1 Introduction

Acquired brain injury refers to any non-hereditary non-degenerative condition arising from events that damage the brain (Goldman et al. 2022). These events include head injury, stroke, infection, anoxia and poisoning. Symptoms and their duration vary greatly, depending on the location and extent of the damage. Sometimes there are long-term changes to the person's social, cognitive, emotional and behavioural functioning, and these can have a negative impact on their relationships with others. Particularly damaging are difficulties in expressing emotion and detecting it in others; apathy and lack of emotional warmth; egocentricity and loss of empathy; and aggression and other challenging interpersonal behaviours (Anderson et al. 2002; van den Broek et al. 2022; Villa and Riley 2017; Wood et al. 2005; Yasmin and Riley 2022).

High levels of dissatisfaction and breakdown in marriages and partnerships (i.e., other forms of romantic relationship) have been reported following brain injury (Anderson and Keating 2018). For example, a recent study in Denmark reported that there are approximately three divorces for couples living with brain injury for every two in the general population (Rytter et al. 2024); and, in a UK sample, non-injured partners on average rated their current relationship as significantly worse than the pre-injury one (Falshaw and King 2026). This is a major issue because, as well as being of intrinsic value, good intimate relationships help protect mental well-being (Stevens et al. 2013; Wang et al. 2022). This protective effect is particularly important in brain injury because of the negative impact the injury can have on the well-being of both the person with the injury and their partner (Low et al. 1999; Vogler et al. 2014).

A range of different therapies has been used to support couples with relationship difficulties following brain injury. These include the application of therapies developed for use with the general population, such as systemic family therapy (Laroi 2003) and emotion focused therapy (Yeates et al. 2013). There are also interventions designed for use in brain injury that target specific issues, such as the management of challenging interpersonal behaviours (Fisher et al. 2018) or a broader range of issues, such as communication, empathy and intimacy (Backhaus et al. 2019). These brain injury-specific interventions have generally adopted a cognitive-behavioural approach.

There have also been previous reports of narrative approaches being used to address relationship issues within the family following brain injury (Butera-Prinzi et al. 2014; Daisley et al. 2014) and couple relationships in particular (Hawkins et al. 2019; Mwale et al. 2022). The primary aim is to help the family or couple move away from problem-focused narratives towards richer and more positive stories about themselves that incorporate their values and strengths as individuals and as a family unit (Freedman 2014; Jacobson 2025). This narrative approach may be particularly useful in a brain injury context because of the dominance of negative medicalised narratives focused on loss and impairment that typically accompany brain injury (Chamberlain 2006; Hutchinson et al. 2018; Whiffin and Ellis-Hill 2022). A particular cluster of problem-focused narratives that has been identified in brain injury research about marriages/partnerships is a sense of rupture and discontinuity between the pre- and post-injury identities of both the relationship and the person with the brain injury. Research on discontinuity in the relationship has been conducted primarily from the perspective of the non-injured partner. In essence, the partner feels like the old relationship has been lost and replaced by something new (Bodley-Scott and Riley 2015; Gill et al. 2011; Kratz et al. 2017; Riley et al. 2020; Villa and Riley 2017; Whiffin et al. 2019; Yasmin et al. 2020; Yasmin and Riley 2022). The relationship is dominated by the giving and receiving of care rather than interactions that bond them as a romantic couple. The relationship comes to be perceived as being more like that between nurse and patient or parent and child, rather than between romantic partners. Non-injured partners may perceive their situation in individual terms rather than couple terms—as ‘I’ and ‘you’ rather than ‘we’—and the sense of togetherness and being a team is lost. Another aspect of the general sense of discontinuity is a perception that the person with the injury is no longer the same person. Comments such as ‘this is not the person that I married’ and ‘it's like living with a stranger’ have been reported (Wood 2005). The present is compared unfavourably with how things were before the injury, and there is a sense of grief and loss for the pre-injury person and relationship. Perceptions of discontinuity in the relationship are associated with a change in feelings towards the injured partner, with love and affection being replaced by other feelings such as care and protectiveness or more negative ones such as dislike and fear (Bodley-Scott and Riley 2015; Villa and Riley 2017).

Both partners can also feel a sense of discontinuity in their individual identities, a sense of radical difference between their pre- and post-injury self. The non-injured partner can feel that they have lost their former life and self, as they become trapped in the role of carer (Kratz et al. 2017; Whiffin et al. 2019). Many people with brain injury similarly perceive a sense of rupture between their pre- and post-injury selves (Freeman et al. 2015; Nochi 1998; Villa et al. 2020). The self may be described as ‘broken’ or ‘lost’, and unfavourable comparisons are made between the pre- and post-injury self, with a sense of grief for the lost self.

Research has found that these narratives centred on rupture and discontinuity are associated with poorer outcomes. Compared to those who endorse continuity, non-injured partners who describe discontinuity give more negative evaluations of their relationship in general (Yasmin et al. 2020), provide a poorer quality of care and support (Riley et al. 2020) and experience worse emotional well-being (Villa and Riley 2017). Perceptions of discontinuity on the part of the person with the injury about their self-identity are associated with low self-esteem and greater depression and anxiety (Beadle et al. 2016; Mascialino et al. 2022). Similarly, discontinuity of self-identity is associated with poorer mental well-being in the non-injured partner (Kratz et al. 2017).

1.1 Aims

The aims of the present study were to (a) provide some guidance for applying narrative couples therapy to address discontinuity narratives in brain injury and (b) carry out an exploratory evaluation of its usefulness for this purpose. The therapy was given to three couples. A description of its application in these three cases is used to illustrate the guidelines.

The study differs in two ways from previous applications of narrative approaches to family relationships in a brain injury context (Butera-Prinzi et al. 2014; Daisley et al. 2014; Hawkins et al. 2019; Mwale et al. 2022). First, it was focused specifically on addressing discontinuity narratives, which the earlier studies were not. Although the earlier studies discuss change and loss, they addressed a broader range of issues. For example, Butera-Prinzi et al. (2014) worked with the trauma experienced by the family in reaction to the brain injury. Second, it focused on providing more structured guidelines for delivering the therapy. In contrast, the earlier studies have described the general principles of narrative family therapy (e.g., ‘thickening the plot’—Hawkins et al. 2019) and described case examples of how these were (or could be) applied in practice. Although these descriptions are valuable, structured guidance may be a useful addition. Without such guidance, delivery of the therapy relies more heavily on the skills and experience of the therapist and is deliverable only by therapists with specialist training in the general approach. Despite their importance, family and couple relationships are often neglected by brain injury rehabilitation services. One of the main reasons for this is the lack of access to therapists skilled in working with families and couples (Stejskal 2012; Yeates et al. 2013). More structured guidance would allow relationship issues to be addressed by a broader range of professionals with experience of working with brain injury. Skilled therapists may still offer a more effective service but having family issues addressed by those with less specialised skills, following a more structured approach, would be better than the current situation of family issues being neglected.

2 Method

The study was approved by the STEM Ethical Review Committee at the University of Birmingham, UK (reference number ERN_21-1608). Participants provided fully informed written consent, including consent for the material to be included in an academic paper. To protect their confidentiality, pseudonyms have been used.

Following completion of the guidance, three couples received the therapy from the first author who was a trainee clinical psychologist at the time. In preparation, the first author completed the online introductory 20-h ‘What is Narrative Practice?’ certification module provided by the Dulwich Centre (details at: https://dulwichcentre.com.au/training-in-narrative-therapy/) along with self-directed reading and approximately 6 h on narrative approaches provided as part of the clinical psychology training program. Supervision was provided by the second author, who is a qualified clinical psychologist. The couples were recruited from Headway, a UK charity providing support for people living with acquired brain injury. To take part, couples were required to be living together at the time of participation and to have lived together for at least 2 years prior to the injury. The brain injury had to have occurred at least 12 months prior to participation, and both members of the couple needed to be capable of meaningful participation in verbal therapy. Because of the recruitment method, the authors had no access to the medical records of the participants.

2.1 Guidance for Delivering the Therapy

Development of the intervention was guided by the general principles of narrative therapy (White 2005, 2007) and by descriptions of the general components of narrative therapy with couples (Freedman 2014; Hawkins et al. 2019; Jacobson 2025). These principles and components include the following:

• creating a safe and validating space for the couple to articulate the problem-focused narratives;
• externalising the problem and encouraging the couple to separate themselves from the brain injury and its effects;
• identifying their strengths and resources, their values as individuals and as a couple and their hopes for the future;
• encouraging them to develop new preferred narratives around the injury and its effects;
• using methods (including bearing witness and letter writing) to help the couple elaborate and consolidate the new narratives so that they become the lens through which the couple experience and respond to their situation; and
• encouraging the couple to consider how they can live their lives in a way that reflects the new narratives and their values.

The evidence base for narrative therapy generally is rather limited and few studies have evaluated narrative therapy for couples in a formal way (Dulwich Centre, n.d.). In a before-and-after study conducted by Chimpén-López et al. (2022), couples showed significant improvements on a relationship questionnaire after receiving a form of narrative therapy for couples. In a randomised controlled trial, Ghavibazou et al. (2020) report significant benefits on a number of relationship questionnaires for the therapy, although it should be noted that the therapy only involved women who were in heterosexual relationships and not the male partners. Because of this limited evidence base, it is unclear which components of narrative therapy are critical to its effectiveness in helping couples improve their relationship. Accordingly, all the components described in some key resources about narrative therapy for couples (Freedman 2014; Hawkins et al. 2019; Jacobson 2025) were included in devising the plan for the therapy. A detailed session plan was developed incorporating these components. Preliminary ideas about the plan were shared with three people with extensive experience of using narrative and systemic approaches in their clinical work with families, and their feedback helped shape the final version.

The therapy also made use of the 'tree of life'. The couples completed a couple's tree of life, as well as an individual tree of life. These were based on the original tree of life for individuals (Ncube 2006) and the couple's tree of life adapted by Chimpén-López et al. (2022) from the individual tree. Others have reported using these trees or similar metaphors in a brain injury context. Butera-Prinzi et al. (2014) describe using the tree of life for family members of people with acquired brain injury, with the former highlighting its usefulness for those who might otherwise find it difficult to articulate their narratives (e.g., children). Mwale et al. (2022) describe the use of individual trees of life for people with acquired brain injury in a group setting, and an example of using a couple tree of life to help a couple living with a progressive neurological condition. The couple reported some benefits for their relationship, including talking more and rediscovering what they valued and enjoyed together as a couple. Chow (2018) evaluates the effectiveness of a 'train of life' in a randomised controlled trial for people living with stroke. Compared to a control group receiving standard psychoeducation, participants in the narrative group experienced better well-being outcomes such as self-esteem and life satisfaction. Chow et al. (2023) describe a randomised controlled trial evaluating the same therapy for couples living with stroke. Again, participants in the narrative group experienced better well-being outcomes. The therapy was not directly focused on the relationship and relationship outcomes were not evaluated.

Trees of life may provide useful scaffolding in a neurological context. Brain injuries can lead to communication and cognitive impairments, such as memory and concentration difficulties and difficulties in abstract thinking (Whyte et al. 2011). Mwale et al. (2022) suggest that, compared to a talking-only therapy, using the trees makes the therapy more accessible by making reduced demands on language, memory and literacy skills. As a visual aid, the tree can help the person focus their attention and, through providing a visual record of what has been discussed, it can help circumvent memory issues. The concrete nature of the task of completing the tree is also easier for those with difficulties in abstract thinking.

The trees were also useful for the therapist in terms of providing a framework for the delivery of the therapy. An additional framework was provided in the form of a session plan, summarised in Table 1. The detailed session plan used by the therapist is not provided. This was to avoid an excessively lengthy paper and because the guidance is still in the process of being refined (see the Discussion). The detailed guidelines that were used are available on request from the authors.

In the first session, the couple are asked to give an account of their history together prior to the injury. They are asked about how they first met, what was important and valuable in the relationship, what ethical values were important (e.g., trust, honesty), what made it work well as a relationship, and how the values and important aspects of the relationship were evident in their daily life together. Reconnecting with their pre-injury life together is intended to widen their focus to encompass the whole of their life together, moving away from a narrow focus on the injury and the problem-focused narratives, and to lay the foundation for exploring in later sessions how some aspects of their relationship had not been changed by the injury. Both aims prepare the couple for moving towards continuity narratives.

The second and third sessions provide the opportunity for the couple to articulate the problem-focused narratives. They are asked to describe the effects of the injury on their life together, their family and friends, their work, social and leisure life, their hopes and dreams and particularly on their relationship. The therapist encourages a more detailed exploration of discontinuity narratives (e.g., that the partnership no longer felt like a romantic partnership) whenever these are raised by the couple. As a way of externalising the problem, the therapist encourages the couple to come up with ways of describing the problems as separate to themselves and their relationship. The therapist's own use of language also reflects this separation—for example, the couple are asked what effects the brain injury had on their friendships, rather than what their friendships are like now. Within narrative therapy, externalising facilitates a shift away from social and cultural narratives that attribute problems to the individual and their personal flaws (and thereby a shift away from the stigma and shame attached to these narratives) towards an empowered position in which they can reframe the problem as an external entity that needs to be dealt with by mobilising their own personal and social resources (Jagatdeb et al. 2024). In the present context, externalising is also considered to facilitate a shift towards continuity narratives: those whose individual and relational identities are heavily intertwined with the brain injury may find it difficult to experience themselves, and their relationship, as a progression of what came before the injury, and be more likely to experience discontinuity and difference.

In these two sessions, the couple are also asked how they felt about the effects the injury had on their lives and to reflect on why they were affected in this way. These questions are intended to aid reflection on underlying values, motivations and aspirations. These discussions help create opportunities to highlight continuities in these underlying influences. For example, in the case illustrations described later, one of the couples reflected that emotional distance within the relationship was not acceptable because they care about each other and miss their close connection. The therapist took this opportunity to highlight the continuity of their love for one another and how this had survived the injury.

Sessions 4–6 focus on completing three trees of life, one for each partner and one for the relationship. Couples are provided with pictures of trees depicting different aspects of their life. On the individual tree, the roots of the tree represent the person's background, history and culture; the ground is for current routines and activities; the trunk for values, accomplishments and skills; the branches for goals, hopes and aspirations; the leaves for significant people from the past or present; and the fruits represent gifts received from others. The couple tree follows a similar format. Each area on the tree is discussed. The couple then write a summary of the discussion on the corresponding part of the tree. As the trees are being completed, couples are also asked to reflect on what helped them and their relationship withstand the ‘storms of life’. This serves to highlight their strengths and social resources. When discussing goals and aspirations, the couples are encouraged to think about how these related to their core values. They are also asked to think about what steps they could take towards achieving the goals, drawing on their strengths and resources and on each other. Discussion of the couple's tree involves thinking about what aspects of the relationship they wanted to improve.

Completion of the trees provides various opportunities to promote continuity narratives. As with the first session, widening the focus to the whole of their life as individuals and as a couple is intended to weaken the dominance of the brain injury and its aftermath in their narratives. The discussions also present opportunities to highlight aspects of themselves and their relationship that have survived the injury, including strengths and values, social resources and aspirations. Highlighting these aspects is important within narrative therapy generally. Narrative therapy takes a ‘de-centred’ approach and places the client being at the centre of creating new narratives rather than having expert solutions imposed on them by the therapist (Gaddis 2016; White 2005, 2007). In order to achieve this, the client must draw on their own values, skills and resources, and so it is important to reflect on what these are. There are also opportunities to reflect on how unchanged values central to the relationship are still at work even when there are superficial changes in routines and activities. For example, in the case illustrations described later, one couple placed a high value on new experiences. This drove their extensive pre-injury travelling. Although this was no longer possible post-injury, other joint activities were found to satisfy the desire for new experience. Encouraging couples to work towards aspirations that predated the injury also promoted continuity in terms of their plans for the future.

The last four sessions are primarily focused on the aims of elaboration, consolidation and ownership of alternative narratives through expressing it to others. From the perspective of narrative therapy, sharing the story is critical for development of the alternative narratives and for embedding it within the person's way of thinking (Freedman 2014; White 2005, 2007). In the context of brain injury, this may be particularly useful because it may help compensate for the impairment in memory and abstract thinking that may accompany the injury. First, the couple are asked to compose a letter, addressed to themselves, as if it were written by their relationship (Bjorøy et al. 2016). Each partner writes a separate letter. The couple are asked to include in the letter key messages from completing the trees, such as what had survived the injury and what strengths had enabled their relationship to survive. During the seventh session, the couple read out these letters to one another for the first time and reflect on what they have written.

In the eighth session, each member of the couple has a conversation with the therapist that the other member is asked to witness—that is, to listen, but not to interrupt or contribute (Freedman 2014). The conversation focuses on aspects of the earlier sessions that the person identified as being particularly important to them. The person is also asked to reflect on the goals and aspirations considered in earlier sessions, and on any change they have noticed in themselves or their relationship since the start of therapy. The therapist takes the opportunity to emphasise any changes that brought the relationship closer to how it was before the injury (e.g., engaging in more leisure activities together), again to consolidate continuity narratives. Following the conversation with one member of the couple, the witnessing partner is asked to reflect on what stood out for them in their partner's account; and the first member of the couple is then asked for their reaction to these reflections.

The ninth session involves an outsider witness (Freedman 2014; White 2005, 2007). The couples are given the choice of inviting someone they know, or the involvement of another clinical worker arranged by the therapist. The outside witness listens to a conversation between the therapist and the couple about themselves and their relationship. The witness is then asked for their response in terms of images that came to mind, personal resonance, and how they were affected. The couple then reflect on what they heard, how it affected them, and what they will take away from what the witness said.

In the tenth and final session, the therapist summarises what has been covered; changes that have been occurring; and changes to which the couple aspire. The couple are then supported to create a document for themselves that contains a brief written summary of what they consider to be the key points arising from the therapy and what aspects of their relationship they want to continue to improve.

2.2 Evaluation

To evaluate the therapy, participants were asked to provide verbal feedback on their experience of the therapy at the end of each session, and written feedback when the therapy was complete. They were asked about specific components of the therapy and reflected on whether they found the components helpful or unhelpful. In the written feedback, they were also asked if the therapy had helped their relationship.

Participants also completed questionnaires before and after the therapy about their relationship and their individual well-being. The expectation that there would be improvement in well-being was based on the research about the negative impact of discontinuity on well-being (e.g., Beadle et al. 2016; Villa and Riley 2017). Both members of the couple completed the Relationship Assessment Scale (Hendrick et al. 1998) and the Warwick Edinburgh Mental Well-being Scale (Tennant et al. 2007), with higher scores indicating, respectively, greater satisfaction with the relationship and better psychological well-being. The non-injured partners also completed the Birmingham Relationship Continuity Measure (Yasmin et al. 2020), which gives a measure of the experience of continuity in the relationship and, given that these perceptions are associated with a better relationship (Yasmin et al. 2020), a measure of the quality of the relationship. Higher scores indicate greater continuity/higher quality. To provide a measure of perceptions of continuity in self-identity, injured partners also completed the Head Injury Semantic Differential Scale on which they rated their pre-injury and post-injury self on a range of opposing qualities (e.g., calm-irritable) (Tyerman and Humphrey 1984).

Improvement on questionnaire scores was evaluated using the reliable change criterion which uses psychometric data about the questionnaire to determine whether the change is statistically reliable or could have been due simply to the measurement error attached to the questionnaire (Blampied 2022). The criterion was set so that a reliable change indicates that there is less than a 5% chance that the change was due to measurement error.

3 Findings

This section presents the three case examples. For each couple, there is a description of some background information; an account of their perspectives on changes in the relationship and their discontinuity narratives; and the therapist's perceptions of how the therapy helped to undermine those narratives and how the couple may have benefited more generally from taking part. The couple's own perspective on whether the therapy helped and what elements they found more or less helpful are also presented, along with the questionnaire data. Pseudonyms have been used.

3.1 Amy and Michael

Amy and Michael are a White British couple who lived together for 3 years prior to Michael's traumatic brain injury. Amy is in her late thirties and Michael in his early fifties. They have two young children. The brain injury occurred 3 years before their participation in the study.

Discontinuity narratives were evident in Amy's account of the impact of the injury. To her, the relationship had become one-sided and no longer a partnership. She felt responsible for looking after Michael as well as the two children. She even felt responsible for Michael's personal safety, citing the example of him not always looking out for traffic when crossing roads. She highlighted a ‘lack of initiative’ which meant she frequently had to prompt him to do things and often did them herself because it was easier that way. She also experienced a lack of warmth and affection from Michael, which impacted on her own feelings for him. In terms of narratives about her own life, discontinuity was also evident. There was a sense of losing her identity and being trapped in the role of carer. She felt the injury had taken away dreams and plans and that their lives revolved around the injury and Michael's recovery.

Michael, too, was aware of the shift in the balance of their relationship. He felt that Amy was too watchful, controlling and restrictive, and expressed his frustration at them being ‘inseparable’ since the injury. Supervision and prompting were a significant source of friction within the relationship. Michael was less aware that Amy experienced a lack of warmth and affection from him. He thought it was ‘obvious’ that he loved Amy and that he often showed this love to her. In terms of his individual narratives, Michael was frustrated by physical limitations imposed by the injury, particularly because sporting activities had figured so prominently in his pre-injury life; but he appeared to be less aware of, or tended to downplay, other ways in which he had been affected.

The letter that Michael wrote and the external witness session helped undermine the narrative about a loss of love within the relationship. Expressing himself in written form appeared to come easier to Michael and the letter provided a lasting material reminder to Amy of the feelings that Michael did not readily express in other ways. The couple shifted to a narrative in which Michael's apparent lack of warmth was due to changes in his ability to express his feelings, rather than as a loss of love. Michael committed to being more explicit in the affection he showed to Amy. To address the imbalance in the relationship, the couple agreed that Amy should reduce the monitoring and restrictions imposed on Michael, allowing him more control and freedom. They also worked on developing ways for Michael to become a more active participant in everyday household chores and family life so that he felt more of an equal partner.

The therapy helped Amy, in particular, to see past the brain injury and escape the grip it had on their lives. She was able to take a step back from the carer role and allow herself to address her own needs again, focusing on personal goals relating to sport and fundraising. She began to appreciate again the positive aspects of her life, such as going out with friends and being with her children. She also began to enjoy her time with Michael more, as she escaped from the trap of focusing solely on his care and rehabilitation. She was able to envision a brighter future together.

The couple highlighted the value of talking openly about their relationship and of the opportunity to make changes in their life. Amy valued the trees of life because they helped her refocus on the good things about her life. Michael found it useful to talk about the strengths of their relationship and the need for him to be more demonstrative in his affection for Amy.

Questionnaire scores are shown in Table 2. There was no improvement on the Relationship Assessment Scale for either person. In Michael's case, improvement was not possible because he scored at the maximum before the therapy. The couple showed improvements in continuity and well-being, but only the Warwick Edinburgh Well-being Scale for Michael and the Birmingham Relationship Continuity Measure for Amy were statistically reliable improvements.

3.2 Caroline and Tony

Caroline and Tony are a White British couple in their early fifties who have been together nearly 30 years. Tony suffered a subarachnoid haemorrhage about 12 years into their relationship. They have one school-aged son and, at the time of the therapy, they were dealing with some challenges relating to him.

Exploration of the problem-focused narratives indicated some divergence between the couple. Tony expressed vague awareness that ‘something was different’ but struggled to articulate how the brain injury had changed him and the impact on their relationship. He tended to minimise the changes to himself described by Caroline and seemed relatively unaware of how Caroline was affected. For Caroline, by contrast, both Tony as a person and their relationship had been transformed. She provided a detailed description of how Tony's personality had radically changed (e.g., lacking initiative, more irritable). The relationship no longer felt like a partnership. For example, Caroline described a lack of practical and emotional support from Tony in dealing with challenges relating to their son. She felt stuck in the carer role, and her own needs and well-being took second place to Tony's. Many of the key memories of the pre-injury relationship revolved around holidays and adventures together, and Caroline highlighted a stark contrast with the lack of such activities in their present life together.

Development of alternative narratives included bringing to the fore the love that the couple shared for one another. The couple reflected on how this had brought them together in the first place and had survived the injury. It featured strongly in the outsider witness session, in which the outsider fed back that it was clear how much they cared for one another. The letters the couple wrote were also helpful in this respect because the format allowed Tony to express his thoughts and feelings towards Caroline, and to connect emotionally with the stress and upset that Caroline was feeling. In the within-couple witnessing session, it was clear that Tony did not easily pick up on Caroline's signals that she was upset and needed support. When Tony did eventually spontaneously reach out to comfort Caroline, Caroline commented that this had not happened for a long time. The therapist encouraged the couple to think about how Caroline could make her signals clearer and how Tony could respond.

The couple also reflected on the level of care and support that Caroline provided and decided that Caroline should step back from being the ‘family carer’ and give Tony more freedom and responsibility. This allowed Tony to become more involved in his roles as partner and father. Examples of this included Caroline letting Tony manage a school emergency rather than leaving work to sort it out herself as she would normally have done. She also allowed Tony and their son to get on with some DIY projects without supervising what they were doing. Stepping back from being the carer allowed Caroline to think about how she could better meet her own needs. While completing her tree of life, Caroline became aware of how little time she spent on enjoyable activities and doing things for herself.

Completing the trees of life also highlighted that there was a lack of enjoyment in their life together and that many of the things they used to enjoy together had been lost. The couple were encouraged to think about how they could bring back some of these things into their lives. These ideas fed into a more positive view of the future, in which they could look forward to enjoying their life together.

In their feedback, the couple said that they found the outside witness session, the trees of life and the letter writing particularly helpful. They felt that these components brought out how much they still cared for one another and that, in this respect, their relationship had survived the injury intact. Caroline expressed some concerns about the longevity of the benefits they had experienced from the therapy. Caroline and Tony both showed improvement on the Relationship Assessment Scale, although only Caroline's improvement was statistically reliable (Table 2). Both also showed improvement on the continuity questionnaires, although only Tony's was reliable. Caroline also showed a reliable improvement on her well-being scores.

3.3 Ellen and Bill

Ellen and Bill are a White British couple in their late 40s and early 50s who have been together for 20 years. Bill suffered a hypoxic brain injury 8 years prior to their involvement in the study. They have one child who has some additional needs.

Prominent in the problem-focused narrative was the idea that Bill needed looking after because of his brain injury. In contrast to the other two injured partners, Bill was very aware of the impact of the injury on his abilities and was very critical of his own perceived shortcomings. This self-criticism appeared to feed into, and be fed by, the narrative that Bill was incompetent and unable to manage. Ellen was also critical of Bill's efforts and often highlighted how or why he had done something ‘wrong’. Ellen acknowledged that she frequently took on a parenting role with Bill and there was some blurring of the lines between how she spoke to Bill and to their son. Despite feeling that he needed to be looked after, Bill resented being talked down to in this way, and this was a frequent source of arguments between them. The couple also described how the enjoyment had disappeared from their relationship. Time spent together felt ‘mechanical’ and was focused on care activities or doing things in which there was little meaningful interaction (e.g., watching TV together).

In developing an alternative, the couple began to move away from the narrative that Bill could do nothing right and needed a high level of care and supervision. Discussions and the witnessing sessions brought to the fore the positive and thoughtful contributions he made as a partner and as a parent. Ellen acknowledged her need to let go of the caring role, to work on coming across as less critical and to trust more in Bill's abilities. This included acknowledging that when Bill did something in a way that was different to Ellen's way, this did not necessarily mean that it was ‘wrong’. Ellen spoke about learning to ‘pick my battles’ rather than feeling things needed to be done her way every time. The couple found it helpful to think about the intentions behind actions rather than just the consequences. For example, when Bill purchased some new crockery, Ellen initially took this as evidence that Bill was irresponsible in his spending. Through discussion, she appreciated that this was motivated by Bill wanting to take the initiative in making improvements in the house.

The couple also committed to bringing enjoyment back into their relationship. Reminiscing about their life together while working on the trees of life sparked some lively conversation and highlighted things that they used to enjoy together. Before the therapy ended, the couple had started to reintroduce some of these, such as going out for a coffee at lunchtime and doing the local park run as a family.

In their feedback, the couple said that they found completing the trees of life to be particularly helpful because it prompted discussion about how to be better partners to each other. Ellen also valued the letters because it allowed her to be open about her feelings. Hitherto, her role as carer had inhibited her from expressing them. Like Caroline, Ellen expressed some concern about the longevity of the benefits from the therapy. Bill said that the work on the couple's core values was very useful. He kept a written copy of these and made frequent reference to them during the sessions. Bill and Ellen showed improvements on all the questionnaires. In Bills' case, there were reliable improvements on the continuity and well-being questionnaires and in Ellen's case on the relationship and well-being questionnaires.

4 Discussion

Narrative therapy may be a useful way of addressing the medicalised problem-saturated stories focused on loss and impairment that typically accompany brain injury (Whiffin and Ellis-Hill 2022). Specifically, a narrative approach may help couples address the damaging effect these stories can have on their relationship. However, many rehabilitation services lack access to clinicians with specialist training in this or other relationship therapies (Laroi 2003; Yeates et al. 2013). The aim of this study was to develop structured guidance that can be used by clinicians with knowledge of brain injury but without extensive specialist training in narrative therapy. The guidance focused on addressing narratives focused on discontinuity between the pre-injury and post-injury relationships and personal identities. The study also aimed to conduct an exploratory evaluation of the usefulness of the therapy for this purpose.

The evaluation suggested that the therapy was generally well received by participating couples. Although some upsetting conversations took place, participants felt these were necessary to moving forwards and no participant reported any longer-term adverse impact on their emotional well-being or relationship. Different participants highlighted different components of the therapy as being particularly useful. There was no negative feedback about any of the components. In general terms, couples valued the opportunity to reflect on themselves and their life together, to appreciate that there were still many good things that had not been affected by the injury and to develop hope about their future together. On the questionnaires given before and after the therapy, everyone showed statistically reliable improvement on at least one questionnaire (Table 2). None of the injured partners reported reliable improvement on the relationship questionnaire, but this may be because, in contrast to their non-injured partners, all three rated the relationship as good on the pre-therapy questionnaire and left themselves little room for improvement.

The discontinuity narratives described by the non-injured partners echoed those described in previous literature (Bodley-Scott and Riley 2015; Gill et al. 2011; Kratz et al. 2017; Riley et al. 2020; Villa and Riley 2017; Whiffin et al. 2019; Yasmin et al. 2020; Yasmin and Riley 2022). In all three cases, the relationship felt like one between a caregiver and a care receiver, rather than one between romantic partners. The person with the brain injury was positioned as someone who was broken and in need of support. A loss of warmth and emotional connection was also evident, as was a sense of contrast between their life before and since the injury and a sense of loss for their pre-injury life together. Amy and Caroline also described how the caring role had taken over at the expense of addressing their own needs, and this, too, has been described in earlier research (Kokorelias et al. 2020; Zarzycki et al. 2024).

In terms of the injured partners, Bill was acutely aware of, and distressed by, the contrast between his pre- and post-injury self and the broken nature of his post-injury self. Again, this repeats a discontinuity narrative often reported in qualitative studies (Freeman et al. 2015; Nochi 1998; Villa et al. 2020). By contrast, although Michael and Tony were aware of themselves and their relationship being different, their understanding of the changes was more limited and the sense of contrast with the past was not as sharp.

The case examples shed some light on what may underlie discontinuity narratives. One contributor to the centrality of care to the relationships of the three couples was the difficulty that couples had in negotiating appropriate levels of supervision and support. The non-injured partners seemed to find it difficult to adjust the level of care required as the injured partner made progress in their recovery. Being stuck in the caring role was also associated with a neglect of the non-injured partner's own needs and with friction within the relationship because of resentment of excessive supervision from the injured partner. All three non-injured partners acknowledged that they needed to let go of the caregiving role. Difficulty letting go is understandable. Decisions about how much care to provide can be complex because of the range of issues that need to be considered, and little guidance is available about how best to make the transition (Carparelli et al. 2026).

The case examples also suggested that discontinuity in what couples do together may contribute to the diminishment of emotional connection. Ellen and Bill, in particular, highlighted how the time they spent together felt ‘mechanical’, focused on care activities and no longer natural or enjoyable. Many of the activities they did together before the injury had stopped, and they decided they needed to reverse this by restoring some of these activities and spending more quality time together. How people spend their time together is important to cementing their emotional bond (Ben-Ari and Lavee 2007), and the changes that occur in these bonding activities after brain injury need to be addressed when trying to repair the relationship.

4.1 Limitations

Although the feedback and questionnaire outcomes were promising, some issues were raised that indicate the need for further development of the therapy in the context of brain injury. Both Caroline and Ellen expressed concern about how long the benefits of the therapy would last. Further consideration needs to be given to how best to ensure that the couple carry the new narratives forward once the therapy is over. One potential way of doing this is to help the couple make concrete changes in their everyday lives and interactions that embody the new narratives. When discussing goals for their relationship, the couples were, indeed, encouraged to think about initial steps they could take towards achieving these. Although it was considered important that the changes came from the couple themselves rather than being imposed by the therapist, more could perhaps be done to support them in making the changes—for example, by exploring potential obstacles and by encouraging them to persist with the efforts to change. Yasmin and Riley (2020) describe a case study in which a more systematic behavioural approach was taken to encouraging a couple to reintroduce ways of interacting as a way of promoting continuity in how they live their lives together. Another step that may help extend the longevity of the new narratives is to provide a written record of the therapy (e.g., in the form of a therapy letter) that couples could revisit at later dates. Clients receiving narrative therapy in other contexts have commented on the value of such documentation (Freeman et al. 1997). The letters that the couple wrote may also need some consideration. They were asked to write a letter to themselves as if it was written by the relationship. This was too abstract a concept for some of the participants, particularly those with a brain injury, and they ended up writing what were essentially just expressions of what they felt about their partner and their relationship. More concrete instructions about writing the letters may be preferable.

Another issue for consideration was flagged by the fact that neither Michael nor Tony appeared to be fully aware of how the injury had affected their partner and their relationship. It was unclear to what extent this reflected their cognitive difficulties and/or dynamics within the relationship and the reluctance of their partners to communicate about such sensitive topics. In Tony's case, the brain injury had occurred 18 years previously and this length of time may have added to his difficulties in comparing life before and after the injury. The process of developing new narratives involves, in part, a rejection of the old problem-saturated narratives. So, a full appreciation of the old narratives may be an important contributor to the couple's development of new narratives. This suggests that care should be taken, early in the therapy, to establish awareness of the old narratives and to provide a supportive therapeutic environment in which the injured partner can hear and understand these narratives. Tony's case suggests the need to explore whether there is an optimum window of time in which the therapy should be delivered and whether its benefits are diminished if too much time elapses between the injury and engagement in the therapy.

The couples were all White British and of a similar age (late 30s to early 50s). This raises questions about whether couples with other cultural and demographic identities would benefit from the therapy. The tree of life approach may have an advantage in terms of cultural accessibility because it was developed in an African context (Ncube 2006) and has been successfully used with marginalised and vulnerable groups such as refugees (e.g., Stark et al. 2019). Parham et al. (2019) review 14 papers that evaluated use of the tree of life in a mental health context and highlight several aspects of the approach that may make it accessible to a wider range of cultures and demographic groups. These include its alignment with the storytelling practices embedded in many cultures; its focus on the collective and the social context that tallies with many cultures, in contrast to the Western focus on the individual; and its flexibility that allows it to incorporate alternative non-Western ways of understanding difficulties. More generally, the emphasis of the narrative approach on empowerment may appeal to those who are disempowered within society.

The therapy focused on discontinuity narratives. Previous applications of narrative therapy in this context have been open to addressing whatever problem narratives the family brings (Butera-Prinzi et al. 2014; Daisley et al. 2014; Hawkins et al. 2019). This flexibility is a clear advantage. However, it comes at the cost of requiring greater skill on the part of the therapist. The focus on one particular kind of narrative provides the opportunity for more structured guidance and therefore opens up the therapy for delivery by a wider range of clinicians with experience in brain injury.

The restricted focus of the therapy also raises issues about its consistency with a narrative approach. The intention of the therapy is to encourage couples to develop new narratives that encompass the continuities in their lives as individuals and as a couple. There is some tension between this and the emphasis on client empowerment within narrative therapy and its ‘de-centred’ approach, which stresses the importance of the client being at the centre of creating new narratives rather than having expert solutions imposed on them by the therapist (Gaddis 2016; White 2005, 2007). However, the therapist is also positioned within narrative therapy as ‘influential’ (Gaddis 2016; White 2005, 2007): the therapist has an important role in guiding the client's reflections and supporting them as they develop new stories. To try to maintain this balance between being de-centred but influential, the guidance emphasised that the therapist should highlight continuities to the couple when they arose in the discussion rather than taking the initiative to suggest them. It was also emphasised that the therapist should avoid suggesting to the couple that continuity narratives were the correct way to think. Ownership of alternative narratives was also promoted in the last four sessions, by means of the couple recounting it to others, independently of the therapist (e.g., in the letter writing). More broadly, the therapy was consistent with the aim of empowerment by its inclusion of reflection on the strengths and resources of the couple that had helped them deal with adversity in the past and are still at their disposal, and encouragement to think about steps they could take to improve their relationship and situation generally. Nevertheless, guidance for delivering the therapy may need to be more detailed in this respect to ensure that the therapist avoids the trap of dictating narratives.

The message of empowerment seems particularly important in the context of brain injury. Dominant medicalised narratives associated with brain injury focus on impairment arising from irreparable damage to the brain (Cloute et al. 2008; Whiffin and Ellis-Hill 2022). In response to these, passivity and helplessness are a natural response. Bill was very critical of his own perceived shortcomings, and this appeared to feed into, and be fed by, a narrative that Bill was incompetent and needed looking after. Cloute et al. (2008) note similar passivity in some of the participants in their qualitative study. Passivity has also been noted on the part of non-injured partners. For example, in the face of a lack of understanding and medicalisation of difficult interpersonal behaviours on the part of the injured person, non-injured partners may feel helpless and reliant on outside assistance to deal with the issue (Bodley-Scott and Riley 2015; Braine 2011). Continuity narratives can allow the non-injured partner to position themselves as having expert knowledge about their partner and to use this knowledge to better understand and manage these situations (Riley et al. 2020). Narrative family therapy, with its emphasis on empowerment, may be a potent way of helping couples shake off the passivity and helplessness engendered by medicalised narratives and to take control of their own lives.

5 Conclusion

Narrative therapy for couples offers a promising way of helping couples to address discontinuity narratives that undermine relationships following brain injury and empowering them to take back control over their own lives. Its usefulness in this context is enhanced by the fact that it can be delivered by clinicians without extensive specialist training in narrative therapy provided that structured guidance is available. This is important because of the difficulties that most rehabilitation services have in accessing therapists with specialist training in working with relationships.

Further refinements are needed to the guidance developed for this study. In the earlier stages of the therapy, partners with a brain injury may sometimes need more help to appreciate how the brain injury has impacted their relationship. Therapists may need more help to avoid the trap of imposing narratives and solutions, and couples may need more support to bring about the changes they want to make to their relationship and their life together.

This application of narrative therapy for couples requires more formal evaluation of its effectiveness in a controlled trial. It needs to be evaluated in culturally diverse contexts and with a wider range of age groups. It usefulness in real-life rehabilitation settings also needs to be tested, specifically whether it can be effectively delivered by clinicians, such as occupational therapists, social workers and psychologists with only introductory training in the narrative approach.