshoot. Early drop-out often happens before significant benefit accrues.

6. Encourage therapeutic fit

Emphasise that comfort is important for both the client and the clinician. As mentioned earlier, the therapeutic alliance is a strong predictor of outcome and is also tied to session attendance/continuation. Reminding the individual that they can try another clinician is key to building confidence in the process.

Also, point out that, if the individual finds the style of therapy doesn’t feel right, it might just be about fit, not about them failing.

7. Offer brief, hybrid, or stepped-care options

For individuals who are time-poor or ambivalent, brief therapy (e.g., 6–8 sessions) or hybrid online/in-person models can reduce perceived burden.

Where appropriate, starting small can build momentum and increase readiness for more intensive therapy later, if needed.

8. Maintain your role as supportive clinician

In subsequent check-ins/appointments continue to ask about therapy. Your interest signals to the individual that therapy is part of their overall care, not a separate silo.

If engagement is slipping, explore alternatives such as different modality, clinician, or adjunctive support, such as a group program.

9. Offer access to Peer Practitioners with lived experience

For many people, one of the most powerful contributors to engagement is feeling understood by someone who has “been there.” Peer Practitioners use their lived experience of mental health challenges and recovery to provide empathy, hope, and practical support, reducing self-stigma, improving motivation, enhancing trust in services, and supporting people to navigate the mental health system more confidently.

Peer Practitioners can work alongside therapy by helping individuals set goals, attend appointments, understand their care plan, and stay connected when motivation dips. For people who are hesitant about therapy, culturally mismatched with services, or unsure where to begin, peer support can offer a safe, relatable, and empowering entry point.

Where available, offering a referral to a Peer Practitioner (either before therapy begins or alongside it) can strengthen engagement and help individuals feel less alone throughout the process. Many of Sonder’s mental health services incorporate peer support.

Example GP consultation script

Below is a short template you might use in your next consultation when recommending therapy:

“Based on what you’ve told me about how anxious you feel, how it’s affecting your work and your relationships, I’d like to talk about seeing someone for therapy. There’s good evidence that, over about 8–12 sessions, it can do more than reduce symptoms; it can help you feel more in control, more confident, better able to manage the future.

There are a couple of options locally. One Clinician works in-person, the other does online sessions. Which of those would suit you best? Do you have concerns about how therapy might go? Are there things that might stop you from being able to show up regularly (work, transport, child-care)?

Before your first appointment, I’ll check in with you in two weeks to see how it’s going. If it feels off, we’ll revisit and find another provider. The key is that we make it work for you, rather than you trying to force something that doesn’t fit. And if anything gets in the way, let me know.”

This kind of proactive framing, planning for barriers, and follow-up engages the patient as collaborator and increases the odds of sustained engagement.

In summary

Psychological therapy is a high-value, evidence-based intervention that supports recovery, resilience, and functional improvement. Yet often, referral alone is not enough – drop-out is common and undermines the benefit.

As a trusted GP or health professional, you play a pivotal role in improving engagement by:

• Using shared decision-making.
• Setting clear expectations.
• Anticipating practical barriers.
• Monitoring early engagement.
• Reinforcing therapy as part of ongoing care.

These small but strategic actions can transform therapy from a single appointment into a sustained process of meaningful change.

For urgent or life-threatening presentations, call 000 immediately.

For more information about Sonder’s mental health services, visit sonder.net.au/mental-health or email info@sonder.net.au. 

Sonder also provides two walk-in mental health services in northern Adelaide: Northern Adelaide Medicare Mental Health Centre and Safe Haven.