On the Reassimilation Risk: A Contextual Behavioral Cautionary Note

By Todd Schmenk

Introduction

As ACT continues to expand into mainstream clinical spaces, I’ve noticed a trend that gives me pause. Increasingly, ACT is being framed and packaged as “ACT for Anxiety,” “ACT for OCD,” “ACT for Trauma,” and so on. On its face, this makes practical sense: people search for “anxiety treatment” more than they search for “values-based, functionally contextual psychotherapy.” Publishers need titles. CE providers need registrants. Clients need a recognizable doorway in.

From a Functional Contextualist (FC) and Relational Frame Theory (RFT) perspective, there are downstream consequences to adopting this frame that we should remain aware of because language does not merely describe targets of intervention,  it can transform them, along with the functions of the clinician’s own behavior.

The Diagnostic Frame as Relational Context

Diagnostic terms such as anxiety or OCD function as relational hubs in cultural meaning networks (Hayes, Barnes-Holmes, & Roche, 2001). They carry assumptions of:

• pathology
• internal causality
• symptom entities
• treatment matching
• symptom reduction as outcome

This is at odds with FC, where behavior in context is the unit of analysis and workability is the criterion (Hayes, Barnes-Holmes, & Wilson, 2012).

In my own clinic, I routinely meet clients who come in saying things like:

“I have anxiety,”
“I have OCD,”
“My trauma is acting up,”
“My ADHD makes me procrastinate.”

From an FC stance, these are verbal behaviors, not explanations, and yet, if the clinician mirrors the frame uncritically, the conceptual analysis begins to collapse into the medical-psychiatric ontology before any functional work has started.

Example 1: The Anxiety Client Who Wasn’t

Recently I worked with a client referred for “generalized anxiety.” That was the category. But functionally, what was happening was something else entirely: the client had an extremely tight rule-governed avoidance repertoire organized around a developmental history of high-performance contingencies. The “anxiety” label masked a pattern of:

• fusion with evaluative private events
• control-based coping strategies
• rigid rule-following
• avoidance of exposure to error and imperfection
• values restriction

The problem wasn’t “anxiety”, the problem was domination by pliance. The “ACT for Anxiety” frame would have narrowed the intervention prematurely to symptom content rather than functional patterns.

Fusion for Clinicians

This isn’t just about clients. Clinicians fuse here too. If a trainee hears “anxiety case,” they may unconsciously shift their analysis toward symptom topography rather than context. I experienced this myself in my early years of learning ACT.  Now, I hear this constantly in supervision:

“He’s anxious, so I used cognitive defusion.”
“It’s OCD, so I tried exposure.”
“She has trauma, so we’ll start with grounding.”

Notice how the label transforms the clinician’s own repertoire. The case becomes an object that dictates intervention selection, rather than an ongoing functional interaction with an organism in context.

This illustrates a key RFT concept: the diagnostic frame alters the transformation of stimulus functions for the clinician (Barnes-Holmes et al., 2017).

Example 2: The “OCD” Case With Zero Compulsions

Another client was referred for “OCD” by a PCP. There were no actual compulsions, only intrusive evaluative verbal behavior combined with rigid experiential avoidance strategies. The diagnostic path had turned a cognitive fusion/exposure problem into a disorder category and now the entire care pathway (including medication) had been built around a label that did not map onto the functional organization of the case.

Had this client simply entered an “ACT for OCD” workshop, the conceptual error would have been reinforced rather than corrected.

The Pliance Problem for Trainees

The next concern is training. Trainees live in high-uncertainty and high-evaluation environments, precisely the conditions that reinforce pliance (Törneke, 2010). The diagnostic frame reinforces rule-governed behavior such as:

“This is a panic case, so we do X.”
“This is OCD, so we do Y.”
“ACT for Depression uses technique Z.”

This is comforting to learners because rules reduce uncertainty, but clinically, it collapses process → protocol and function → category.  It certainly was for me, yet it slowed my desire to look deeper and see the framework underneath. 

In my residency program, I’ve seen bright new clinicians make impressive gains once they drop the diagnostic matching mindset and begin asking questions like:

• What’s the organism trying to do?
• What’s being avoided?
• What are the contingencies?
• How is rule governance functioning?
• What gets selected and what gets punished?
• How workable is the repertoire across contexts?

These are FC/RFT questions. And you can feel the precision increase immediately when these replace diagnosis-driven formulations.

Reassimilating ACT Back Into the Medical Ontology

The bigger concern is not that diagnostic language is used, but that diagnostic framing may reassimilate ACT into the very system it once sought to transform. This isn’t theoretical — we’ve seen this historical trajectory before. CBT began as a radical departure from psychoanalytic models and later became a syndromal, protocolized, symptom-reduction treatment anchored to DSM categories.  With ACT, the risk is that the distinctive contributions of FC and RFT:

• contextual control
• relational framing
• values-based selection
• workability
• idiographic analysis

become diluted until ACT becomes simply:

“CBT plus mindfulness plus values for anxiety.”

Once that happens, the revolution is over.

Alternative: Process-Based Titling

If titles must exist (and I believe they should), there is an alternative that preserves fidelity to the science:

• ACT for Cognitive Fusion Patterns
• ACT for Experiential Avoidance
• ACT for Control-Based Coping
• ACT for Rule-Governed Dominance
• ACT for Values Restriction

These map directly onto recognized process targets (Hayes et al., 2012) and align with Process-Based Therapy (Hofmann & Hayes, 2019) and network models (Borsboom, 2017).

They also reflect the actual content of my clinic. I rarely see “anxiety”; I see:

• fusion
• avoidance
• over-control
• pliance
• restricted sensitivity
• disrupted augmental networks
• narrowed values repertoires

These are process classes, not diagnoses.

Why Awareness Matters

The solution is not to ban diagnostic language. Instead:

We should remain contextually aware of the functional consequences of adopting it.

If we uncritically adopt the diagnostic ontology, we reinforce it. If we reinforce it, we train clinicians inside it. If we train clinicians inside it, we lose the capacity to challenge it and once the field fuses to that ontology, it will be very difficult to unfuse.

References

Barnes-Holmes, D., Barnes-Holmes, Y., Luciano, C., & Mcenteggart, C. (2017). From the IRAP and REC model to a multi-dimensional multi-level framework for analyzing the dynamics of arbitrarily applicable relational responding. Journal of Contextual Behavioral Science, 6(4), 434-445. doi:10.1016/j.jcbs.2017.08.001

Borsboom, D. (2017). A network theory of mental disorders. World Psychiatry.

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational Frame Theory. Springer.

Hayes, S. C., Barnes-Holmes, D., & Wilson, K. G. (2012). Contextual behavioral science: creating a science of change. JCBS.

Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and Commitment Therapy (2nd ed.). Guilford.

Hofmann SG, Hayes SC. The Future of Intervention Science: Process-Based Therapy. Clin Psychol Sci. 2019 Jan;7(1):37-50. doi: 10.1177/2167702618772296. Epub 2018 May 29. PMID: 30713811; PMCID: PMC6350520.

Törneke, N. (2010). Learning RFT. New Harbinger.