Prasko, J., Abeltiņa, M., et al. (2025).
Neuro endocrinology letters, 46(1), 33–48.
Advance online publication.
Abstract
Background: Power dynamics are fundamental to therapeutic and supervisory relationships in psychotherapy. In cognitive-behavioural therapy (CBT) and schema therapy (ST), the therapist's power management can help the patient make positive changes. On the other hand, the abuse of power can undermine the patient's autonomy and worsen therapeutic outcomes. Understanding these dynamics is essential for effective and ethical practice.
Objectives: This article aims to explore how power and powerlessness manifest themselves in the practice of cognitive behavioural therapy (CBT) and schema therapy (ST), analyse their impact on therapeutic and supervisory processes, identify the risk of abuse of power, and suggest strategies to support patient and supervisee autonomy.
Methods: The text provides a theoretical and practical analysis of the manifestations of power in therapy and supervision, illustrated with case vignettes to explain important processes. The discussion includes a comparison of CBT and ST, focusing on their respective approaches to power dynamics. Ethical principles, supervision practices, and cultural and institutional influences are also examined.
Results: Effective use of power in therapy and supervision increases trust, cooperation, and autonomy for both client and supervisee. In CBT therapy and supervision, collaboration with an appropriate power distribution between therapist and patient or supervisor and supervisee promotes patient or supervisee engagement. Still, excessive directiveness can sometimes threaten the relationship. In ST, where limited reparenting is the main vehicle for the therapeutic and supervisory relationship, therapeutic and supervisory leadership requires increased sensitivity by the therapist or supervisor to avoid reinforcing maladaptive modes. Supervisory approaches that rely on collaborative approaches are more supportive of professional growth than those dominated by hierarchical power structures.
Conclusions: Reflection on power dynamics is vital in cognitive-behavioural and schema therapy for maintaining ethical and effective therapeutic and supervisory relationships. Strategies that help maintain a balance of power include adherence to ethical principles, self-reflection, and regular supervision. Future research should focus on developing innovative methods to capture solutions to power distribution issues in therapy and supervision.
Here are some thoughts:
This article examines the complex role of power dynamics in cognitive-behavioral therapy (CBT), schema therapy (ST), and clinical supervision, emphasizing both the constructive use and potential misuse of power that can significantly influence therapeutic and professional outcomes. The authors highlight that power in psychotherapy stems from the therapist’s expertise, authority, and role, but it is not static—it emerges from the interaction between therapist and patient, shaped by transference, countertransference, cultural context, and institutional structures. When used ethically, power supports patient autonomy, competence, and growth; however, its misuse can lead to patient helplessness, resistance, and deterioration in mental health, while in supervision, it may result in supervisee insecurity, burnout, and impaired professional development. The paper contrasts CBT and ST: CBT’s structured, directive approach as a “coach” or “teacher” can be effective but risks undermining autonomy if overly authoritative, whereas ST’s emphasis on “limited reparenting” and emotional attunement requires heightened sensitivity to avoid reinforcing maladaptive schemas or fostering dependency. Case vignettes illustrate how therapist behaviors—such as excessive directiveness, moralizing, silence, or nonverbal cues—can subtly convey dominance and disrupt the therapeutic alliance. In supervision, hierarchical, critical, or non-collaborative approaches can replicate these dynamics, hindering the supervisee’s growth. The authors stress that self-reflection, adherence to ethical principles, ongoing supervision, and personal therapy are essential for managing power responsibly. They advocate for collaborative, transparent, and empathic relationships in both therapy and supervision, where power is shared rather than imposed, and recommend institutional support for open dialogue and accountability. Ultimately, the article calls for greater awareness and research into power dynamics to ensure ethical, effective, and empowering practices across therapeutic and supervisory settings.
