Supported storytelling through the ‘Life Threads’ approach for family members after traumatic brain injury: “We’ve been through all of this trauma, and you’re giving me some string?”

Charlotte Jane Whiffin; Caroline Ellis-Hill; Alyson Norman; Morag Lee; Parmjeet Kaur Singh; Mark Holloway; Jo Clark-Wilson; Natasha Yasmin; Sara Rose; David Sheffield; Fergus Gracey

doi:10.1371/journal.pone.0349304

Peer Review History

Original SubmissionAugust 15, 2025
13 Jan 2026 Decision Letter - Kamalakar Surineni, Editor -->PONE-D-25-43207-->-->Supported storytelling through the ‘Life Threads’ approach for family members after Traumatic Brain Injury: ‘We've been through all of this trauma, and you're giving me some string?’-->-->PLOS One Dear Dr. Whiffin, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Feb 27 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: 1. Theoretical Framework The manuscript would benefit from a clearer articulation of the theoretical underpinnings of the Life Threads approach. While storytelling and narrative therapy concepts are implied, referencing key frameworks (e.g., narrative identity reconstruction, post-traumatic growth, meaning-making) would strengthen conceptual grounding. Clarify how the creative arts component (the “thread” metaphor) integrates with established psychological constructs to promote recovery and resilience. 2. Methodological Transparency The methods are consistent with qualitative rigor, but additional detail is warranted: Specify participant recruitment strategies and inclusion/exclusion criteria (e.g., relationship to TBI survivor, time since injury, level of functional impairment). Elaborate on data collection — for example, duration and format of sessions, interviewer background, and reflexivity considerations. Describe the analytic process more thoroughly: How were themes generated, reviewed, and validated among authors? Was data saturation achieved? Consider including a brief reflexive statement addressing the researchers’ positions and potential influence on interpretation. 3. Data Presentation and Credibility The use of participant quotations is effective, but ensure each theme is consistently illustrated with verbatim excerpts from multiple participants. In Table or Appendix form, provide a concise summary of major themes/subthemes and representative quotes to improve accessibility and transparency. Clarify whether the quotes were edited for brevity or grammatical correction and how confidentiality was preserved. 4. Interpretation and Discussion The discussion insightfully links findings to emotional adaptation and meaning-making, but could be deepened by connecting to broader literature on family identity reconstruction after TBI, ambiguous loss, and family systems recovery. Address possible limitations in generalizability, as participants may represent families with higher engagement in rehabilitation or more open communication styles. The phrase in the title (“you’re giving me some string?”) powerfully captures ambivalence; consider analyzing this further as an example of the initial skepticism families may feel toward non-traditional interventions and how that evolves into acceptance. 5. Ethical and Practical Implications Expand briefly on ethical safeguards for emotionally sensitive interviews (e.g., availability of psychological support if participants became distressed). Include implications for clinical implementation — for instance, how Life Threads could be integrated into multidisciplinary neurorehabilitation settings or adapted for other caregiver populations. Some Minor Comments: The title is evocative and engaging; ensure quotation marks are consistent with journal style. The abstract should explicitly mention sample size, analytic approach (e.g., reflexive thematic analysis), and main themes. Minor grammatical and stylistic adjustments are recommended (e.g., “effecting” → “affecting”; “participants’ voices were captured authentically”). References to similar narrative or arts-based rehabilitation programs (e.g., creative reminiscence therapy, photovoice) would enhance context. Verify formatting of quotations (indentation, punctuation) per PLOS ONE style guide. Reviewer #2: The study is well-written and addresses a significant gap in long-term family support . The integration of Patient and Public Involvement and Engagement (PPIE) is a major technical strength; the authors demonstrate high-quality collaborative research by involving family members as co-investigators and advisory group members throughout the study lifecycle . - Re-title the manuscript as a "Qualitative Proof-of-Concept" rather than a "pre-feasibility" study, as your data concludes that a traditional randomized control trial (RCT) is likely inappropriate for this intervention. - The sample is 95% White and 85% female; please expand the discussion on how the metaphor-heavy "Life Threads" approach might be received by more diverse cultural groups or male family members. - Explicitly address whether the approach can be a standalone tool, as the data indicates success relied heavily on skilled facilitation and expert-led unstructured interviews. - Briefly detail the vetting process used to manage the 22% of expressions of interest identified as phishing attempts to ensure data integrity. - Include any available insights into why three participants withdrew after the first focus group to better evaluate the intervention's "acceptability" . - While the study follows Reflexive Thematic Analysis (rTA) standards, ensure the re-framing acknowledges the shift from quantitative feasibility to qualitative insight. ****** -->6. 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If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0349304.r001
Revision 1
4 Mar 2026 Author Response We would like to thank both reviewers for their thoughtful and constructive feedback. We have carefully considered all comments and have revised the manuscript accordingly. Below, we provide a detailed, point-by-point response. Revisions requested by the editor are detailed in the cover letter. A 'response to reviewers' file has also been uploaded to the Editorial Manager with editorial and reviewer revisions summarised in a tabular format. Reviewer 1 The manuscript would benefit from a clearer articulation of the theoretical underpinnings of the Life Threads approach. Referencing key frameworks (e.g., narrative identity reconstruction, post-traumatic growth, meaning-making) would strengthen conceptual grounding. Clarify how the creative arts component (the “thread” metaphor) integrates with established psychological constructs to promote recovery and resilience. Thank you for this helpful suggestion. We have now strengthen the manuscript by adding further explanation of theoretical underpinnings of the LTA including narrative, identity reconstruction and post-traumatic growth. Further, we have clarified the thread metaphor and how this integrates with creative arts approaches. p.3-4 Specify participant recruitment strategies and inclusion/exclusion criteria (e.g., relationship to TBI survivor, time since injury, level of functional impairment). We have updated Table 3 to include the exclusion criterion for this study. We have added further detail on the recruitment process to ensure this is transparent. I can confirm there were no restrictions based on injury type, family role or level of impairment. We have clarified this in the manuscript. p.7 – 8 Elaborate on data collection — for example, duration and format of sessions, interviewer background, and reflexivity considerations. Under the guidance of Braun and Clarke, we use the header ‘dataset generation’ to refer to data collection. However, we acknowledge that it may not be immediately clear that dataset generation refers to data collection. We have therefore added ‘data collection’ to the heading for clarity. We can confirm that all details pertaining to the duration and format of the interviews and focus groups are described here. Interviewer backgrounds are contained within a ‘positionality statement’ under the main header of analysis. p.9 Describe the analytic process more thoroughly: How were themes generated, reviewed, and validated among authors? Thank you for requesting further information on this important step. We have now moved the information from the supporting file into the main manuscript so that our methods are transparent and explicit for readers. p.11-12 Was data saturation achieved? You are right to raise the question of data saturation. However, in the analytical method we have used, saturation is contentious and Braun and Clarke have written extensively about the lack of alignment of data saturation with their reflexive approach to thematic analysis. We have now added clarity on this point to the manuscript and signposted to a more appropriate concept of ‘data sufficiency’. p.8 Consider including a brief reflexive statement addressing the researchers’ positions and potential influence on interpretation. We do have a positionality statement that addresses all of the researchers’ backgrounds. I have now added to this that our experiences within this field will have influenced how we interpreted the data. p.10 Ensure each theme is consistently illustrated with verbatim excerpts from multiple participants. I have mapped the respondent quotes against the themes and identified those where no data were presented. I have now added data from Res 15, 16, 18 and 20. The manuscript now contains data from every participant at least once. In Table or Appendix form, provide a concise summary of major themes/subthemes and representative quotes to improve accessibility and transparency. I can confirm that Table 8 provides a useful summary of the themes and sub-themes. Direct quotes are contained in this table; however these were not shown as such. We have now added quotation marks so that this is clear. Table 8 Clarify whether the quotes were edited for brevity or grammatical correction and how confidentiality was preserved. Quotes used in the manuscript are de-identified verbatim extracts of raw data. We have now explained this in the manuscript. p.16 The discussion insightfully links findings to emotional adaptation and meaning-making, but could be deepened by connecting to broader literature on family identity reconstruction after TBI, ambiguous loss, and family systems recovery. Many thanks for this important suggestion. We have now extended the debate around emotional adaptation and key constructs in the ABI literature including ambiguous loss and the family tasks model. We have also discussed the wider literature on family interventions after ABI. p.35 – 41 Address possible limitations in generalizability, as participants may represent families with higher engagement in rehabilitation or more open communication styles. Thank you for identifying this important limitation. We have now added this to the strengths and limitation section of the manuscript. p.41 The phrase in the title (“you’re giving me some string?”) powerfully captures ambivalence; consider analyzing this further as an example of the initial skepticism families may feel toward non-traditional interventions and how that evolves into acceptance. Thank you for this helpful suggestion. We have now alluded to this initial doubt in under the sub-title. p.34 Expand briefly on ethical safeguards for emotionally sensitive interviews (e.g., availability of psychological support if participants became distressed). Our ethical safeguards for participant’s emotional wellbeing are now described as requested. p.5 Include implications for clinical implementation — for instance, how Life Threads could be integrated into multidisciplinary neurorehabilitation settings or adapted for other caregiver populations. We have made it clear that we are not ready to recommend use of the LTA in clinical practice without further research. However, we do advocate for family centred rehabilitation and that families have access to supportive interventions in their own right. We have also signposted to the Life Thread Network for people interested in the approach (www.anchorpointabi.org/research) p.44 The title is evocative and engaging; ensure quotation marks are consistent with journal style. I have reviewed the style guides for manuscript titles. I can confirm that the title meets the character limit. There does not appear to be clear guidance on the use of quotation marks. However, we have revised the title to use quotation marks specifically. p.1 The abstract should explicitly mention sample size, analytic approach (e.g., reflexive thematic analysis), and main themes. We have made revisions to the abstract to ensure these methods are explicit. p.2 Minor grammatical and stylistic adjustments are recommended (e.g., “effecting” → “affecting”). We have reviewed the manuscript and made adjustments to improve grammar and correct errors. References to similar narrative or arts-based rehabilitation programs (e.g., creative reminiscence therapy, photovoice) would enhance context. Thank you for suggesting this. We have reflected on the basis of the approach in creative arts in the introduction and have returned to related work in the discussion. Here we also recognise the potential for methods originating as research methods (such as photo elicitation and the ‘wool and stones’ approach) in offering creative opportunities for resources or interventions to help families negotiate the challenges of life after brain injury and to find new and adaptive meanings. Introduction/ Discussion Verify formatting of quotations (indentation, punctuation) per PLOS ONE style guide. I have reviewed the style guides for PLOS ONE and cannot see explicit guidance for the presentation of direct quotes. I have reviewed recently published qualitative manuscripts and there does not appear to be a consistent approach. The current manuscript is in line with current styles. Reviewer 2 Re-title the manuscript as a "Qualitative Proof-of-Concept" rather than a "pre-feasibility" study, as your data concludes that a traditional randomized control trial (RCT) is likely inappropriate for this intervention. Thank you for this suggestion which we have discussed at length. However, given that the published protocol and original funding were aligned to a qualitative pre-feasibility study we feel it is important to maintain this consistency. We do then highlight that the answers to the objectives were not as clear cut as those typically yielded in pre-feasibility studies in the strengths and limitations. The sample is 95% White and 85% female; please expand the discussion on how the metaphor-heavy "Life Threads" approach might be received by more diverse cultural groups or male family members. This is an important point and one that we explored in our PPIE group. We have added this insight into the manuscript. p.44 Explicitly address whether the approach can be a standalone tool, as the data indicates success relied heavily on skilled facilitation and expert-led unstructured interviews. We have now added to Table 9, that we do not support use of the Life Threads approach as a standalone tool. Table 9 Briefly detail the vetting process used to manage the 22% of expressions of interest identified as phishing attempts to ensure data integrity. Thank you for requesting clarification of this point. I have added further detail to the manuscript about this. p.12 Include any available insights into why three participants withdrew after the first focus group to better evaluate the intervention's "acceptability". I have now added further insight into why these three family members felt unable to complete the LTA. However, this data was not collected formally. p.12-13 While the study follows Reflexive Thematic Analysis (rTA) standards, ensure the re-framing acknowledges the shift from quantitative feasibility to qualitative insight. Thank you for this helpful recommendation. This has been added to the manuscript. p.43 Attachments Attachment Submitted filename: Life Threads TBI Response to reviewers.docx https://doi.org/10.1371/journal.pone.0349304.r002
29 Apr 2026 Decision Letter - Kamalakar Surineni, Editor Supported storytelling through the ‘Life Threads’ approach for family members after Traumatic Brain Injury: ‘We've been through all of this trauma, and you're giving me some string?’ PONE-D-25-43207R1 Dear Dr. Whiffin, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Kamalakar Surineni, MD, MPH Guest Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** -->2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes Reviewer #2: Yes ****** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: N/A Reviewer #2: N/A ****** -->4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: No Reviewer #2: No ****** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: The authors have provided a thorough and thoughtful revision of the manuscript, and I appreciate the detailed point-by-point responses to the previous review. The revisions have significantly strengthened the manuscript across multiple domains. In particular, the manuscript now demonstrates: Improved conceptual clarity, with clearer articulation of the theoretical underpinnings of the Life Threads Approach, including links to narrative identity reconstruction, meaning-making, and post-traumatic growth. Enhanced methodological transparency, especially regarding recruitment, data collection, and the analytic process consistent with reflexive thematic analysis. Stronger analytic rigor, with clearer description of theme development and inclusion of representative participant quotations across themes. A more comprehensive discussion, incorporating relevant literature (e.g., ambiguous loss, family systems perspectives) and acknowledging limitations appropriately. Clarification of ethical considerations, reflexivity, and implementation boundaries, including the need for skilled facilitation and trauma-informed delivery. The findings are presented in a coherent and compelling manner, and the conclusions are appropriately cautious and aligned with the qualitative nature of the study. The manuscript makes a meaningful contribution to the literature on family experiences following traumatic brain injury and offers valuable insights into narrative-based supportive interventions. I have no further substantive concerns and believe the manuscript is suitable for publication in its current form. Reviewer #2: - In response to question 4: The authors have provided a fully compliant Data Availability Statement that appropriately handles ethical restrictions for sensitive qualitative data. - The shift from "data saturation" to "data sufficiency" effectively justifies the sample size , and detailing the phishing vetting process strengthens study integrity . - The manuscript is clear, professional, and well-written. ****** -->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.--> Reviewer #1: Yes: VENKATA VIJAYA K DALAI Reviewer #2: Yes: Ivanshu Jain ******** https://doi.org/10.1371/journal.pone.0349304.r003
Formally Accepted
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