The use and misuse of power in cognitive-behavioral therapy, schema therapy, and supervision

Neuro Endocrinol Lett. 2025 Apr 28;46(1):33-48. Online ahead of print.

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.

PMID:40319458