Childhood neglects: intimate partner violence in PTSD–SUD comorbid patients treated with narrative exposure therapy

ABSTRACT

Background: Childhood emotional neglect is a prevalent form of maltreatment, with long-term consequences on emotional regulation and relational patterns. Existing literature indicates associations between emotional neglect, substance use disorder (SUD), post-traumatic stress disorder (PTSD), and intimate partner violence (IPV).

Objective: This study investigates how experiences of parental emotional neglect in childhood reflect on behaviours related to the perpetration of IPV in adulthood, with a particular focus on the interaction with PTSD and SUD.

Method: A qualitative thematic content analysis was conducted on N = 28 narratives collected from individuals who underwent Narrative Exposure Therapy (NET) within a long-term inpatient substance use treatment facility in the west of Norway. Of the 28 participants 67% were male, and the participants’ age ranged from 23 to 58 years (M = 37.5, SD = 8.8). The age of onset of substance use ranged from 11 to 33 years (M = 18.0, SD = 6.8). All fit the criteria for PTSD, and all had been subjected to three or more types of potentially traumatic events. Data was collected between May 2021 and May 2024 from a larger clinical project integrating NET and Dialectical Behaviour Therapy (DBT) for individuals with SUD and PTSD.

Results: Four interconnected themes emerged: (1) Enduring impact of childhood experiences on adult life; (2) Interplay between emotional neglect and the search for validation; (3) PTSD Symptoms and Substance Use as Intermediary Factors Connected to Violence; (4) Continuity between early family dynamics and adult intimate relationships.

Conclusion: The findings indicate that childhood emotional neglect contributes to adult IPV perpetration through specific PTSD and SUD pathways. The study identified concrete mechanisms linking early emotional wounds to adult violent behaviour, with gender-specific patterns and inferences related to intergenerational transmission.

HIGHLIGHTS

• Childhood emotional neglect influences adult emotional regulation and relationship patterns, being an intermediate factor in intimate partner violence.

• Narratives highlighted gendered aspects of intimate partner violence: men often experiencing normalising violence and women internalising emotional pain, reflecting intergenerational trauma.

• The study displays how unaddressed childhood adversity in the sample could perpetuate cycles of violence and neglect, impacting adult parenting practices and relationships.

Introduction

Childhood experiences are a documented risk factor for violent behaviour in close adult relationships (Burke et al., 2023; Díaz-Faes & Widom, 2024). Emotional neglect represents one of the most pervasive forms of childhood maltreatment, affecting an estimated 18% of the global population (Mehta et al., 2023), with far-reaching consequences that impact multiple generations (Su et al., 2022). While research has shown evidence of the impact of physical abuse and violence perpetration later in life (Stöckl & Sorenson, 2024), the consequences of parental emotional neglect and its connection with later substance use disorder (SUD) and post-traumatic stress disorder (PTSD) remain underexplored and require a comprehensive approach. In addition, exposure to intimate partner violence (IPV) during childhood increases the risk of further abuse and neglect, and elevates the likelihood that individuals exposed will later experience or perpetrate IPV in adulthood (Oram et al., 2022). Therefore, this study employs a phenomenological qualitative approach, focusing on how experiences of emotional neglect are connected to PTSD, SUD and IPV.

Unlike physical abuse, emotional neglect often goes undetected, creating a silent behavioural pattern that can manifest after childhood as violence in close relationships (Sun et al., 2021). This invisibility, combined with the complexity of intervening factors such as SUD and PTSD (Miller et al., 2024), is key in understanding IPV and working to prevent it at the primary, secondary, and tertiary level, based on a better comprehension of the risk and protective factors involved. The relationship between childhood emotional neglect and adult violence perpetration has been investigated over the past decade. The comprehensive meta-analyses by Li et al. (2020) and Kisely et al. (2024) found that individuals who had experienced emotional neglect in childhood were three times more likely to perpetrate violence as an adult in intimate relationships, compared to those without such experiences. This association appears to be particularly strong in connection with SUD. Longitudinal studies have found that 45% of individuals with a history of emotional neglect develop SUDs before engaging in violent behaviour (Greene et al., 2020); furthermore, PTSD has been identified as a relevant mediating factor, with findings indicating that 67% of individuals who perpetrated IPV exhibited both childhood emotional neglect and PTSD symptoms (Cruz et al., 2022; Pugliese et al., 2024). These findings align with the neurobiological research reported by Tabachnick et al. (2022), which discusses that ‘children who have experienced maltreatment display flatter, more blunted, patterns of diurnal regulation, relative to non-maltreated children' (p. 200). Tabachnick’s research also suggests that these altered patterns may contribute to increased vulnerability to SUD and violent behaviour in patients who present with PTSD co-occurring with a history of emotional neglect, highlighting that ‘disruptions in frontolimbic circuits may be associated with problems in emotion regulation, reward processing, motivation, and aggression observed among individuals who experience maltreatment' (p. 207). In addition, the research of Warmingham et al. (2023) and Simon et al. (2024) indicates that emotional neglect, in contrast to other forms of childhood maltreatment, exhibits distinctive patterns in its impact on emotion regulation and impulse control, which are core elements in both the perpetration of violence and SUD.

Despite existing research on adverse childhood experiences as a predictor of violent behaviour in adulthood (Burke et al., 2023), more studies are necessary to further understand the role of emotional neglect in violence victimisation and perpetration. While Pugliese et al. (2024) emphasise the importance of differentiating trauma responses in IPV, the specific pathways from emotional neglect to violent behaviour, especially IPV, require further research, particularly in clinical settings. Current research has predominantly examined direct relationships between adverse childhood experiences and adult violence, neglecting the potential cumulative and interactive effects of intermediary factors (Martins et al., 2021; Nikulina et al., 2021; Zamir, 2022). Tabachnick et al. (2022) exemplify that ‘children involved with Child Protective Services due to neglect or abuse often face a multitude of inherently overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology' (p. 200) and underline that ‘it is important that researchers characterize children’s experiences of maltreatment (i.e. timing, type, severity), measure concurrent risk factors, and report comorbid psychopathology' (p. 200). According to Simon et al. (2024), childhood neglect is one of the most prevalent forms of maltreatment, despite the common co-occurrence of multiple abuse types during development. Furthermore, childhood neglect is found to be an indicator for IPV. Findings of Widom et al. (2014) revealed that ‘childhood neglect increases a person's vulnerability to IPV victimization in adulthood' (p. 660) and their results showed that ‘adults with documented histories of childhood neglect were at increased risk for a greater number and variety of acts of psychological abuse and a greater variety of IPV acts of physical violence from an intimate partner, compared to matched controls' (p. 660). The importance of neglect is further illustrated by Dubowitz et al. (2022) where findings revealed that youth who begin to experience neglect in mid-adolescence are especially vulnerable to later criminal behaviour, psychological distress, and involvement in IPV. These findings by Widom et al. (2014) and Dubowitz et al. (2022) highlight the important association between neglect and IPV. Widom et al. (2014) reference Dutton’s (2003) research in their paper, which suggests that ‘emotion dysregulation which, in turn, renders a person more vulnerable to being victimized by IPV leading to injury' (Widom et al., 2014, p. 660). Despite the multifactorial nature of neglect and its associations with significant adverse health outcomes throughout the lifespan, the phenomenon still remains a gap in clinical research – being called by Dubowitz (1994) ‘Neglecting the Neglect of Neglect' (p. 556).

As described by Gilchrist et al. (2023), emotional neglect in childhood disrupts emotional regulation and increases vulnerability to PTSD and SUD. These conditions influence the relationship between early neglect and later IPV perpetration by heightening emotional reactivity, impulsivity, and impaired conflict resolution skills, and by lowering empathy and impulse control. When SUD exacerbates PTSD symptoms, it further compounds relational instability and aggressive responses. Such interactions contribute to an intergenerational cycle in which neglect, PTSD, and SUD increase the likelihood of perpetuating violence or neglect in the next generation. Therefore, this study aims to examine how experiences of parental emotional neglect in childhood contribute to the perpetration of violence in adult intimate relationships, with particular attention to the intermediary factors of SUD and PTSD symptoms. The study intends to contribute to the field through employment of a phenomenological approach combined with thematic analysis to examine and synthesise narratives produced in a larger study that employed both Narrative Exposure Therapy (NET) and Dialectical Behaviour Therapy (DBT) in individuals with SUD and PTSD. The investigation aimed to answer the following research questions:

1. What specific patterns of parental emotional neglect are associated with adult violence perpetration in the narratives collected in patients with PTSD in comorbidity with SUD?

2. How are PTSD symptoms, in comorbidity with SUD, portrayed by participants’ narratives in the context of the occurrence of violent behaviour among adults who experienced childhood emotional neglect?

Methods

Research design

This study employed a qualitative research design utilising thematic content analysis, as described by Green and Thorogood (2018), to examine the personal narratives of individuals with trauma experiences. The narratives were collected through NET according to the context and inclusion criteria outlined in the ‘Data Collection’ section. The methodological approach was grounded in established qualitative content analysis principles presented by Braun and Clarke (2025), employing a phenomenological lens to understand participants’ lived experiences.

The phenomenological approach focused on understanding the lived experiences of trauma through participants’ personal narratives, allowing for a deep exploration of how individuals make sense of and attribute meaning to their traumatic experiences in a context involving emotional neglect and SUD (Alhazmi & Kaufmann, 2022). This approach acknowledged that trauma is not just an event, but a personal experience that contributes to the formation of one’s perception of self, relationships, and the surrounding environment. By examining the narratives of the participants, the study aimed to capture their trauma experiences while respecting the subjective nature of their interpretations and the ways in which trauma has influenced their life trajectories.

Study context

This study was part of a larger project evaluating the feasibility and acceptability of integrating a combination of trauma-focused therapy, NET, and emotion regulation intervention DBT into long-term inpatient treatment for SUD. The project was conducted within the inpatient department of a drug rehabilitation centre on the west coast of Norway. The average treatment duration for the participants of this research was six to nine months, in a facility with capacity for a maximum of 15 patients. Before admission and treatment, all patients were required to complete the detoxification process and maintain a period of abstinence. The standard treatment at the facility consists of a version of the therapeutic community model (Vanderplasschen et al., 2014), family therapy (Hogue et al., 2022), DBT skills for SUD (Dimeff & Linehan, 2008), and NET (Schauer et al., 2025).

NET is a treatment for trauma disorders, particularly suited for individuals suffering from complex or multiple traumas (Schauer et al., 2025). With the guidance of the therapist, a chronological narrative of the patient’s life is constructed during the treatment (exposure sessions), focusing primarily on traumatic experiences but also incorporating positive events. For patients who have also been offenders, narratives of violent or sexual acts are included, as outlined in the adapted version known as Forensic Narrative Exposure Therapy (FORNET) (Elbert et al., 2012). The therapy combines mapping, acceptance, and exposure to traumatic experiences. In this study, the NET intervention consisted of ten to eighteen 90-minute sessions with a NET therapist; these were conducted once or twice weekly over five to ten weeks. The therapy included 1–2 sessions of introduction and psychoeducation on PTSD, SUD and NET, 1–2 sessions constructing the lifeline (where the most important events of the patient’s life are addressed in chronological order and represented by specific symbols – stones for traumatic events, candles for grief, flowers for good experiences in life, and sticks for perpetration of violence), and 3–15 sessions working through the most relevant traumatic events. The number of sessions depends on the number of traumatic experiences reported by the patient in the screening process (see instruments used below) and during the construction of the lifeline. Therefore, heterogeneity mirrors diversities in life experiences. Following the NET guidelines (Schauer et al., 2025), the written testimony of the patient´s life was written by the therapist following the exposure treatment, up to the point where the narration stopped. At the beginning of the next exposure session, the written narrative was read to the patient by the therapist, allowing the participant to add, change, and correct any misinterpretation. The narratives were always written in the past tense and included sensations and feelings from the events, in accordance with NET guidelines (Schauer et al., 2025). The therapists in the current study spent 10–45 min writing the narratives after each session. In the final session, the therapist presented the patient with a written autobiographical narrative, composed of all events addressed across the different exposure sessions.

The inclusion criteria for the NET intervention were:

1. The patient had experienced an aversive event meeting Criterion A for PTSD (direct exposure to a traumatic event, witnessing the trauma, or learning that the trauma occurred to a close relative or close friend), as defined by the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) (American Psychiatric Association [APA], 2013).

2. The patient presented with symptoms of PTSD as defined by the DSM-5 (APA, 2013), or with subthreshold PTSD (Grubaugh et al., 2005); alternatively, the patient exhibited clinically relevant symptoms as assessed by a NET therapist. Subthreshold PTSD is defined as having experienced a traumatic event (Criteria A), meeting Criteria B (re-experiencing symptoms), Criteria E (one-month symptom duration), and Criteria F (significant distress or functioning impairment) and either Criteria C (avoidance or numbing symptoms) or Criteria D (hyper arousal symptoms) (APA, 2013).

Exposure to traumatic events was measured with the Stressful Life Events Screening Questionnaire-Revised (SLESQ), a self-report instrument designed to map and assess 15 potentially traumatic experiences. The potentially traumatic experiences include: Life-threatening illness, life-threatening accident, life-threatening natural disaster, robbery or mugging involving physical force or weapons, death of a close person due to accident, homicide, or suicide, forced sexual intercourse or oral/anal sex, unwanted sexual touching or attempted sexual acts, physical abuse during childhood (e.g. beatings by caregiver), physical abuse in adulthood (e.g. by romantic partner or stranger), emotional abuse (e.g. repeated ridicule or verbal degradation), threatened with a weapon (e.g. knife or gun), witnessing someone being killed, seriously injured, or assaulted, exposure to other life-threatening situations (e.g. combat, war zone) (Goodman et al., 1998). The instrument has shown good test-retest reliability, with a κ = .73, adequate convergent validity, and good discrimination between Criterion A and non-Criterion A traumatic events (Goodman et al., 1998). Patients that marked exposure to one or more potentially traumatic event answered the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), a 30-item structured interview used to make current (past month) and lifetime diagnosis of PTSD (Weathers et al., 2018). The CAPS-5 has good psychometric properties for measuring PTSD symptom severity and is considered the gold standard in diagnosing PTSD (Hunt et al., 2018).

Data collection

The study employed a comprehensive recruitment strategy, targeting all patients admitted to the facility during the intervention period from May 2021 to May 2024. The inclusion criteria were established as follows: (1) participants had to be adults aged 18 or older, meeting the general admission requirements for the inpatient programme; (2) participants had to demonstrate proficiency in a Scandinavian language (Norwegian, Danish, or Swedish); and (3) participants had to provide written informed consent. Individuals with clinically significant cognitive or linguistic impairments were excluded to ensure data quality and to prevent potential misunderstandings during the completion of self-report instruments.

Sample characteristics

Of the 77 participants initially recruited for the larger study, 74 (96%) met PTSD Criterion A for traumatic event exposure according to DSM-5 criteria (APA, 2013). Most participants (72%, n = 55) fulfilled complete PTSD diagnostic criteria, while an additional 20% (n = 15) met subthreshold-PTSD criteria, leaving only 8% (n = 7) without PTSD symptomatology. Sixty-eight participants commenced NET treatment, with 63 (93%) successfully completing the intervention.

From the 63 participants who completed NET treatment, 28 (44%) consented to share their personal narratives for systematic analysis, constituting the final study sample (N = 28). The primary data comprised personal narratives collected through individual document submissions by JV and EB at the long-term inpatient SUD treatment facility between May and June 2024. These narratives, originally documented by therapists as integral components of the NET process, were provided in DOCX format and detailed participants’ experiences with trauma, relationships, and subsequent life trajectories. All narratives were written in Norwegian and subsequently anonymised by JV and EB to ensure participant confidentiality.

A relatively low number of patients were expected to be willing to participate and share their narrative for this sub-study. Almost no patients gave a reason for declining, except some saying it was too difficult to share. Emotional avoidance and social emotions such as shame, social pain and guilt are all common in this severely traumatised and vulnerable population (Vigfusdottir et al., 2025). There were also patients who had committed severe violations to others, including violations that have not been processed through the legal system. Some patients had ties to criminal organisations and feared the risk of facing consequences if being too open. All these components represent a bias, were the most severely traumatised patients and those who have committed criminal offences towards others were less inclined to give consent to this sub-study.

Of the 28 participants included in this sub-study, 67% were male. The participants’ ages ranged from 23 to 58 years (M = 37.5, SD = 8.8). The age of onset of substance use ranged from 11 to 33 years (M = 18.0, SD = 6.8). Most had more than one SUD diagnosis (72%). Forty-four percent were engaged in polysubstance drug use (indiscriminate drug use), and about half had a history of intravenous drug use (46%). Almost all participants were unemployed (96%), and about half (45%) had no higher education beyond the 10th grade. Participants were predominantly single (70%). All fit the criteria for PTSD, and all had been subjected to three or more types of severe traumatic events. The most common traumatic events were having been threatened by violence with a weapon (74%), subjected to repeated humiliation by family or others (67%), exposed to violence as a child (59%) and/or as an adult (59%), rape (56%), or having been robbed or attacked (56%). The mean age of first exposure to a traumatic event was 11 years old (range from 2 to 30 years old).

Data analysis

The thematic analysis followed Braun and Clarke's (2025) six-phase approach. Each narrative was read in full to establish familiarity with the content. Initial codes were generated inductively by identifying recurring patterns in participants’ descriptions. Codes were then compared across cases and grouped into components, which formed the basis for broader themes capturing patterned meaning across the dataset. Through iterative review, codes and components were refined to ensure clear data support. The final thematic structure contained four themes, each with defined components and underlying codes.

The research team (VNF and MT) compiled all narrative documents into a unified dataset for analysis. This consolidation process preserved the original text while organising it for systematic examination. Each narrative was assigned a unique identifier (e.g. ‘Participant 4' or ‘P4') to maintain anonymity while allowing traceability of specific quotes and experiences. The analysis followed a structured, multistep approach:

• Initial reading and identification of meaning units: VNF and MT conducted thorough readings of each narrative to identify meaning units – segments of text containing specific experiences, emotions, or events relevant to the research focus. These units were then highlighted and extracted for further analysis.

• Condensation of meaning units: The identified meaning units were condensed into more concise forms while preserving their essential meaning. This step made the data more manageable for coding, while maintaining the integrity of participants’ experiences.

• Coding process: VNF and MT developed codes based on the condensed meaning units. These codes served as descriptive labels representing specific concepts within the text, such as emotional neglect, pride, loneliness, and drug involvement.

• Category development: Related codes were grouped into broader categories representing common themes across the narratives. These categories included family dynamics, emotional experiences, substance use, and romantic relationships.

• Theme identification: VNF and MT identified overarching themes that emerged from the categories, capturing broader patterns and insights from the data. These themes included the enduring impact of childhood experiences on adult life and the interplay between emotional neglect and the search for validation.

The analytical process from meaning units through to final themes, including representative quotes from participants’ narratives, is comprehensively documented in Table 1, presented in the results section. z

Table 1.

Analytical framework: from meaning units to themes.

Illustrative Quotes	Meaning Units	Condensed meaning units	Codes	Categories	Themes
‘My father was very emotionally absent and scolded me a lot.’ [P4] ‘My father was always away and never cared about what I did.’ [P20]	Emotional neglect and discipline from father	Emotional neglect and discipline	Emotional neglect	Family dynamics	Theme 1: Enduring Impact of Childhood Experiences on Adult Life
‘My parents got divorced and it changed everything.’ [P17] ‘One summer, when I was five or six years old, I witnessed an intense argument between my mother and father that ended with them getting divorced.’ [P4]	Impactful experiences of parents’ divorce	Impact of divorce	Divorce impact	Family dynamics
‘Very proudly I said to him, ‘Did you see I scored a goal?’ He turned around and walked away with a look that said, ‘calm down, I have more important things to do’.’ [P4] ‘I felt so alone, even when I achieved something good.’ [P52]	Pride and loneliness from interactions with parents	Mixed feelings of pride and loneliness	Pride and loneliness	Emotional experiences	Theme 2: Interplay Between Emotional Neglect and the Search for Validation
‘I always felt somewhere between happiness and sorrow.’ [P31] ‘I feel a very deep loneliness when I think about it.’ [P4]	Joy and sorrow in familial and romantic interactions	Complex emotions in familial interactions	Mixed emotions	Emotional experiences
‘I was involved in the drug community and received many threats.’ [P35] ‘I started using and selling cocaine, which led to dangerous situations.’ [P4]	Involvement in drug use and dealing	Dangerous situations lead by addiction	Drug involvement	Substance use	Theme 3: PTSD Symptoms and Substance Use as Intermediary Factors Connected to Violence
‘I drank so I didn't have to think about what happened when I was a kid.’ [P41] ‘When my parents argued, I felt like I couldn't breathe … later I used drugs to calm down.’ [P55]	Substance use as trauma coping	Self-medication for trauma	Addiction as Trauma coping	Substance use
‘My relationships were always full of conflicts.’ [P24] ‘At home, shouting and hitting were just part of solving problems.’ [P57]	Complicated, often turbulent relationships	Turbulent romantic relationships	Relationship turbulence	Romantic relationships	Theme 4: Continuity between Early Family Dynamics and Adult Intimate Relationships
‘My stepfather used to punish me harshly, and I started treating my younger siblings the same way.’ [P51]  ‘What I saw at home, I later did in my own relationships.’ [P9]	Intergenerational violence patterns	Transmission of violent patterns	Mirroring the Modelled violent patterns	Romantic relationships

The process was reviewed by ARB and SAD, who acted as independent peer reviewers. Quality assurance measures were implemented throughout the research process to ensure credibility, transferability, dependability, and confirmability (Ahmed, 2024). The research team employed triangulation by analysing multiple narratives, which allowed the findings to be validated across different participant experiences (Carter et al., 2014). This approach increased the quality and validity of the analysis by identifying consistent patterns and themes across different personal accounts, while also highlighting individual experiences that contributed to a more nuanced understanding.

The integration of direct quotes from participants, preserved in their original Norwegian, was crucial in maintaining authenticity and providing concrete evidence for the themes identified. These verbatim quotes supported the analytical findings and gave voice to the lived experiences of the participants, ensuring that their personal narratives remained central to the research findings. This preservation of the original language also allowed nuanced cultural and linguistic elements to remain intact throughout the analytical process. VNF translated the individual quotes into English; EB and JV ensured that the translations maintained the accuracy of the narrative in the Norwegian language.

The research team systematically documented all analytical steps, providing a clear audit trail from the initial identification of units of meaning through to the development of codes, categories, and themes. This comprehensive documentation approach ensured transparency in the research process and allowed for verification of the conclusions reached. The systematic nature of the documentation also facilitated consistency in the analytical process across the different researchers involved in the study, contributing to the overall reliability of the findings.

Reflexivity statement: ER HER

The authors acknowledge that their diverse backgrounds and roles may have introduced bias into the study. Data collection was conducted by health professionals specialising in psychology and psychiatry within the inpatient institution where the study took place. The authors analysing the data have expertise in the interface between trauma and violence prevalence. Consequently, the research team recognises their backgrounds as potential sources of bias and emphasises the need to consider other bias sources mentioned in this statement. The data were derived from personal narratives written in collaboration with therapists as part of the NET process, which may reflect therapist influence in wording, framing, or interpretation. To address this, participants were invited to review and correct their narratives after each session, a step that follows NET guidelines (Schauer et al., 2025), ensuring accuracy and preserving their own perspective. Second, selection bias was present, as individuals with more severe trauma histories or criminal involvement were less likely to consent to the use of their narratives. This limitation was mitigated by acknowledging the partial representativeness of the sample and focusing the analysis on patterns across the available data rather than generalisability. Third, researcher subjectivity in coding and theme development could affect interpretation. To reduce this risk, coding was conducted independently by two researchers, followed by iterative comparison and consensus meetings, with peer review by two additional researchers to enhance confirmability. Finally, issues of translation introduced the possibility of semantic bias. This was addressed through collaborative translation, cross-checking of English versions against the Norwegian originals, and retention of verbatim Norwegian quotes in reporting. By documenting each stage of the analytic process and maintaining a clear audit trail, the team sought to ensure transparency and strengthen the trustworthiness of the findings.

Ethics approval

The study maintained participant confidentiality using numerical identifiers. All personal identifying and traceable information were removed from the narratives during the analysis process. The research focused on understanding trauma experiences, although sensitivity to the personal nature of the shared stories was paramount. The study is approved by the Regional Committees for Medical and Health Research Ethics (REK) under the reference number 203 428/2020.

Results

From the thematic content analysis, four interconnected themes emerged that illustrate the ways in which participants described pathways linking childhood trauma and adult violence perpetration in the sample analysed. Key meaning units identified were emotional neglect and discipline from father, pride and loneliness from interactions with parents, impactful experiences of parents’ divorce, involvement in drug use and dealing, complicated and often turbulent relationships, and joy and sorrow in familiar and romantic interactions. These meaning units (e.g. ‘emotional neglect and discipline from father’) were simplified into core elements (e.g. ‘emotional neglect and discipline’) and later organised into codes (e.g. ‘emotional neglect’).

The analysis grouped these codes into categories (e.g. ‘family dynamics’) based on common features. In total, four categories were defined: family dynamics, emotional experiences, substance abuse, and romantic relationships. Each category highlights specific aspects of the participants’ lives, helping to identify patterns and relationships within the data. From these categories, themes emerged (e.g. ‘the enduring impact of childhood experiences on adult life’), providing insights into the factors affecting the participants’ lives. The four themes emerged were: (1) the enduring impact of childhood experiences on adult life, (2) interplay between emotional neglect and the search for validation, (3) PTSD symptoms and substance use as intermediary factors connected to violence, and (4) continuity between early family dynamics and adult intimate relationships. The findings were organised in a comprehensive table that mapped the progression from meaning units to themes, including representative quotes (Table 1). This structured presentation allowed for clear visualisation of the analytical process and its outcomes.

Theme 1: enduring impact of childhood experiences on adult life

The first theme shows effects of early emotional neglect, exposure to parental conflict, and the absence of meaningful emotional communication within family systems. This theme includes how childhood experiences of emotional dismissal and neglect altered participants’ capacity for secure attachment, emotional regulation, and interpersonal functioning throughout their adult lives.

Emotional unavailability of close caregivers surfaced as the most common pattern, characterised by parents who maintained physical presence while remaining emotionally inaccessible during critical developmental periods. Participants consistently described fathers who combined emotional distance with harsh criticism, creating environments where children learned that emotional needs were unwelcome, and achievements were inconsequential: ‘My father was very emotionally absent and scolded me a lot' [P4]; ‘My father was always away and never cared about what I did' [P20].

Witnessing parental conflict represented another pathway through which emotional neglect manifested as an adverse childhood experience. Participants recounted exposure to family disruption that altered their sense of safety and stability. Many identified specific moments when their childhood security was permanently shattered: ‘One summer, when I was five or six years old, I witnessed an intense argument between my mother and father that ended with them getting divorced' [P4]; ‘My parents got divorced and it changed everything' [P17].

The absence of emotional communication within family systems emerged as a third critical component, with participants describing households where feelings were neither expressed nor acknowledged. This pattern created a developmental environment where participants learned that their internal emotional experiences were irrelevant or unwelcome: ‘I never really talked to my parents about how I felt; they didn't ask, and I didn't say' [P33]; ‘Mom and dad started arguing louder and louder … the idyll at home was gone' [P73].

Theme 2: interplay between emotional neglect and the search for validation

The psychological mechanism by which early emotional dismissal created persistent validation-seeking behaviours that extended into adulthood, was revealed in the second theme. Specifically, achievements consistently met with parental indifference created feelings of invisibility and unmet relational needs that structured adult relationship patterns.

Systematic dismissal of childhood pride and accomplishments emerged as a particular pattern, where moments that should have fostered self-esteem became, instead, experiences of rejection and emotional abandonment. These interactions taught children that their achievements were worthless, and their excitement was not welcome: ‘Very proudly I said to him, “Did you see I scored a goal?” He turned around and walked away with a look that said, “calm down, I have more important things to do”’ [P4]; ‘I felt so alone, even when I achieved something good' [P52]. This pattern of experiencing or perceiving dismissal created an ‘emotional landscape’ characterised by feelings of loneliness and inadequacy, which participants carried into adulthood. The emotional neglect fostered a sense of unworthiness that permeated their self-concept as demonstrated in the quotes of participant 4 and 31: ‘I feel a very deep loneliness when I think about it.' [P4]; ‘I always felt somewhere between happiness and sorrow' [P31].

The search for validation became a behavioural pattern that modelled adult relationships, with participants describing persistent efforts to gain recognition and acknowledgment that had been denied during childhood. These accounts demonstrate how early emotional neglect creates a struggle for validation: ‘I kept trying to do well in school so they would notice me’ [P35]; ‘I never heard that I was good enough … it became a fight to be seen [as such] in my relationships' [P61].

Theme 3: PTSD symptoms and substance use as intermediary factors connected to violence

From the analysis arose also critical intermediary factors of PTSD symptoms and SUDs. The third theme demonstrates, through the analysed narratives, the pathway from childhood emotional neglect to adult IPV perpetration. It highlights the semiological signs of PTSD and SUD, and through analysing the narratives, it was possible to recognise patterns coming from childhood emotional wounds that intermediated their development into adult violent behaviour through interconnected psychological and physiological processes. Participants explicitly described substance use as a strategy to manage overwhelming trauma symptoms stemming from unresolved adverse childhood experiences as a form of self-medication. The substances served as ‘emotional calming tools or emotional anaesthetics’ that temporarily provided relief from psychological pain: ‘I drank so I didn't have to think about what happened when I was a kid' [P41]; ‘When my parents argued, I felt like I couldn't breathe … later I used drugs to calm down' [P55]. The involvement in substance use related activities created additional layers of exposure to danger and violence, with participants describing how their coping mechanisms led to increasingly risky behaviours and involvement in environments that normalised aggression: ‘I started using and selling cocaine, which led to dangerous situations' [P4]; ‘I was involved in the drug community and received many threats' [P35].

Most critically, the analysed narratives revealed how substance use lowered psychological defences and triggered traumatic re-experiencing that seems to be linked to pathways to violent episodes. Episodes that in some cases presented similarities to patterns of adverse childhood experiences, especially connected to the emotional neglect narrated during the NET process. Participants described how intoxication dismantled emotional barriers that typically regulated trauma responses, allowing suppressed reactions to emerge as aggressive behaviours. This pattern can be connected to the dismantling: ‘We fought a lot when I was drunk, and sometimes it got physical' [P59]; ‘When I was high and she raised [her] voice, it was like I was back there … I couldn't control what happened next' [P24].

The connection and interaction between PTSD symptoms and substance use was also evident in participants’ descriptions of trauma responses during intoxication. These states caused past and present to become confused, activating childhood defensive reactions within adult relationships: ‘When my partner got angry, I froze … Just like I did when my parents argued' [P71].

Theme 4: continuity between early family dynamics and adult intimate relationships

The mechanism of intergenerational transmission, where childhood relational patterns replicate in adult intimate relationships, constitutes the fourth theme. Participants connected their current relationship difficulties to early family experiences, revealing how patterns of conflict, insecurity, and maladaptive coping strategies were unconsciously transferred from their family of origin to their adult relationships.

Participants’ accounts suggested intergenerational dimensions of violence, with some recognising parallels between behaviours they witnessed in childhood and those they later enacted. This pattern revealed a cyclical nature of family violence: ‘My stepfather used to punish me harshly, and I started treating my younger siblings the same way' [P51]; ‘What I saw at home, I later did in my own relationships' [P9]. Participants’ accounts of relationship turbulence reflected patterns associated with childhood environments where conflict was often managed through aggression and difficulties in emotion regulation. Patterns of adult relationships characterised by similar dynamics to those they had experienced in their families of origin are reflected in these quotes: ‘The scuffle got so bad that I slapped her … I feel so guilty when I think about it now.' [P4]; ‘My relationships were always full of conflicts' [P24].

Gender-specific patterns emerged within this theme. Male participants more often described how their families normalised violence as a way to resolve conflicts: ‘At home, shouting and hitting were just part of solving problems' [P57]. In contrast, female participants described developing different adaptive strategies in response to their family environments. They learned emotional withdrawal and self-blame as coping mechanisms when direct expression of needs or emotions was punished or ignored: ‘I learned to keep quiet … it was easier than being ignored or yelled at' [P20]; ‘I was always afraid of saying something wrong … it was easier to withdraw than to address problems' [P72].

Early family experiences influenced participants’ adult relationship expectations. Some of them internalised negative beliefs about relationships and trust that were communicated during childhood, mirroring how they approached intimate partnerships in adulthood: ‘When my father disappeared, my mother said men couldn't be trusted … I carried that into my own relationships' [P57]; ‘I got used to being on guard … I became more dependent on others for security' [P73].

The narratives also revealed protective factors in the form of supportive relationships that provided alternative models of care and validation. These relationships show the potential for changing patterns of trauma replication: ‘My grandparents were always there for me, even when my mother was not' [P20]; ‘One teacher told me I was capable … that stayed with me' [P32]; ‘My older sister listened to me … it made me feel less alone' [P57].

Discussion

The findings indicate that the participants’ experiences of parental emotional neglect in childhood contribute to the development of behaviour pattern linked with perpetration of violence in adult intimate relationships, with particular attention to the intermediary factors of SUD and PTSD symptoms. The findings directly address the research gaps identified by Dubowitz (1994) regarding the ‘Neglecting the Neglect of Neglect' (p. 556) phenomenon and extend the current understanding of the intermediary relationship between PTSD and SUDs. The analysis of the narratives also indicates that SUD play, in the sample, the role of self-medication in traumatic reenactments from adverse childhood experiences linked with neglection (Costanzo et al., 2023). In addition, dismantling, as conceptualised by Meltzer (1986, referenced in Barrer & Gimenez, 2015, pp. 1–2), appears to serve to shield individuals from pain and psychic conflict, allowing them to react to their reality, something that cannot be classified as a defence mechanism, but which shows a behavioural pattern among the narratives analysed.

The identification of neglect patterns challenges the current emphasis on physical abuse in violence prevention research. Emotional unavailability, systematic dismissal of achievements, and the absence of emotional communication in the family emerged as risk factors in the present study. These findings support those of Li et al. (2020) and Kisely et al. (2024), demonstrating that emotional neglect increases violence perpetration risk. However, the current in-depth results present psychological mechanisms underlying this relationship. The narratives described patterns of validation-seeking behaviours, where participants associated adverse childhood experiences and connected them to later vulnerabilities in relationship conflicts and violence (Burke et al., 2023).

The three-pathway moderation and mediation model identified in this study provides empirical support for theoretical frameworks proposed by Goldstein et al. (2023) and Gilchrist et al. (2023). The self-medication pathway aligns with longitudinal quantitative findings showing that 45% of individuals with emotional neglect histories develop SUDs before engaging in violent behaviour (Greene et al., 2020). The identification of substance-induced emotional dysregulation and trauma re-experiencing pathways represents an advance in understanding, especially in what concerns the presentation of these patterns in a clinical setting.

While the current study demonstrates associations between substance use and violence escalation, the specific mechanisms by which intoxication facilitates aggressive behaviour did not clearly emerge in a way that could be categorised and thematised within the analysis. The present study reflects the limitation of using a model of normally functioning emotion regulation that may not always apply to individuals with extensive trauma histories. This aligns with the statement of Expósito-Álvarez et al. (2025) when analysing Gilchrist et al. (2023); ‘Understanding the emotional dynamics of IPV perpetrators may be critical for developing effective interventions while targeting important risk factors for IPV perpetration such as trauma and ADUPs [Alcohol and/or other drug use problems]' (Expósito-Álvarez et al., 2025, p. 3).

The results in this present study show some behaviour evidence that matches the description presented by Tabachnick et al. (2022) in what concerns disrupted frontolimbic circuits, particularly in relation to difficulties in emotional regulation and aggression, which manifest in violent intimate relationships. However, the study's reliance on retrospective narratives cannot establish whether observed behavioural patterns reflect neurobiological damage or learned maladaptive responses. The documented breakdown of emotional barriers during intoxication may represent either a neurological vulnerability or psychological coping strategies that become problematic in intimate relationships. The intergenerational transmission patterns observed by Kellermann's (2001) framework raise questions about determinism versus agency. The normalisation of violence among male participants and withdrawal strategies among female participants suggest that emotional neglect interacts with gender socialisation to produce distinct pathways to relationship dysfunction. However, this study cannot determine whether these patterns represent inevitable outcomes of childhood experiences or potentially modifiable responses. The gender-specific findings extend the work of Warmingham et al. (2023) and Simon et al. (2024), but they require replication in more diverse and larger samples.

In what concerns protective factors, while supportive relationships demonstrated mitigating effects consistent with resilience research by Werner and Smith (2001) and Díaz-Faes and Widom (2024), the infrequence in the study sample raises questions about selection bias. Individuals who experienced protective relationships may be less likely to develop severe PTSD and SUD presentations, which could potentially create an underestimation of the prevalence of protective factors. Additionally, the retrospective identification of protective factors can reflect post-hoc rationalisation rather than genuine protective mechanisms.

The three-pathway moderation and mediation model, according to Gilchrist et al. (2023), suggests that interventions targeting both trauma symptoms and substance use simultaneously may be more effective than sequential treatments. However, this assumption rests on the premise that addressing intermediary factors will reduce the risk of violence. The identification of validation-seeking behaviours as a core mechanism implies that therapeutic approaches emphasising emotional validation may be beneficial. However, the study provides no evidence for intervention effectiveness due to its phenomenological qualitative nature, which highlights how participants experience and address behavioural patterns and symptoms in the narratives constructed through NET treatment.

The documentation of specific neglect patterns provides targets for primary prevention efforts, though the study cannot establish whether preventing emotional neglect would reduce violence rates, due to the complexity of violence as a multifactorial phenomenon (Krug et al., 2002). The identified intermediation factors indicate potential opportunities for secondary prevention; however, the efficacy of early intervention strategies can only be conclusively demonstrated through a quantitative study with a sufficiently powered sample. Nevertheless, the phenomenological approach of this study may serve as a foundation to further sequential explanatory designs that aim to explore the phenomenon discussed here. The findings from this study can be used to generate hypotheses, theories, or specific variables, which can inform the design of quantitative studies connected to the interplay between emotional neglect, PTSD, SUD and IPV.

Conclusion

This study examined participants’ narratives and how childhood emotional neglect, SUD, PTSD, and IPV are interconnected in the sample. The findings that emerged, reflect that early experiences of emotional neglect were associated with later difficulties in emotional regulation, maladaptive coping strategies such as substance use, and involvement in violent intimate relationships as victims or perpetrators. From the analysis, gendered patterns in the manifestation of violence also emerged, as well as instances where attachment relationships acted as protective factors. The identification of such patterns across participants’ experiences corroborates with literature findings that early relational environments influence adult relationship functioning and behavioural outcomes. The results indicate that interventions addressing both the psychological consequences of neglect and its behavioural manifestations, may play a role in preventing the continuation of these patterns into adulthood.

Funding Statement

This work was supported by the Central Norway Regional Health Authority – Helse Midt Norge RHF and the Norwegian University of Science and Technology NTNU [grant number 2020/7923-17].

Author contributions statement

1. Vanessa Nolasco Ferreira: Conceptualisation, Methodology, Data Compilation, Initial Reading and Identification of Meaning Units, Condensation of Meaning Units, Coding Process, Category Development, Theme Identification, Translation, Writing – Original Draft Preparation.

2. Johanna Vigfusdottir: Validation of Translations, Writing – Review & Editing.

3. Edvard Breivik: Validation of Translations, Writing – Review & Editing.

4. Egil Jonsbu: Supervision, Visualisation, Writing – Review & Editing.

5. Ashley Rebecca Bell-Mizori: Peer Review, Quality Assurance, Writing – Review & Editing.

6. Signe Alexandra Domogalla: Peer Review, Quality Assurance, Writing – Review.

7. Miroslava Tokovska: Methodology, Data Compilation, Initial Reading and Identification of Meaning Units, Condensation of Meaning Units, Coding Process, Category Development, Theme Identification, Writing – Review & Editing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The anonymised data that support the findings of this study are available from the corresponding author, VNF, upon reasonable request.