Evaluating the UE-ATR Checklist: Nuanced Attribution in Unsuccessful Therapeutic Outcomes

Abstract

Unwanted events in psychotherapy can hinder treatment, yet clinicians overlook them and tend to attribute treatment stagnation mainly to patient-related factors. The unwanted events–adverse treatment reaction (UE-ATR) checklist was developed to encourage a more balanced reflection on treatment difficulties, but its effectiveness remains unclear. This study investigated whether the UE-ATR checklist enables clinicians to allocate treatment difficulties in a more nuanced way across various contributing factors. Clinicians and psychology students (N = 104) were randomly assigned to either use the UE-ATR (n = 59) or not (n = 45) while reviewing a case vignette of a patient who experienced unwanted events during therapy and treatment stagnation. They allocated responsibility for suboptimal treatment outcome across five factors: the patient, the therapist, the treatment method, the patient's pathology or other circumstances. Attribution was analysed using the Herfindahl–Hirschman index (HHI), where higher scores indicate a monocausal and lower scores reflect a multicausal view. No significant differences were found between the conditions. Although most users found the checklist clinically useful, this positive perception did not lead to a more balanced perspective on the causes of unwanted events. Although the UE-ATR checklist can support clinical reflection, additional training is necessary to maximize its effectiveness.