By Todd Schmenk @ RIACT/AQAL Therapies
Introduction
Clinical work carries an embedded paradox: the very interventions designed to reduce suffering can sometimes produce it. Iatrogenic harm — harm that originates in treatment itself — is not rare, and it is not limited to dramatic errors in judgment. It can emerge from the ordinary accumulation of well-intentioned clinical decisions that fail to account for how a specific person, with a specific learning history, will respond to a specific procedure or relational context.
From a Functional Contextual perspective, behavior is always a function of context. This means clinician behavior, client behavior, and the therapeutic relationship itself are all subject to the same principle: function is determined by context, not by form. An intervention that reliably reduces distress for one client may reliably increase it for another — not because the intervention is inherently flawed, but because the contextual variables that determine its function differ across people.
This article examines the relationship between iatrogenic risk and idiosyncratic responding, with the goal of helping clinicians develop a more discriminating awareness of how their actions may be functioning in the particular context of each client they serve.
What Is Iatrogenic Harm in Psychotherapy?
The term iatrogenic comes from the Greek iatros (healer) and genesis (origin). In medicine, it refers to harm caused by medical treatment. In psychotherapy, the concept is more complex because the 'treatment' is largely relational and linguistic, and its effects are often delayed, cumulative, or ambiguous.
Iatrogenic outcomes in clinical work include: the inadvertent reinforcement of avoidance patterns, the strengthening of rigid rule-governed behavior through poorly calibrated psychoeducation, the activation of trauma-related responding through exposure-like procedures delivered without adequate preparation, and the erosion of self-directed behavior through excessive reassurance or problem-solving on the client's behalf. These outcomes are not exotic. They are common, and they are more likely when clinicians apply interventions in a relatively uniform way across clients without tracking what is actually happening functionally for the person in front of them.
It is worth noting that iatrogenic harm does not require clinician error in the conventional sense. A clinician can use an evidence-based protocol with fidelity, in the context of a genuinely caring therapeutic relationship, and still produce outcomes that increase suffering or reduce functioning. This happens precisely because the protocol was developed for a population and the client is a person — and person-level variation in learning history, derived relational networks, and contextual sensitivity is not captured by population-level data.
Idiosyncratic Responding: A Functional Contextual View
Relational Frame Theory (RFT) provides a conceptual foundation for understanding why the same stimulus, in the same apparent context, can function very differently across individuals. Human language and cognition operate through derived relational responding, the capacity to transform the functions of events based on their relational membership, without requiring direct conditioning history with every member of the network.
What this means practically is that any clinical stimulus — a therapist's tone, a metaphor, a particular intervention technique, even the physical arrangement of the therapy room — enters into each client's unique relational networks. A mindfulness exercise that functions as a safe haven for one client may function as an aversive reminder of being told to 'calm down' for another. An inquiry into childhood experiences that facilitates meaningful narrative construction for one person may activate suppressed emotional content that overwhelms regulatory capacity for someone else.
This is not simply a matter of individual differences in the everyday sense. It is a systematic consequence of the fact that language-capable organisms accumulate extended, highly interconnected relational networks that are not directly observable. Two clients presenting with superficially similar profiles — similar diagnoses, similar symptom severity, similar stated goals — can have profoundly different underlying relational architectures that will determine how any given intervention functions for them.
Idiosyncratic responding, then, is not an exception to be managed or explained away. It is the baseline condition of clinical work with human beings.
How Iatrogenic Risk Increases When Idiosyncrasy Is Overlooked
The most common pathway from clinical intervention to iatrogenic harm involves a mismatch between the assumed function of a procedure and its actual function for the client. When clinicians treat their theoretical models or evidence-based protocols as if they were context-independent truths rather than probabilistic guides derived from group data, they reduce their sensitivity to the signals that a particular intervention is not functioning as intended.
Several patterns are especially worth tracking.
1. Normative framing that misfires
Clinicians frequently use normalization as a therapeutic tool — for example, informing a client that their anxiety response is understandable given their history, or that their emotional reactions are within the range of what many people experience. For some clients, this functions as genuine relief. For others, it can function as invalidation of the severity of their experience, or as a directive to minimize rather than explore their distress. The clinician's intent is irrelevant to this analysis; what matters is the function the statement serves for that person in that moment.
2. Psychoeducation that generates unhelpful rule governance
Detailed explanations of psychological processes — the nature of anxiety, the function of avoidance, the mechanics of cognitive fusion — can assist some clients in developing flexible, functional understanding of their own experience. For others, the same explanations may generate rigid rule-following that actually increases psychological inflexibility. A client told that 'anxiety is just a feeling and it passes' may develop a rule about tolerating anxiety that functions as a suppression strategy rather than a move toward values-consistent behavior.
3. Reassurance seeking and provision
The provision of reassurance is almost never inert. In the context of a client whose behavior is governed extensively by social-relational reinforcement, repeated reassurance from a clinician can function to maintain avoidance, reduce tolerance of uncertainty, and create a dependency structure that is difficult to disentangle from genuine therapeutic progress. Clinicians who experience reassurance-seeking as relationally warm or who find relief-seeking behavior activating of caregiving responses are at elevated risk of drifting into reinforcement patterns that produce iatrogenic outcomes over time.
4. Exposure without functional assessment
The logic of exposure-based procedures is sound at a general level: contact with avoided stimuli, in the absence of the feared consequence, under conditions that support new learning, can reduce avoidance and its associated suffering. However, whether this logic applies to a given clinical moment depends entirely on what is actually being avoided, what the functional relationships are between the stimulus and the client's relational networks, and whether the conditions necessary for new learning are actually present. Exposure conducted without this level of functional clarity carries meaningful risk of strengthening avoidance, activating overwhelming emotional responses, or disrupting therapeutic alliance in ways that compromise subsequent treatment.
Attending to Function, Not Form
The practical implication of everything above is this: clinicians need ongoing, active assessment of how their interventions are actually functioning, not how they are intended to function, and not how they typically function across populations, but how they are functioning for this person, in this context, right now.
This is not a call for abandoning structure or abandoning evidence. It is a call for holding clinical knowledge lightly enough to remain genuinely curious about whether that knowledge is being confirmed or contradicted by the specific person sitting across from you.
Several practical habits support this orientation.
Tracking what follows intervention
When a clinician introduces a technique or a reframe, the client's subsequent behavior provides data about how that input functioned. Did the client become more open and exploratory, or more closed and ruminative? Did they engage more fully with their values-based behavior between sessions, or retreat further into avoidance? These outcomes are not secondary; they are the primary evidence base for clinical decision-making with an individual client.
Taking mismatch seriously
When a client signals, verbally or through behavioral change, that an intervention did not work as anticipated, this signal is informative. It is not a sign that the client is resistant or that the therapist needs to try harder with the same approach. It is data about the client's idiosyncratic relational history and functional responding, and it should prompt genuine recalibration rather than explanation or perseveration.
Maintaining relational flexibility
The therapeutic relationship is itself a powerful and often under-analyzed contextual variable. What a clinician does within the relationship, their level of directiveness, their tolerance for silence, their use of self-disclosure, their response to client distress, all function as stimuli within the client's extended relational networks. Awareness of this means attending not only to what is being said but to the relational texture of how it is being said, and to what the client's behavior suggests about how that texture is being experienced. Think evoking, modeling, and reinforcing.
Seeking client input as functional data
Asking clients directly about how they are experiencing the work, what is helping, what is not, what feels right and what feels off, is not simply a gesture of collaborative respect, though it is that. It is also the most direct available method for assessing function in the absence of direct observation. Clients who are linguistically able to describe their own experience can often provide clinicians with precisely the data they need to reduce iatrogenic risk and increase workability.
A Note on Clinician Behavior as Contextual Variable
It would be incomplete to address iatrogenic risk without noting that the clinician's own psychological functioning is part of the contextual field that determines treatment outcomes. Clinicians who are operating under conditions of high cognitive load, who are navigating unprocessed personal material that is activated by particular clients, or who have inflexible rule-governed behavior around certain clinical situations are themselves sources of contextual variability that can increase iatrogenic risk.
This is not a failure of training or character. It is a direct consequence of the same principles that govern client behavior: behavior is a function of context, and clinicians are not exempt. The practical implication is that clinician self-awareness, not as an ethical ideal but as a functional competency, is a genuine component of reducing iatrogenic harm. A clinician who can notice their own experiential avoidance, their own drift toward reassurance provision, or their own difficulty tolerating a client's distress without intervening is better positioned to make deliberate, functionally informed choices in session.
Conclusion
Iatrogenic harm in clinical work is not primarily a consequence of incompetence or malice. It is primarily a consequence of applying knowledge derived from populations to individuals without adequate attention to idiosyncratic function. The remedy is not more certainty but more careful observation — ongoing, humble, and genuinely curious tracking of whether what is being offered is actually serving the person receiving it.
Functional Contextualism, grounded in RFT and extended through ACT, offers a framework for this kind of practice. When clinicians hold the question 'what is this actually doing for this person?' as a living clinical concern rather than an occasional check-in, they reduce the distance between their intent and their impact, and they increase the likelihood that the help they offer functions, in this context, as help.