“Hello Again” letters aid reconnection after acquired brain injury

Acquired brain injury, or ABI, refers to any kind of brain injury that occurs post-birth, normally sustained through accidents or illness. The impact can be significant: along with the physical changes that happen post-ABI, many experience differences in their emotional life, with some having different feelings towards or relationships with loved ones after their injury.

For those living with people with acquired brain injuries, this can be a challenge. Sometimes referred to as 'ambiguous grief', family members and friends often experience what the University of Plymouth's Elizabeth Gilmour and Alyson Norman refer to as "the loss of a person who is still physically present". In the Family Journal, the pair report the results of a pilot writing intervention designed to help family members of those with ABI understand and manage their grief — finding a complex emotional landscape.

All three participants were mothers of teenagers living with ABI. Firstly, they were asked to write a heartfelt letter to their loved one as they remembered them before their brain injury — a "Hello Again" letter. To support them, the researchers provided writing prompts and a resource sheet with grounding techniques to help manage difficult emotions.

Two weeks later, participants met with the researcher to reflect on what it was like to write the letter and what, if anything, it helped them understand about their relationship. They were then asked to write a second Hello Again letter, this time written in response to the first from the perspective of their loved one prior to their ABI. They then met the researcher, again two weeks later, to reflect on the overall experience, before the team analysed the data and drew out four key themes.

The first, 'acknowledging grief', captures how writing the initial Hello Again letter triggered a previously unspoken sense of loss for all three participants. Though all three mothers had been aware of the changes in their children after brain injuries, the act of writing prompted a deeper recognition that they were grieving: one described it as an "epiphany". Others noted that they were often described as "lucky" their child had survived, but that such responses made it difficult to express sadness for who their children used to be. For one mother, the letter writing task was "the first time I was really aware about how difficult it is to talk to other people about it."

The second theme was 'finding space to mourn', something all three participants said the letters helped them do. One mother described being constantly in motion: "you're on a permanent mission fighting some kind of battle." For another, the weight of unprocessed grief had built up over time: "it's really hard to keep it together when you've got this weighing down on you all the time." Having the space to reflect allowed feelings to emerge without guilt: slowing down gave one mother the "time and space to think about [her son]" without sweeping things "under the carpet." The act of writing gave all three women "permission" to grieve.

The letters also helped participants step back from the immediacy of their trauma, placing the brain injury within a broader life story — the third theme. Writing allowed one mother to see how other life experiences had shaped her response to her daughter's injury and to rediscover her identity beyond being a carer: "I so desperately just want to be your mum again. Not your carer… I just want to be your mum." Revisiting memories from before the injury was painful ("photos from that time feel unreal… a cruel taste of how life should be") but also enabled her to integrate her memories, not avoid them. Another parent described how the first letter had helped her see what she had lost, and the second "what's still there": "he's fundamentally the same person in a different package". Loss and renewal went hand in hand.

Finally, the act of letter writing itself was emotionally challenging but therapeutic, surfacing buried emotions but allowing parents to be "completely honest... without being tactful or diplomatic." One mother even opened up to her son after writing the second letter: "the most conversation we've had about it for a very long time". The emotional effort of writing was high, but the connection and catharsis it brought were significant.

The team refer to their intervention as a 'continuing bonds' technique — maintaining an ongoing relationship with a pre-injury loved one as well as tending to the post-injury relationship. When someone has been changed by an injury, as evidenced by some of the descriptions of the mothers involved in this study, it can be easy to feel guilt for missing or loving the 'old' version of that person. With this intervention, creating letters that took those feelings of grief and loss and acknowledged them was crucial to processing those difficult emotions.

The sample size of this study was small, and consisted exclusively of parents; larger trials including other types of relationships could also be considered in future research. Overall, though, this approach could form the basis of an intervention for those seeking to make sense of their experiences, encouraging them to find space to write, think, and reflect on supporting and loving someone after an acquired brain injury.

Read the paper in full:
Gilmour, E., & Norman, A. (2025). Reconnecting to the Person Before Acquired Brain Injury: A Continuing Bonds Grief Intervention. The Family Journal, 0(0). https://doi.org/10.1177/10664807251349843

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