The Use & Misuse of Power in Cognitive-Behavioral Therapy, Schema Therapy, & Supervision

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.

A pdf is here.

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.

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track.

Waller, G., & Turner, H. (2015).

Behaviour Research and Therapy, 77, 129–137.

https://doi.org/10.1016/j.brat.2015.12.005

Abstract

Therapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments.

Highlights

• We consider the recent evidence that therapist drift is a common phenomenon in psychological therapies.

• We consider the reasons that therapist drift takes place.

• A cognitive-behavioural approach to overcoming therapist drift is outlined.

Here are some thoughts:

Therapist drift is when clinicians fail to deliver evidence-based treatments effectively, despite having the training and resources to do so.  This drift can occur consciously or unconsciously and results in patients receiving suboptimal care, reducing their chances of recovery.  Factors contributing to therapist drift include the therapist's knowledge, beliefs, emotions, personality, behaviors, and social environment.  Research indicates that therapist drift is a significant issue in delivering cognitive-behavioral therapy (CBT).  To address therapist drift, strategies incorporating a cognitive-behavioral approach may be beneficial, targeting the beliefs, emotions, and behaviors that lead therapists away from evidence-based practices. 

Telehealth Brief Cognitive Behavioral Therapy for Suicide Prevention: A Randomized Clinical Trial

Baker, J. C., et al. (2024).

JAMA Network Open, 7(11), e2445913.

https://doi.org/10.1001/jamanetworkopen.2024.45913

Abstract

Importance  Suicide rates continue to increase in the US. Evidence-based treatments for suicide risk exist, but their effectiveness when delivered via telehealth remains unknown.

Objective  To test the efficacy of brief cognitive behavioral therapy (BCBT) for reducing suicide attempts and suicidal ideation among high-risk adults when delivered via telehealth.

Design, Setting, and Participants  This 2-group parallel randomized clinical trial comparing BCBT with present-centered therapy (PCT) was conducted from April 2021 to September 2023 with 1-year follow-up at an outpatient psychiatry and behavioral health clinic located in the midwestern US. Participants reporting suicidal ideation during the past week and/or suicidal behavior during the past month were recruited from clinic waiting lists, inpatient service, intermediate care, research match, and direct referrals from clinicians. A total of 768 participants were invited to participate, 112 were assessed for eligibility, and 98 were eligible and randomly assigned to a treatment condition. Data analysis was from April to September 2024.

Interventions  Participants received either BCBT, an evidence-based suicide-focused treatment that teaches emotion regulation and reappraisal skills, or PCT, a goal-oriented treatment that helps participants identify adaptive responses to stressors. Participants were randomized using a computerized stratified randomization algorithm with 2 strata (sex and history of suicide attempts).

Conclusions and Relevance  The findings of this randomized clinical trial suggest that BCBT delivered via video telehealth is effective for reducing suicide attempts among adults with recent suicidal thoughts and/or behaviors.

The research is here.

Here are some thoughts:

The study investigated the effectiveness of brief cognitive behavioral therapy (BCBT) delivered via telehealth for suicide prevention. Conducted from April 2021 to September 2023, the randomized clinical trial involved 96 adults with recent suicidal ideation or behaviors, comparing BCBT with present-centered therapy (PCT).

The research addressed a critical public health concern, noting that suicide rates in the US have increased by over 33% since 2000, with 49,449 suicides recorded in 2022. The study aimed to test whether BCBT could be effectively delivered through telehealth, a method that became increasingly prevalent during the COVID-19 pandemic.

Key findings revealed that participants receiving BCBT experienced significantly fewer suicide attempts compared to those in the PCT group. Specifically, participants in the BCBT group made 0.70 attempts per participant, while PCT participants averaged 1.40 attempts, representing a 41% reduced risk for suicide attempts. Both treatment groups showed significant reductions in suicidal ideation severity, with no statistically significant difference between them.

The study's design included 12 weekly individual sessions delivered remotely, with participants randomized across two strata: biological sex and history of suicide attempts. BCBT focused on teaching emotion regulation and cognitive reappraisal skills, while PCT provided a more supportive, less structured approach to addressing life stressors.

These findings are particularly significant as they demonstrate the potential of telehealth in delivering evidence-based suicide prevention interventions, potentially improving access to critical mental health services for high-risk individuals.