Out On The Couch

Making the most of your clinic’s power

Posted: 9-1-21 | Melissa Dellens

Collage of people in meetings and a water droplet leading to ripples to represent how power dynamics can play out within an organization, between organizations, and within organizations.

Organizational empowerment is an active and participatory process through which individuals, organizations, and communities gain greater control, efficacy, and social justice (Peterson & Zimmerman, 2004). Firstly, we explored Brofenbrenner’s ecological model (Hess & Schultz, 2008), and Prillelensky’s (2008) understanding of power dynamics.  Secondly, we will introduce organizational empowerment theory (Peterson & Zimmerman, 2004) and then explore how clinics, treatment centers, and group practices can be more intentional about the power they hold in the communities they serve. Importantly, Prilleltensky (2008) reminds us that the actions of institutions (including clinical communities) reflects how conscious they are about the power they hold. 

Certainly, there is a lot of focus on individual empowerment in psychotherapy. However, this can unintentionally place blame on one person when more dynamic forces are at play (Peterson & Zimmerman, 2004). In short, organizational empowerment uses Broffenbrenner’s Ecological Model to visualize how power moves, and how communities, collectives, and coalitions can use power as a resource to make impactful change. 

In short, organizational empowerment theory considers how the power dynamics in larger systems affect and impact individual empowerment. Above all, clinical and program directors must consider providing affirmative care in their clinical communities. Organizational empowerment theory assesses power and its leverage at the intraorganizational, interorganizational and extraorganizational levels. 

Personal Power Dynamics: Seating yourself in the ecosystem

In the microsystem, we begin to understand who has more access to power and who doesn’t. Individual status begins to take shape in relationships. Children have less power than grown ups. Employees have less power than employers. Clients have less power than therapists. Additionally, there can be real and perceived power differences between friends and colleagues. For example, other individual social characteristics like intelligence, beauty, confidence, humor or assertiveness can be forms of power as well.  Some questions to consider in exploring your access to power:

  • What people in your life influence your beliefs and values? 
  • Who has the power to influence your expression of self or your identities? 
  • When you think about the people you spend the most time with, where do you hold more or less power in relationship to: 
    • age
    • race
    • religion
    • ability
    • socio-economic status
    • ability
    • gender
    • sexuality
    • relationship constellations  
  • Are the people in your ecosystem positioned similarly to you? 
  • Where do you situate yourself when you consider socially constructed power (beauty, intelligence, assertiveness, humor, social skills?)
  • Do these secondary privileges become more or less important depending on your community setting?

There isn’t necessarily anything good or bad in this. Simultaneously locating yourself in your microsystem while understanding the part power plays in each of your relationships is a start in understanding your role in creating safer communities for LGBTQIA+, consensually non monogamous, and kinky people. 

Thinking about your clinical community

Mesosystems begin to group the people from microsystems together into communities gathering around a common interest, task, mission, or setting (Hess & Schultz, 2008). This is the most important level of the ecological model when considering organizational empowerment (Peterson & Zimmerman, 2004).  

As a clinical community, seeing yourself as an essential mesosystem for the clients and patients you serve deeply affects how you provide care. When considering the treatment your LGBTQIA+, CNM, and kink clients are currently receiving, seeing each of those communities as an additional mesosystem can help leverage your power dynamics in providing affirmative care. 

In short, organizational empowerment theory assesses intra-organizational, inter-organization power, at this level in the ecosystem, and identifies ways to leverage that power more equitably amongst members. 

Intraorganizational power dynamics

This is the power dynamic within your mesosystem. In other words, it is the capacity to provide the highest level of care possible to the most amount of people. This assessment considers your power and ability to do what you said you set out to do. Consequently, you can identify the individual empowerment of your staff and their confidence in their ability to act on the clinic’s mission and values. 

Some things to consider: 

  • What are your organizational mission and values? 
  • Do they actively include LGBTQIA+, CNM, and kink clients? 
  • How diverse are the demographics of your clientele? 
  • What incentives do your staff have to become more affirmative? 
  • Are you providing ongoing education? 
  • What about ongoing anti-racism or anti-bias training?
  • Are there opportunities for personal growth? 
  • Are you aware of the emotional labor of your staff, especially members of more marginalized communities? 

Interorganizational power dynamics

Next, we look at collaboration, coalitions, and alliance building. In short, this is the power your clinic has to partner with other organizations, communities, and actions. However, this power dynamic is most often complicated by time, money, and priorities. Thinking about the care of LGBTQIA+, CNM, and kinky clients in your mesosystem isn’t enough. Leveraging your power to collaborate with their mesosystem can increase your capacity to provide healing is key. 

Some things to consider:

  • Are you collaborating with others in the field in providing affirmative therapy? 
  • Have you considered the current challenges different mesosystems are facing? 
  • Is the power of your mesosystem helping to build alliances with others? 
  • Do you know how to access social support systems, medical care, and other affirming mesosystems for all your clients?

"Empowerment is an active, participatory process through which individuals, organizations, and communities gain greater control, efficacy, and social justice." (Peterson & Zimmerman, 2004). Grey background with white text. Rainbow colored exclamation points.

Considering the greater community

Finally, extraorganizational power is your clinic’s power in impacting and influencing cultural and political considerations for LGBTQIA+, CNM, and kink communities. In short, clinical communities have power in impacting macrosystems through the individual patients they treat, the microsystems they influence, the other meso systems they collaborate with, and the kind of treatment, legislation, and funding they advocate for. 

Some things to consider: 

  • Are you advocating and supporting your clients to advocate for the less affirming systems in their life? 
  • At an organizational level, are you engaged in political advocacy? For example, supporting the passage of the Equality Act at the federal level, and other local legislation that limit power and wellness of your clients? 
  • Do you offer clinical programs that affect the power and wellness of LGBTQIA+, CNM, and kink communities? 
  • Are you positioning yourself as a leader in affirmative care? 
  • Can you share your power and resources across multiple levels of your local ecosystem? 

Being more conscious about power dynamics

When we return to Prilletensky’s hypotheses about power, it becomes important to think about a couple things. Clinical communities have to promote health and wellness, but also the power to resist oppression in all levels of the ecosystem. Prilleltensky reminds us that time is short, and suffering is vast. Access to care for gender-, sexuality-, and relationship- expansive communities depends entirely on individual access to basic needs and resources like time and money. To sum up, clinical communities should constantly be assessing their access to power in every level of their ecosystem, and proactively considering how to do more for LGBTQIA+, CNM, and kink communities.  

Learn More from Melissa Dellens, MA, AMFT

             Text: “Autistic Affirmative Therapy for Allistic Providers Presenter: Melissa Dellens, MA, AMFT, 3 CE Course” under an image of infinity symbol in rainbow colors on rainbow background depicting Autistic affirmative therapy         Text: “Power dynamics in the facilitating environment presented by Melissa Dellens, MA 6 CE Course” under an image of two heads in rainbow colors facing each other depicting the tension between community and clinical approaches in healing LGBTQIA+ communities         



Hess, S. & Schultz, J.  (2008), Chapter 3: Bronfenbrenner’s Ecological Model. Lenses: Applying lifespan development theories in counseling, p. 52-79.

Peterson, N. A., & Zimmerman, M. A. (2004). Beyond the Individual: Toward a Nomological Network of Organizational Empowerment. American Journal of Community Psychology, 34, 129-145.

Prilleltensky, I. ( 2008). The role of power in wellness, oppression, and liberation: The promise of psychopolitical validity. Journal of Community Psychology, 36, 2, 116-136.

Defining Power for Affirmative Therapists

Posted: 8-4-21 | Melissa Dellens

Collage of powerful images (waves crashing on shore, wind turbines in a green field, and a bright sun to represent how affirmative therapists can either assert or withhold their power within the ecosystem to assist LGBTQIA+, consensually non-monogamous or kinky clients.

Clinics, treatment centers, and group practices play an important role in the communities they serve. Power flows through every relationship from the individual dyad in treatment to a community clinic’s relationship with federal policy (Hess & Schultz, 2008).  Moreover, these dynamics can be seen as both a commodity and resource (Peterson & Zimmerman, 2004) in working toward social justice for gender-, sexuality-, and relationship- expansive communities. First, this article will explore Brofenbrenner’s ecological model, and then Prilletinsky’s (2008) definitions of power as they apply to affirmative therapy with LGBTQIA+, consensual non-monogamous, and kink communities. Secondly, this article will set the foundation on how clinical communities can benefit from organizational empowerment theory to affect change. 

Brofenbrenner’s Ecological Model 

Development is clearly a lifelong process impacted by multiple forces throughout the lifespan (Hess & Schultz, 2008). Broffenbrenner’s ecological model envisions radiating rings that the individual moves in and out of as they interact with multiple levels of society throughout their life. This model is likely familiar from early psychology classes. Using this model can be helpful for therapists working individually with clients. Even more impactfully, clinical directors may be able  to consider the context in which their clinicians are working, and advocate toward impacting messages and policy throughout the ecosystem. 

Brofenbrenner’s Ecological Model applied to the idea of power for therapists. The inner circle says "PERSON: personal power" within a larger circle saying "MIRCOSYSTEM: Interpersonal Power" within a larger circle saying "MESOSYSTEM: Intraorganizational and Interorganizational Power" within a larger circle saying "MACROSYSTEM: Extraorganizational Power". This image is used to empower affirmative therapists and clinical directors to utilize their microsystem and mesosystem power to empower LGBTQIA+, consensual non-monogamous and kink communities.

Microsystems & Assessment of Individual Power

Our microsystems are our direct personal relationships (Hess & Schultz, 2008). In other words, the people in our lives who we are closest to: first our families and families of choice, and then our friends, mentors, colleagues, and therapists. From our earliest moments, these people impact our sense of safety and security, and also the way we experience pride and shame. 

LGBTQIA+, consensually non- monogamous, and kinky people take in a lot of information from these people. For example, knowing which parts of them are safe to show, and what has to be hidden for safety can depend on who are they with. It follows that most of the work in individual therapy focuses on a client’s microsystem. Further understanding the impact of being LGBTQIA+, consensually non monogamous, or kinky has on a client’s microsystem is important to affirmative care. Consequently, if clinicians are not considering the context of the larger ecosystem, they will miss a lot of the clients’ experience. 

Mesosystems & Organizational Power

Next, mesosystems begin to group the people from microsystems together into communities gathering around a common interest, task, mission, or setting (Hess & Schultz, 2008).  Mesosystems are where individuals first begin to gather. This level is also where people gather around their identities, political ideations, religions, and values that are most important. Affirmative therapists should consider collective systems of support. 

Some examples:

  • family
  • school systems
  • occupational settings
  • recreational settings
  • sports and athletics
  • recovery communities
  • clinics
  • group practices
  • community mental health providers 

Macrosystems & Systemic Change

Finally, macrosystems are the overall cultural patterns in society. On a social level, this system is how we understand ideas of development, identity, privilege and our sense of worth in the larger contexts where we live (Hess & Schultz, 2008).  From the first brick thrown at the Stonewall Inn the LGBTQIA+ communities have historically been fighting for liberation and empowerment, equal access to housing, employment, and medical care for decades. Additionally, the field of psychiatry and psychology is a mesosystem that still has a lot of work to do to provide affirmative care. 

Understanding the relational levels of the ecosystem informs how power moves through our individual autonomy, collective power, and the power to make systemic change. This clarifies how power exists both as a psychological and political force. 

What is power, and why does it matter? 

It follows that understanding some basic definitions of power is a first step to engaging with it. Isaac Prilletinsky (2008) is a community psychologist who thinks about meso and macro level problems. He offers us some ideas about different ways to define the idea of power. 

Power is

  1. Our capacity and opportunity to fulfill or obstruct personal, relational, and collective needs. 
  2. A psychological and political resource
  3. Currency in the ability to liberate, oppress, and resist. 

These ideas about power exist at all levels of the ecosystem:

  • This is a commitment to anti-bias, anti-racist work, and the individual impact we have to fulfill or obstruct need in our communities.
  • Therapists’ individual votes in a democratic society is a demonstration of psychological and political power. 
  • Staying involved in political advocacy and including that in professional practice is an opportunity to impact need on a larger level. 
  • Acknowledging the power a therapist holds to fulfill or obstruct need is a part of cultural humility. 
  • Social isolation is a meso level problem; a problem about how groups include and exclude others. 
  • For LGBTQIA+, CNM, and kink communities, the reasons for inclusion and exclusion are as political as they are psychological. 
  • The LGBT community has proven to be a powerful political force in enacting both systemic and individual psychological change over the past decade.
  • Power is indeed a currency to resist homo/bi/trans/polyam/kink phobia. 

Accessing or withholding power

First, affirmative therapists and clinical directors need to know what power is. Secondly, they need to understand what it can do. That way they can know where they can exert their power to fight bias and improve patient care on multiple levels in the ecosystem.

Power can

  1. Be overt, covert, subtle, blatant, hidden, or exposed. 
  2. Apply to the self, others, and collectives
  3. Afford people multiple identities in order to acquire resources for their collective needs. 

Accessing or withholding micro power

The decision not to engage with individual power is a covert and subtle decision. Moreover, this is a choice that maintains oppressive psychological and political structures. First, being willing to engage with the people closest in your life about their individual biases and political influences is blatant and exposed. Secondly, exploring how clients do this too can have an impact on their awareness of power. Clients with more privilege can become more aware of their capacity to affect change.  Speaking about religion and politics was considered rude a generation ago. As a result, personal beliefs were not be challenged.  Consequently, children were expected to adopt the beliefs of their parents. Choosing whether or not to challenge this in your close relationship is a microlevel exertion or withholding of power.  Challenging some of these ideas in the therapeutic setting can help clients begin engaging with power too. 

"Power is never political or psychological. It is always both. The same goes for wellness, liberation, and oppression. They are never political or psychological; they are always both." (Pilleltensky, 2008) on a grey background with a rainbow ampersand sign.

Accessing or withholding meso power

Next, grassroots organizing efforts, the development of feminist psychology, and the collective ability to resist status quo are forms of power. So it follows, these efforts are important for challenging social isolation and building community. In short, these are both psychological and political ways to impact social change in the mesolevel. Subsequently, considering the collaboration opportunities organizations have in their community is an important use of power. 

Choosing where to place those communal efforts is a choice of macro level power. For example, LGBTQIA+, CNM, and kink communities have fought the pathologies of their identities, decriminalization of healthy sexual behavior, marriage equality, and currently many different issues related to transgender rights. Consequently, it becomes clear that the political is personal, and the personal is political in all levels of the ecosystem when looking at power from this perspective.  

Power can be complicated

In short, power can be complicated by personal wellness, relationships, organizational dynamics, the political climate, and trends in current events. As a result, putting all this into action is hard work! Systems theorists talk about homeostasis, the internal self-regulation of systems that resist change (Smith-Acuna, 2014). Certainly, this is a dynamic ongoing process. 

Here, we can introduce the chronosystem in Brofenbrenner’s model. This is a model to look at the events and transitions that impact power over time. Therefore, some things to consider when thinking about power in the chronosystem and environment are: 

  1. Context and setting matters. An individual can experience empowerment in one setting, and feel oppressed in another. 
  2. Structural factors like class, race, gender, sexuality, ability affect access to power. 
  3. Social and personal constructs like beauty, intelligence, assertiveness, humor, or social skills affect degrees of power. 
  4. The exercise of power can reflect varying degrees of consciousness with respect to the awareness of one’s actions. 

Putting it all together

To sum up, consciousness and awareness of power is an ongoing, iterative, and lifelong process. Therefore clinician’s evolving understanding of the impact and influence they have on the world around them is an essential part of being affirmative. Similarly, this requires therapists to continue doing their own inner work, engaging in community, having ideas challenged, and listening to those who hold less power.  To clarify, a willingness to engage with power helps bring more awareness to power! 

As we bring all these ideas together in context to LGBTQIA+, CNM, and kink communities, affirmative therapists can relate to how complicated power can be. Certainly, empowerment and oppression is directly related to how well we are positioned in each level of the ecosystem. Therefore resilience and coping skills to manage, navigate, and engage with more systemic forces is essential. Most importantly, engaging in structural anti-bias work can help identify where you are seated both in and out of queer community. An ongoing and increased awareness of where, when, how and why you are engaging with your personal, collective, and political power is an essential part of affirmative therapy. 

Learn More from Melissa Dellens, MA, AMFT


Text: “Power dynamics in the facilitating environment presented by Melissa Dellens, MA 6 CE Course” under an image of two heads in rainbow colors facing each other depicting the tension between community and clinical approaches in healing LGBTQIA+ communities


Hess, S. & Schultz, J.  (2008), Chapter 3: Bronfenbrenner’s Ecological Model. Lenses: Applying lifespan development theories in counseling, p. 52-79.

Peterson, N. A., & Zimmerman, M. A. (2004). Beyond the Individual: Toward a Nomological Network of Organizational Empowerment. American Journal of Community Psychology, 34, 129-145.

Prilleltensky, I. ( 2008). The role of power in wellness, oppression, and liberation: The promise of psychopolitical validity. Journal of Community Psychology, 36, 2, 116-136.

Smith-Acuna, S. (2014). Systems theory in action: Applications to individual, couple, and family therapy. Hoboken, N.J: Wiley.

We can help you and your clinic become more affirmative!