A group of young people sitting and talking together

NHS Talking Therapies play a vital role in supporting people with common mental health problems. Evidence shows that people who attend more sessions tend to achieve better outcomes. Yet many patients leave treatment early, potentially missing out on the full benefits of therapy.

To better understand how services are addressing this challenge, the NHS England Behavioural Science Unit (BSU) commissioned the Strategy Unit to evaluate a range of interventions designed to improve adherence, help people stay engaged in therapy and improve recovery outcomes.

How we evaluated the interventions 

Services were invited to take part through an open call and targeted outreach. We reviewed a range of interventions and assessed their impact using a mixed-methods approach. This included:

  • Qualitative interviews with staff who designed and delivered the interventions
  • Quantitative analysis of national data, using a combination of matched and synthetic comparisons and difference-in-differences methods
  • Meta-analysis to bring together findings from different analytical approaches

This mixed-methods approach allowed us to understand both the impact of the interventions and the reasons for that impact.

Key findings

Services are already taking a wide range of approaches to support engagement with NHS Talking Therapies

Staff described a wide range of approaches designed to help people stay engaged in therapy, including:

  • Setting clear expectations before therapy begins
  • Exploring readiness for treatment
  • Offering flexible appointment options
  • Supporting people while they wait
  • Managing waiting lists to reduce delays
  • Training staff to strengthen engagement skills

Many services also involved patients in developing materials and approaches, helping ensure they were relevant, accessible, and easy to use.

However, capacity constraints within services often limited the delivery of interventions. Notably, there was an absence of a consistent national measure for adherence, making it harder to monitor and track progress.

Small but encouraging improvements in outcomes

Across all analytical methods, the interventions showed modest but consistently positive trends. These included:

  • Slight increases in the proportion of people attending five or more sessions
  • Small improvements in reliable recovery

Although many estimates were not statistically significant, the overall pattern consistently pointed towards improved engagement and recovery.

What services demonstrating effective engagement practices have in common

Across the evaluation, several features were consistently associated with stronger engagement practices:

  • Early and proactive engagement
  • Clear, accessible information
  • Flexible and inclusive pathways
  • Skilled and confident staff.

Based on the evaluation findings, we developed a logic model that shows how these mechanisms can support better engagement, session completion, and recovery.

Recommendations for services

Our evaluation highlights several practical steps that services can take to strengthen engagement and improve outcomes:

Services that provided short, clearly written materials found these were easier for patients to use. Written information should be concise, use accessible language, and be available in alternative formats such as audio or braille.

Patient feedback helped ensure resources were relevant and appropriate. Services should continue to involve people with lived experience (including those who disengaged from therapy) when developing intervention materials. For interventions aimed at specific underrepresented groups, services should draw on guidance in the NHS Talking Therapies positive practice guides to promote equity of access and experience.

The logic model developed through this evaluation provides a clear framework for understanding how interventions may support better adherence and recovery. Services can use it to design, refine, and evaluate their own approaches.

Capacity pressures mean staff often face a trade-off between delivering adherence-focused interventions and seeing patients for therapy. Staff need protected time to carry out engagement activities effectively, including follow-up with people who may be at risk of disengaging.

Recommendations for national teams

Some recommended changes require national coordination to support consistency, reduce burden on services, and strengthen the evidence base:

Currently, there is no consistent definition or measure of adherence across NHS Talking Therapies services. A national standardised measure would support clearer monitoring and enable meaningful comparison across services.

Services reported limited time to design and implement adherence interventions. Nationally coordinated resources would help reduce duplication and support more consistent delivery.

Much of the evidence in this evaluation came from services in the South of England. Further evaluation is needed to understand how well these approaches work in other regions and for different patient populations.

Several quantitative analyses were inconclusive because only one service implemented a particular intervention, limiting statistical power. Larger-scale evaluations involving more services would reduce uncertainty and strengthen the evidence base.

The evaluation logic model includes assumptions about patient understanding, motivation and readiness. Future evaluations should include patient interviews or surveys to test these assumptions and explore how interventions are experienced from the service-user perspective.

Why this matters

Improving engagement in NHS Talking Therapies is not just about increasing attendance; it is about helping more people achieve meaningful recovery.

While the effects identified in this evaluation are modest, they point in a positive direction.

With clearer expectations, better-designed support and the right infrastructure, services can make a real difference to people’s experiences and outcomes.