Causal effects in psychotherapy: counterfactuals counteract overgeneralization

Causal inference of psychotherapy effects is usually based on the theory of internal and external validity. The authors argue that as an inductive strategy it often leads to overgeneralization because it promotes neglect of specific clinical boundary conditions (such as practically relevant combinations of treatments, settings, patients, and therapists). Adding the counterfactual conceptualization of causal effects counteracts overgeneralization by considering individuals at a fixed time under two possible treatment conditions as basic units of a causal effect. Consequently, causal effects are regarded as varying in nature as local pieces of a global theory. The authors outline the main deductions from the counterfactual conceptualization with regard to understanding causality, average effects, bias, and study design and address some controversies in psychotherapy research.