Adverse Childhood Experiences and Emotional Exhaustion in Therapists: The Mediating Role of Early Maladaptive Schemas

ABSTRACT

Objective

Therapist burnout is prevalent and can negatively impact both therapists and their clients. This study aimed to investigate whether (a) therapists who report more adverse childhood experiences report higher levels of emotional exhaustion and (b) whether this is explained by the extent to which they endorse early maladaptive schemas relating to feeling unlovable or flawed and prioritising achievement and the desires of others over one's emotions, preferences and needs.

Method

A cross‐sectional survey was completed by therapists recruited online. Eligible participants were 18 years or older, fluent in English, currently practising as therapists and had been practising for at least 1 year. Hierarchical regression analyses and the PROCESS macro were used to investigate the defectiveness shame, unrelenting standards, self‐sacrifice and subjugation schemas as parallel mediators of the relationship between childhood adversity and emotional exhaustion in therapists.

Results

The sample comprised 383 therapists (M _age  = 46.0 years, SD _age  = 12.79; 89% women). Cumulative adverse childhood experiences scores were positively associated with emotional exhaustion in therapists. The unrelenting standards and subjugation schemas mediated this relationship, whilst the self‐sacrifice and defectiveness shame schemas did not.

Conclusion

This preliminary research indicates that schemas relating to excessively high personal standards and subjugating one's emotions and needs to avoid negative consequences may play an important role in the link between childhood adversity and therapist burnout. Future research is necessary to gather longitudinal evidence and examine whether targeting these schemas in self‐reflective practice, personal therapy or consultation could reduce emotional exhaustion in therapists.

SUMMARY

• Therapists who recall more adverse childhood experiences report higher levels of burnout (i.e., feeling emotionally fatigued or overextended by one's work).

• The relationship between childhood adversity and therapist burnout is partially explained by the extent to which therapists endorse schemas relating to (a) excessively high internalised standards (i.e., the unrelenting standards schema) and (b) suppressing one's own emotions or needs to avoid conflict, mistreatment or abandonment (i.e., the subjugation schema).

• In the current sample, the extent to which therapists endorsed schemas relating to feeling fundamentally flawed or unlovable (i.e., the defectiveness shame schema) and focusing on the needs and preferences of others (i.e., the self‐sacrifice schema) did not explain the relationship between childhood adversity and therapist burnout.

1. Introduction

Burnout is a psychological syndrome involving a state of emotional exhaustion and fatigue, which typically emerges as a prolonged response to chronic interpersonal stressors at work (Maslach and Leiter 2016). The International Classification of Diseases, 11th revision (ICD‐11; World Health Organization 2019), recognises burnout as an occupational phenomenon. Burnout is prevalent among therapists as they are frequently exposed to narratives of distress, loss and trauma; often manage high workloads; and are vulnerable to poor work–life balance (Kotera et al. 2021; Vivolo et al. 2024). Indeed, a systematic review found that more than 50% of therapists reported moderate to high levels of burnout (Simionato and Simpson 2018). The current study focused on therapists' subjective experience of burnout, referred to as emotional exhaustion. Emotional exhaustion is characterised by feeling depleted, emotionally fatigued or overextended by one's work (Maslach et al. 2001). Although burnout is typically conceptualised as a tripartite construct that also encompasses low personal accomplishment and high depersonalisation (Maslach et al. 2001), emotional exhaustion is the most prevalent feature of burnout in therapists (McCormack et al. 2018; Simionato and Simpson 2018).

Emotional exhaustion can negatively impact both therapists' personal well‐being and their work with clients. A systematic review of 44 qualitative and quantitative studies found that emotional exhaustion in mental health professionals was associated with poorer physical and psychological health and higher job turnover (Yang and Hayes 2020). Burnout in therapists has also been linked to lower work conscientiousness (e.g., tending to be late; Salyers et al. 2015), lower confidence in their capacity to cope with job‐related stressors (Shoji et al. 2016) and poor therapeutic alliance (Zarzycka et al. 2022). Given the negative outcomes of emotional exhaustion for therapists and their capacity to support clients, identifying risk factors for emotional exhaustion is crucial.

Research has traditionally focused on how organisational factors, such as excessive workload, confer risk for burnout (Lee et al. 2020; Simpson et al. 2019). Although these structural factors are important, examining potentially modifiable factors for therapist burnout warrants increased empirical attention (Simionato and Simpson 2018; Yang and Hayes 2020). This study focused on two personal risk factors for therapist burnout: adverse childhood experiences (ACEs) and early maladaptive schemas (EMSs).

2. Relationship Between ACEs and Therapist Burnout

A substantial proportion of mental health workers reported a history of ACEs (Brown et al. 2022; Simpson et al. 2019). ACEs are distressing or traumatic experiences that occur before the age of 18 years and include abuse (i.e., physical, emotional, sexual), neglect (emotional and physical) and household dysfunction (i.e., parental separation, intimate partner violence, incarceration of a family member, parental mental illness or substance use) (Felitti et al. 1998). Consistent with the ‘wounded healer’ archetype (i.e., individuals who experience early adversity are motivated to become psychotherapists; Zerubavel and Wright 2012), therapists typically report more ACEs than the general population (Nikčević et al. 2007; Parker et al. 2022; Yellowlees et al. 2021). La Mott and Martin (2019) found that 83% of 371 mental health providers endorse at least one ACE, whilst 45.8% endorse three or more ACEs.

Although a history of adversity can enhance therapist empathy (McBeath 2019; Pilkington et al. 2022), emerging research has highlighted the potential role of ACEs as a risk factor for therapist burnout (Brown et al. 2022; La Mott and Martin 2019; Rossi et al. 2012). The link between ACEs and burnout has been found in a range of helping professions, including physicians and healthcare workers (Clemens et al. 2021; Macdonald et al. 2015; Mercer et al. 2023; Trockel et al. 2023; Yellowlees et al. 2021), counsellors in training (Parker et al. 2022), nursing students (McKee‐Lopez et al. 2019) and other mental health professionals (e.g., psychiatrists, rehabilitation therapists; Rossi et al. 2012). A systematic review by Mercer et al. (2023) reported that health and social care workers with a history of ACEs were more likely to report burnout and poor mental health. La Mott and Martin (2019) surveyed 371 mental health providers and found that participants with a history of ACEs reported significantly higher levels of burnout than those with no history. Further, Brown et al. (2022) found that ACEs significantly predicted burnout in a sample of 140 mental health counsellors. The current exploratory study builds upon this growing research by examining ACEs and emotional exhaustion in a large international sample of therapists (i.e., psychologists, counsellors) and potential mediators of this association.

3. EMSs

The potential role of EMSs as mediators in the association between ACEs and emotional exhaustion warrants exploration. Schema therapy is an integrative approach developed by Jeffrey Young et al. (2003) and used to treat common mental disorders and more entrenched characterological problems. Young et al. (2003, 7) outlined 18 EMSs, defined as ‘broad, pervasive theme[s] or pattern[s] comprised of memories, emotions, cognitions, and bodily sensations, regarding oneself and one's relationships with others, developed during childhood or adolescence, elaborated throughout one's lifetime, and dysfunctional to a significant degree’. The central tenet of schema theory is that traumatic or distressing experiences in childhood (i.e., ACEs) lead to the development of EMSs, which in turn increase one's vulnerability to psychopathology and difficulties in adulthood (Young et al. 2003). In contrast to ACEs, which are static, historical risk factors, EMSs are modifiable and, thus, the mechanism through which ACEs can lead to poor psychological and relational outcomes (Young et al. 2003). Indeed, meta‐analytic evidence indicates ACEs are associated with EMS endorsement in adolescence and adulthood (May et al. 2022; Pilkington, Bishop, and Younan 2021). In turn, EMSs show strong positive associations with mental health outcomes, including anxiety (Tariq et al. 2021), depression (Bishop et al. 2022) and suicidal ideation (Pilkington, Younan, and Bishop 2021). Broad support for Young's model comes from a systematic review of 98 studies by Aafjes‐van Doorn et al. (2020), which concluded that the relationship between childhood trauma and adult psychopathology is mediated by cognitive factors (i.e., internalised beliefs about one's self derived from childhood experiences).

Based on Young et al.'s (2003) schema model, ACEs are likely to be associated with an increased risk of therapist emotional exhaustion, and this may be partially accounted for by the extent to which therapists endorse EMSs. Previous studies have identified ACEs and EMSs as predictors of burnout (La Mott and Martin 2019; Parker et al. 2022; Simpson et al. 2019). However, to our knowledge, no studies have examined the interrelationships between ACEs, EMSs and burnout as a comprehensive test of Young's schema model. The potential role of EMSs in the association between ACEs and emotional exhaustion in therapists is essential to explore, as EMSs can be addressed through supervision and modified through personal therapy and corrective emotional experiences (Young et al. 2003). Therefore, the present study sought to provide novel insights into EMSs as mediators of childhood adversity and emotional exhaustion in therapists.

Drawing on schema theory, we identified four EMSs as likely mediators of the relationship between ACEs and emotional exhaustion: defectiveness shame, unrelenting standards, self‐sacrifice and subjugation. The defectiveness shame schema refers to the self‐perception that one is inherently flawed, unlovable or worthless (Young et al. 2003). The unrelenting standards schema relates to the belief that one must meet extremely high benchmarks of behaviour and achievement (Young et al. 2003). The self‐sacrifice schema involves excessively prioritising the needs of others at the expense of one's own needs (Young et al. 2003). The subjugation schema relates to the belief that one cannot express their needs, boundaries or emotions because doing so will cause anger or rejection from others (Young et al. 2003).

These four EMSs were selected for this exploratory study as they are prevalent in therapist populations (Kaeding et al. 2017) and are relevant based on schema theory (Young et al. 2003) and literature linking EMSs to burnout (Bamber and McMahon 2008; Kaeding et al. 2017; Simpson et al. 2019). Young et al. (2003) argued that the defectiveness shame schema is one of the most potentially harmful EMSs. The defectiveness shame schema has consistently featured as one of the strongest predictors, compared to other EMSs, when examining emotional exhaustion in therapists (Kaeding et al. 2017; Simpson et al. 2019). In a sample of 443 psychologists, defectiveness shame was the EMS most strongly associated with emotional exhaustion (Simpson et al. 2019). Due to the nature of the defectiveness shame schema, which results in one feeling inherently flawed, therapists who endorse the schema may be more vulnerable to feeling emotionally exhausted as they are constantly questioning their ability as a therapist. The remaining three EMSs examined in the current study—unrelenting standards, self‐sacrifice and subjugation—were selected given their shared theme of suppressing one's emotions, needs and preferences whilst over‐prioritising achievement and the well‐being of others. For example, therapists who endorse the unrelenting standards and self‐sacrifice EMSs may be more likely to experience emotional exhaustion as they are likely to strive to meet excessively high standards and overextend themselves to meet their clients' needs (e.g., answering calls out of hours), whilst neglecting their own boundaries and preferences. These three EMSs are also some of the most prevalent EMSs among therapists, making them important targets of empirical investigations into therapist emotional exhaustion (Kaeding et al. 2017; Saddichha et al. 2012; Simpson et al. 2019).

4. The Current Study

Extensive evidence has linked ACEs and EMSs, whilst emerging literature supports a link between EMSs and burnout. However, a comprehensive examination of Young et al.'s (2003) schema therapy model in the context of therapist burnout has not been conducted. Therefore, the current study aimed to investigate whether the relationship between ACEs and emotional exhaustion in therapists is mediated by the defectiveness shame, unrelenting standards, self‐sacrifice and subjugation schemas using a parallel‐mediation model. It was hypothesised that (1) cumulative ACE scores would be positively correlated with therapists' emotional exhaustion and (2) the defectiveness shame, unrelenting standards, self‐sacrifice and subjugation schemas would mediate the positive relationship between ACEs and emotional exhaustion (see Figure 1). Examining the relationships between these constructs can provide insights into cognitive–affective risk factors for therapist burnout that can potentially be targeted to reduce emotional exhaustion.

FIGURE 1.

Conceptual model for the mediation analysis.

5. Method

5.1. Design and Procedure

A cross‐sectional survey was utilised to examine ACEs, EMSs and emotional exhaustion in therapists. The study advertisement included a hyperlink to the plain language statement, consent form, details regarding support services and an online survey questionnaire. Informed consent was obtained before starting the questionnaire. The project was reviewed by the Australian Catholic University Human Research Ethics Committee (Project # 2024‐3629).

5.2. Participants

Participants were recruited internationally via Listservs, advertisements on social media and emails sent to mental health organisations (e.g., professional groups, interest groups and private practices). Therapists were encouraged to share the advertisement and survey link with colleagues. The inclusion criteria required participants to be currently working and have at least 1 year's experience as a professional therapist (e.g., psychologists, social workers, psychotherapists, counsellors), be at least 18 years old and speak fluent English. Participants could reside in any geographical location. Therapists were defined as individuals who practise one or more types of therapy to treat psychological problems (American Psychological Association 2015). Individuals currently studying to become a therapist (e.g., provisional psychologists) were excluded as this study focused on burnout in therapists in paid roles. The final sample comprised 383 participants. Descriptive statistics are provided in Table 1.

TABLE 1.

Sample characteristics (N = 383).

Variable		Statistic
Age in years, M (SD)		46.0 (12.79)
Gender
Women, n (%)		328 (89%)
Men, n (%)		35 (9.9%)
Non‐binary or agender, n (%)		4 (1%)
Geographic location
Australia, n (%)		199 (52.0%)
United States, n (%)		70 (18.3%)
United Kingdom, n (%)		57 (14.9%)
Europe, n (%)		37 (9.7%)
Canada, n (%)		6 (1.6%)
New Zealand, n (%)		4 (1.0%)
Other, n (%)		17 (4.4%)
Profession
Psychologist, n (%)		196 (51.2%)
Social worker, n (%)		57 (14.9%)
Counsellor, n (%)		53 (13.8%)
Psychotherapist, n (%)		50 (13.1%)
Family therapist, n (%)		4 (1.0%)
Psychiatrist, n (%)		4 (1.0%)
Other, n (%)		19 (5.0%)
Work setting
Private practice, n (%)		301 (64.9)
Community mental health, n (%)		62 (13.4%)
Psychiatric hospital, n (%)		20 (4.3%)
General hospital, n (%)		9 (1.9%)
Forensic, n (%)		7 (1.5%)
Other, n (%)		59 (12.7%)
Client age group
Adults only, n (%)		196 (51.2%)
Children/adolescents only, n (%)		166 (43.3%)
Both children/adolescents and adults, n (%)		21 (5.5%)
Primary therapeutic orientation
Integrative, n (%)		118 (30.8)
Cognitive, n (%)		82 (21.4%)
Psychoanalytic or psychodynamic, n (%)		38 (9.9%)
Humanistic, n (%)		34 (8.9%)
Behavioural, n (%)		12 (3.1%)
Other, n (%)		99 (25.8)

Note: The summed percentages for work setting exceed 100% as participants could select multiple responses.

5.3. Measures

5.3.1. Socio‐Demographics

Participants were asked questions about the following demographic and professional characteristics: gender, profession, years of professional experience, theoretical orientations, professional setting, age groups they work with and country they practise in (see Table 1).

5.3.2. ACE Questionnaire (ACE‐Q)

The ACE‐Q (Felitti et al. 1998) is widely used to assess childhood adversity. It consists of 10 items that ask participants to retrospectively indicate whether they experienced a series of adverse and potentially traumatic experiences before the age of 18 years. The items assess 10 ACEs, including abuse (physical, sexual, emotional), neglect (physical, emotional) and household dysfunction (i.e., household member incarcerated, parental mental illness, witnessing domestic violence, substance abuse, parental separation or divorce). Participants respond on a dichotomous scale of 0 (no) or 1 (yes). Item responses are summed to provide an ACE total score, with scores ranging from 0 to 10 and higher scores indicating a greater number of ACEs.

5.3.3. Young Schema Questionnaire Version 3 (YSQ‐3)

Endorsement of the defectiveness shame, unrelenting standards, self‐sacrifice and subjugation schemas was measured via the relevant subscales of the YSQ‐S3 (Young and Brown 2005). Each subscale is represented by five items, rated on a 6‐point scale from 1 (completely untrue of me) to 6 (describes me perfectly; Young and Brown 2005). Example items included the following: ‘I feel that I'm not lovable’ (defectiveness shame schema), ‘I feel that there is constant pressure for me to achieve and get things done’ (unrelenting standards schema), ‘I'm so busy doing things for the people that I care about that I have little time for myself’ (self‐sacrifice schema) and ‘I think that if I do what I want, I'm only asking for trouble’ (subjugation schema). The items relating to each EMS are summed to produce subscale scores ranging from 5 to 30. A higher score indicates the EMS is endorsed more strongly by the individual. Internal consistency in the current sample was α = 0.90 for defectiveness shame, α = 0.79 for unrelenting standards, α = 0.84 for self‐sacrifice and α = 0.78 for subjugation.

5.3.4. Maslach Burnout Inventory: Human Services Survey (MBI‐HSS)

Therapist burnout was measured utilising the emotional exhaustion subscale of the MBI‐HSS (Maslach et al. 1996), which was developed for use with human services professionals and is the most common measure used to assess burnout in therapists (McCormack et al. 2018). The subscale assesses how emotionally fatigued and overextended someone feels by their work (Maslach et al. 1996). The emotional exhaustion subscale comprises nine statements, such as ‘I feel emotionally drained from my work’, with participants rating how often each item occurs on a 7‐point scale ranging from 0 (never) to 6 (every day). Total scores range from 0 to 54. A score of ≤ 16 indicates low levels of burnout, a score between 7 and 26 indicates moderate burnout, and a score of ≥ 27 indicates high burnout (Berjot et al. 2017). The emotional exhaustion scale of the current sample had excellent internal consistency α = 0.94.

5.4. Statistical Analyses

Analyses were completed using IBM SPSS Statistics (Version 29). Descriptive statistics were run for the total sample (N = 383). Pearson's correlations were conducted to examine the bivariate associations between the ACE‐10 cumulative score; defectiveness shame, unrelenting standards, self‐sacrifice and subjugation EMSs; and emotional exhaustion. A two‐step hierarchical regression was conducted to assess ACE‐10 scores and the four EMSs as predictors of emotional exhaustion. At Step 1, ACE‐10 scores were entered to predict emotional exhaustion. At Step 2, the four EMSs were added to the model (defectiveness shame, unrelenting standards, self‐sacrifice and subjugation). A parallel‐mediation analysis was conducted using the PROCESS macro (Hayes 2017) to assess whether the four EMSs mediated the relationship between ACEs and emotional exhaustion (see Figure 1). A parallel‐mediation model was selected to examine the unique contribution of each mediator whilst controlling for the other mediators since EMSs are known to be interrelated (Aloi et al. 2020; Jain and Singh 2019). The bootstrapped confidence intervals for the indirect effects were based on 5000 samples. Assumptions were assessed via visual inspection of histograms, scatterplots and P–P plots, demonstrating that normality, homoscedasticity and linearity were satisfied. No multicollinearity was detected based on the variance inflation factor (VIF) and tolerance values. No multivariate outliers were detected based on Cook's distance.

6. Results

6.1. Descriptive Statistics

Table 1 presents descriptive statistics for the variables included in the hierarchical regression and mediation analyses. On average, the sample reported a moderate level of emotional exhaustion and an average of three ACEs. A total of 15.9% of participants reported no ACEs, whilst the remainder of the sample (84.1%) reported at least one ACE. Most people reported one to three ACEs (45.7%), followed by four to six ACEs (30.5%). Few participants reported more than seven ACEs (7.8%).

6.2. Correlations Between the Schemas, ACE‐Q Scores and Emotional Exhaustion

Table 2 presents the descriptive statistics and the bivariate correlations between the variables included in the mediation analyses. ACE‐Q scores were positively and significantly associated with all four schemas and emotional exhaustion (see Table 2). Further, all four schemas were significantly positively associated with emotional exhaustion and ACE‐Q scores (see Table 2).

TABLE 2.

Pearson correlations, means and standard deviations for variables included in the mediation model (N = 383).

Variable	M	SD	1.	2.	3.	4.	5.	6.	7.	8.
1Age	46	12.79	—
2Gender	—	—	−0.01	—
3Defectiveness shame	8.90	4.78	−0.11*	−0.04	—
4Unrelenting standards	16.83	5.41	−0.17**	−0.00	0.43**	—
5Self‐sacrifice	16.66	5.57	−0.09	0.02	0.36**	0.51**	—
6Subjugation	10.33	4.17	−0.16**	−0.02	0.60	0.41**	0.51**	—
7Adverse childhood experiences	3.0	2.28	−0.17	0.12*	0.28**	0.21**	0.26**	0.22**	—
8Emotional exhaustion	21.13	12.05	−0.33**	0.01	0.35**	0.32**	0.25**	0.39**	0.14**	—

*p < 0.05, **p < 0.01, and ***p < 0.001.

6.2.1. Mediation Analysis Examining ACEs, EMSs and Emotional Exhaustion

See Table 3 for a summary of the hierarchical regression results and Figure 2 for a path diagram of the mediation analysis, including the standardised regression coefficients. At Step 1, age and gender explained 10.2% of the variance in emotional exhaustion, F(2, 380) = 21.47, p < 0.001. At Step 2, the model consisted of ACE‐Q scores, age and gender, which explained 12.4% of the variance in emotional exhaustion, F(3, 379) = 17.86, p < 0.001. The ACE‐Q scores alone explained an additional 2% of the variance in emotional exhaustion. At Step 3, the four schemas (defectiveness shame, unrelenting standards, self‐sacrifice and subjugation schemas), ACE‐Q scores, age and gender explained 25% of the variance in emotional exhaustion, F(7, 375) = 17.81, p < 0.001. The four schemas explained an additional 13% of the variance in emotional exhaustion. Age and the unrelenting standards and subjugation schemas were significant predictors in the final model. ACEs and the self‐sacrifice and defectiveness shame schemas were not significant predictors (see Table 3).

TABLE 3.

Hierarchical regression analysis examining adverse childhood experiences and early maladaptive schemas as predictors of emotional exhaustion.

Variable	B	95% CI for B		SE B	$\beta$	sr	R 2	∆R 2
		LL	UL
Step 1							0.10***	0.10***
Constant	36.16***	28.50	43.82	3.90
Age	−0.30***	−0.32	−0.21	0.05	−0.32	−0.32
Gender	−0.59	−3.70	2.47	1.56	−0.02	−0.02
Step 2							0.12***	0.02*
Constant	35.0***	27.35	42.57	3.87
Age	−0.30***	−0.39	−0.21	0.05	−0.32	−0.32
Gender	−1.12	−4.18	1.92	1.55	−0.04	−0.04
ACE score	0.80*	0.30	1.30	0.26	0.15	0.15
Step 3							0.25***	0.13***
Constant	17.90***	9.34	26.36	4.33
Age	−0.24***	−0.32	−0.16	0.04	−0.25	−0.25
Gender	−0.16	−3.01	2.69	1.45	−0.01	−0.01
ACE score	0.22	−0.28	0.72	0.25	0.04	0.04
Defectiveness shame	0.27	−0.02	0.55	0.15	0.11	−0.08
Unrelenting standards	0.30*	0.06	0.53	0.12	0.13	0.11
Self‐sacrifice	−0.02	−0.26	0.23	0.12	−0.01	−0.01
Subjugation	0.66***	0.31	1.01	0.18	0.23	−0.17

*p < 0.05, **p < 0.01, and ***p < 0.001.

FIGURE 2.

Path diagram and standardised regression coefficients for the mediation analysis. Note: All coefficients are standardised. Confidence intervals are bootstrapped at 95% confidence intervals. *p < 0.05, **p < 0.01, and ***p < 0.001.

7. Discussion

This study aimed to investigate the defectiveness shame, unrelenting standards, self‐sacrifice and subjugation schemas as mediators of the relationship between ACEs and emotional exhaustion in therapists. Whilst prior research has examined the relationship between ACEs and EMSs in various populations (Pilkington, Bishop, and Younan 2021) and EMSs and burnout in therapists (Kaeding et al. 2017; Simpson et al. 2019), this, to our knowledge, is the first study to examine the associations between all three constructs. Hypothesis 1 was supported, with ACEs showing a small positive correlation with emotional exhaustion in therapists. Consistent with previous studies reporting small to moderate associations between ACEs and burnout in mental health professionals and related professions (Brown et al. 2022; La Mott and Martin 2019; Parker et al. 2022), therapists who reported more childhood experiences of abuse, neglect or household challenges were more likely to report feeling emotionally drained, fatigued and frustrated in their work.

Hypothesis 2 was partially supported: Unrelenting standards and subjugation schemas mediated the relationship between ACEs and emotional exhaustion, whilst the defectiveness shame and self‐sacrifice schemas did not. The association between childhood adversity and emotional exhaustion was partially explained by the extent to which therapists endorse an excessive focus on achievement and not making mistakes (i.e., the unrelenting standards schema) and the extent to which therapists ignore their own needs and surrender control to others to avoid anger or rejection (i.e., the subjugation schema). Therapists who endorse the unrelenting standards schema may put excessive pressure on themselves to perform and achieve treatment goals, which may increase the vulnerability to burnout among therapists with a history of childhood adversity (Pilkington et al. 2022). Therapists with a subjugation schema may struggle to be assertive with clients out of fear that the client will get angry (i.e., letting the session run over time). The ongoing suppression of the therapist's needs may, in turn, be associated with feeling more emotionally fatigued and overextended.

The findings are consistent with the notion that individuals with a history of childhood adversity report greater EMS endorsement, which is then associated with poor emotional and relational outcomes in adulthood (Young et al. 2003). Our findings support the Young et al. (2003) schema theory by demonstrating that ACEs are associated with endorsement in EMSs, with EMSs (the unrelenting standards and subjugation schema) increasing one's vulnerability to emotional exhaustion. Empirically, the current findings align with the broader systematic review evidence that cognitive factors, such as EMSs, mediate the relationship between ACEs and psychopathology (Aafjes‐van Doorn et al. 2020).

Surprisingly, the defectiveness shame schema did not mediate the relationship between ACEs and emotional exhaustion. This finding may be due to the sample's relatively low average scores on the defectiveness shame subscale. Given that this schema pertains to feeling inherently flawed, it is possible that therapists who endorse this schema were hesitant to participate in a study centred on self‐reflection on their current functioning as therapists. Future research could seek to recruit therapists who report higher endorsements of the defectiveness shame schema.

Although we found a weak positive bivariate correlation between self‐sacrifice and emotional exhaustion, consistent with previous research (Bamber and McMahon 2008; Simpson et al. 2019), this relationship became non‐significant when the unrelenting standards and subjugation schemas were controlled for in the full parallel‐mediation model. This could reflect the conceptual overlap between self‐sacrifice, unrelenting standards and subjugation, which all relate to over‐functioning and excessive responsibility (Young et al. 2003). Accordingly, these EMSs showed moderate to large correlations with one another in the current sample. Alternatively, given that a central aspect of the self‐sacrifice schema is prioritising others' well‐being, this EMS may serve as an adaptive function for therapists, enhancing their empathic capacity to meet their clients' needs and being ego‐syntonic with the ideal therapist archetype (Kaeding et al. 2017; Simpson et al. 2019). Whilst self‐sacrifice is one of the most prevalent EMSs in therapists (Kaeding et al. 2017; Simpson et al. 2019), future research is needed to investigate the potential role of this EMS in the relationship between ACEs and emotional exhaustion.

Our findings must be interpreted within the context of small effect sizes and the relatively small amount of variance explained by the predictors (Cohen 1988; Sullivan and Feinn 2012). Multiple factors are likely to contribute to therapists' levels of burnout, such as high workload, excessive job demands and challenging client behaviours (for reviews, see Lee et al. 2020; Van Hoy and Rzeszutek 2022; Yang and Hayes 2020). The possible interactions between EMSs and contextual factors (e.g., workload) warrant further investigation. Nonetheless, the current study provides a starting point for identifying modifiable targets that may reduce burnout (i.e., EMSs) and highlights the relevance of individual risk factors for burnout in therapists.

8. Clinical Implications

Our findings have implications for the treatment and prevention of burnout in therapists. Future research could explore whether engaging in personal therapy or supervision to address the unrelenting standards and subjugation schemas could reduce burnout in therapists. One technique used to target EMSs in schema therapy is imagery rescripting, which involves revisiting and reimagining past experiences (Schaich et al. 2020). For example, a therapist may have experienced emotional abuse as a child, where their parents responded with anger when they expressed their needs, resulting in a subjugation schema. Imagery rescripting revisits this experience, whereby the individual might visualise asserting their boundaries and needs to their parents, challenging and potentially healing their subjugation schema.

Additionally, targeting therapists' unrelenting standards and subjugation schemas may, in turn, reduce burnout by decreasing behaviours of over‐functioning and ignoring one's needs. Consciously targeting these two EMSs may be congruent with a broader movement for therapists to use self‐practice/self‐reflection across several therapeutic modalities (Bennett‐Levy et al. 2015; Farrell and Shaw 2018; Tirch et al. 2019). Future research could examine whether schema‐focused self‐reflection is associated with lower scores of emotional exhaustion or lower levels of burnout more broadly in therapists.

9. Limitations

Our findings are interpreted in the context of several limitations. Firstly, the study was cross‐sectional, meaning we cannot establish the temporal sequence or causal pathways between the constructs (i.e., ACEs, EMSs and burnout). Despite this, the current study's mediation model provides preliminary evidence consistent with schema theory (Young et al. 2003). The findings can motivate future large‐scale longitudinal and experimental research to investigate a causal relationship and temporal sequencing of ACEs, EMSs and burnout and to assess whether intervening with therapists' EMSs can prevent or reduce burnout.

Secondly, other variables that may moderate the relationship between ACEs and burnout were excluded in the current study. Review evidence indicates that personal therapy and supervision can protect therapists from burnout (O'Connor et al. 2018; Van Hoy and Rzeszutek 2022), and some research suggests that self‐care moderates the relationship between ACEs and burnout (La Mott and Martin 2019). These potential moderator variables were not included in the current study due to limitations in scope and power. Future research could recruit larger samples to enable complex analyses like structural equation modelling, exploring how moderator variables influence ACEs, EMSs and therapist burnout, offering important insights into risk factors and potential moderators and mechanisms to reduce burnout.

Finally, the sample reported relatively low levels of burnout. The study recruited only therapists who were currently working, and it is possible that our sample did not include therapists who had left the workforce due to the severity of their burnout. Further, participants were not asked if they currently had or have ever received a formal diagnosis of burnout as per the ICD‐11 (World Health Organisation 2019). Future research could seek to include therapists who have recently left the field or taken a leave of absence and seek to recruit therapists with clinical levels of burnout.

10. Conclusion

The current study found that therapists with a history of ACEs are more likely to experience emotional exhaustion, and the unrelenting standards and subjugation schemas mediated this relationship. Whilst causality cannot be established due to the cross‐sectional design, this study provides important preliminary evidence that these two EMSs partially account for the association between ACEs and emotional exhaustion. The current findings can encourage future research to investigate EMSs as a potential target to reduce burnout in therapists. Such interventions could provide significant value, given burnout is highly prevalent among therapists and can have lasting consequences for therapist and client outcomes.

Author Contributions

All authors contributed to study design, data collection and conceptualisation. Matilda Fitzhardinge analysed the data and wrote the first draft of the manuscript. All authors contributed to and approved the final manuscript.

Ethics Statement

The project was approved by the Australian Catholic University Human Research Ethics Committee (Project #: 2024‐3629).

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Fitzhardinge, M. , Blackman L., and Pilkington P.. 2025. “Adverse Childhood Experiences and Emotional Exhaustion in Therapists: The Mediating Role of Early Maladaptive Schemas.” Clinical Psychology & Psychotherapy 32, no. 4: e70115. 10.1002/cpp.70115.

Data Availability Statement

Supporting data are unavailable. Due to the nature of this research, participants of this study did not agree for their data to be shared publicly.