Feeling Unsafe in One’s Own Body: The Impact of Illness on Psychological Safety and Social Engagement

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

thank you very much.

1-)please mention sample size in the abstract.

2-)if possible , the abstract can precisely summarize main goals of your study.

3-)you can also interpret the results based on evolutionary psychology approaches.

4-)please be more precise:

Existing literature has primarily focused on chronic conditions [21]

5-)authors can mention sample size calculation before the study.

6-)the results should be interpreted cautiously considering the small sample size.

7-)also there are other confounding factors such as gender.

Participants ranged in age from 20 to 79 years (M = 40.8, SD = 18.3). The sample was 132
predominantly female (n = 10; 91%) with one male participant (9%).

 

Author Response

The authors would like to thank the reviewer for reviewing our manuscripts and for their helpful comments.  We have taken on board all the feedback and revised the Manuscript accordingly.  Please see below for more details about how we have addressed each comment.  

Comment: please mention sample size in the abstract. 

Response:  The sample size was already mentioned in the abstract, this has been highlighted for your convenience. 

 

Comment: if possible, the abstract can precisely summarize main goals of your study. 

Response: Again, the aim of the study which was ‘how experiences of being unwell, across both acute and chronic contexts, affect individuals’ neuroception of psychological safety’ is stated in the abstract, and this has been highlighted for your convenience.  

 

Comment: you can also interpret the results based on evolutionary psychology approaches. 

Response: This would not be appropriate given the theoretical underpinning of the study.  

 

Comment: please be more precise, Existing literature has primarily focused on chronic conditions [21] 

Response: We have clarified this sentence.  

 

Comment: authors can mention sample size calculation before the study. 

Response: We have further clarified information about the sample size. This range was informed by guidance from Namey et al., who highlight that focused, smaller samples are effective in qualitative research when participants share common, lived experiences. This size was deemed appropriate to allow for in-depth exploration of individual perspectives while maintaining a manageable volume of data for rigorous analysis. Additionally, a smaller sample ensured that the unique voices of participants could be closely examined and accurately represented, aligning with the study’s aim to amplify patient experiences.  

 

Comment: the results should be interpreted cautiously considering the small sample size. 

Response: As above 

 

Comment: also there are other confounding factors such as gender.  Participants ranged in age from 20 to 79 years (M = 40.8, SD = 18.3). The sample was 132 predominantly female (n = 10; 91%) with one male participant (9%). 

Response:  The limitations of the study are reported in the discussion under ‘5. Strengths and Limitations’ specifically it is noted that “However, the study has several limitations. The sample size was small (n = 11), and participants were predominantly female, limiting the generalisability of findings. The absence of data on ethnicity, race, and cultural background also precludes intersectional analysis.” 

 

Reviewer 2 Report

Comments and Suggestions for Authors

I would like to thank the authors for the opportunity to read this very interesting paper. I appreciate the subject matter and am pleased to see this type of research being conducted.

The manuscript details a qualitative study that seeks to unpack how chronic illness undermines psychological safety through the lens of the Neuroception of Psychological Safety and Polyvagal Theory to better understand the embodied experience of being unwell. Semi-structured interviews were conducted with participants aged 20 to 79 who had experienced significant periods of being unwell, whether currently or in the past. Using reflexive thematic analysis themes of reduced emotional tolerance and dysregulation; a sense of distrust in and threat from the body; personal shame and guilt; and reduced capacity for social engagement and empathy were identified. The authors concluded that psychological safety was a valid dimension of healthcare and applying a trauma-informed relational approach would enhance a persons’ ability to navigate through illness with dignity and respect.

However, there are some areas of concern to be addressed before it can be recommended for publication.

General comments

There is quite a lot of repetition throughout the manuscript, especially in the method section. A tightening of the language throughout would greatly enhance the readability of the work.

I particularly liked the Reflexive Statement.

Introduction

Lines 81-82 repeat Lines 53-54. Suggest deleting “While psychological safety has gained prominence in organisational and clinical research, its relevance to personal experiences of illness remains underexplored “

Suggest moving Lines 85 (“Physical symptoms…) to 91 to somewhere in the previous paragraph.

Lines 92-103 is repetitive, suggest editing down.

 

Methods

Lines 107-109. This information has been provided already in the introduction. Suggest deleting and starting with “A qualitative …”

2.2 Participants: Lines 121-127. These sentences belong in the results section. Suggest the paragraph starts at “Participants were recruited ..”

Lines 132-147 These sentences and the ones identified above should form the first paragraph of your results section. Table 1 is also results.

You reference Braun & Clarke for your reflexive thematic analysis methodology (Line 188), while previously reporting that “data saturation was reached” (Line 157). Braun and Clarke actually question the concept of saturation. Suggest finding another reference or removing the term saturation from your methodology.

Line 195: Has a couple of typos.

Discussion 

Lines 431-444:  Some of the sentences seem like they might be missing a word or two. Please review and revise accordingly.

The findings and discussion are appropriate and informative and the recommendations are thoughtful. 

Comments on the Quality of English Language

As per my comments above, there is a lot or repetitive language in the manuscript and particularly the methods section. I suggest a thorough trimming down of the text would greatly improve the readability of the paper. 

 

Author Response

The authors would like to thank the reviewer for reviewing our manuscripts and for their helpful comments.  We have taken on board all the feedback and revised the Manuscript accordingly.  Please see below for more details about how we have addressed each comment.  

 

Comment: There is quite a lot of repetition throughout the manuscript, especially in the method section. A tightening of the language throughout would greatly enhance the readability of the work. 

Response: We would like the thank the reviewer for their comments and we have revised this section to tighten up the language used.  

 

Comment: Lines 81-82 repeat Lines 53-54. Suggest deleting “While psychological safety has gained prominence in organisational and clinical research, its relevance to personal experiences of illness remains underexplored “ 

Response: We have removed this line as suggested.  

 

Comment: Suggest moving Lines 85 (“Physical symptoms…) to 91 to somewhere in the previous paragraph. 

Response:  We have moved this sentence as recommended. 

 

Comment: Lines 92-103 is repetitive, suggest editing down. 

Response: We have edited this down.  

  

Comment: Lines 107-109. This information has been provided already in the introduction. Suggest deleting and starting with “A qualitative …” 

Response: This change has been made. 

 

Comment: 2.2 Participants: Lines 121-127. These sentences belong in the results section. Suggest the paragraph starts at “Participants were recruited ..” 

Response: This has been moved and re-organised. 

 

Comment: Lines 132-147 These sentences and the ones identified above should form the first paragraph of your results section. Table 1 is also results. 

Response:  This has been moved and re-organised.  

 

Comment: You reference Braun & Clarke for your reflexive thematic analysis methodology (Line 188), while previously reporting that “data saturation was reached” (Line 157). Braun and Clarke actually question the concept of saturation. Suggest finding another reference or removing the term saturation from your methodology. 

Response: We have removed the term data saturation.  

 

Comment: Line 195: Has a couple of typos. 

Response: This has been corrected. 

 

Comment: Lines 431-444:  Some of the sentences seem like they might be missing a word or two. Please review and revise accordingly. 

Response: We have revised the MS. 

 

Comment: The findings and discussion are appropriate and informative and the recommendations are thoughtful.  

Response: Thank you.  

 

Comment: As per my comments above, there is a lot or repetitive language in the manuscript and particularly the methods section. I suggest a thorough trimming down of the text would greatly improve the readability of the paper.  

Response: We have revised the MS accordingly.  

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

The study is original and contributes to the literature by addressing how the experience of illness affects individuals' neurobiological and psychological perception of safety (neuroception) within the framework of Polyvagal Theory. The inclusion of not only chronic but also acute illness experiences broadens the scope of the study. However, before the manuscript can be accepted for publication, the following points need to be corrected and clarified by the authors:

1. Upon examining the participant group (Table 1), it is evident that a significant portion of the participants (P1, P5, P7, P8, P9, P11) work in health or social care fields, such as auxiliary nurse, educator, trainee psychologist, and youth worker. This suggests that the participants may possess an above-average awareness or professional jargon regarding concepts like "illness," "care," and "psychological safety." The potential impact of this "professional bias" on the results should be discussed more explicitly in the Limitations section .

2. The footnote under Table 1 states that the participant coded P7 was excluded from the final analysis due to incomplete data. However, there is no explanation regarding the reason for or the process of this data loss within the text of the "Participants" or "Procedure" sections. For the sake of transparency, this situation should be briefly explained within the main body of the text.

3. In the Implications section, 452–460 lines discuss "technology-enhanced approaches" and "AI-driven interventions". However, the study's findings are based entirely on participants' "embodied and relational" experiences, and no theme related to technology use emerged from the data. This paragraph appears disconnected from the study's main theme and seems like a forced addition. It is recommended that this section be removed or organically linked to the study's findings (e.g., how digital interventions might align with participants' desire for isolation ).

4. There are minor spelling and grammatical errors throughout the manuscript. For example, in line 195, there is a spacing error in the word "co mpassionthe". Additionally, in line 432, the sentence "They suggest that psychological safety—particularly in the context of illnesses shaped by..." appears to have a missing predicate or a structural flaw; a correction such as "illnesses is shaped by" may be required.

5. The study sample consists of 11 individuals, 10 of whom are female. Although the authors have noted this as a limitation, the potential for neurobiological or sociocultural differences in the perception of "safety" between genders is a topic discussed in the literature (particularly within Polyvagal Theory). In the Discussion section, providing a more in-depth interpretation of the relationship between the findings (especially the "Responsibility and Internalised Guilt" theme ) and gender roles (e.g., the caregiving role) would strengthen the study.

I believe the manuscript could be re-evaluated for publication in the journal provided that these corrections are made.

Sincerely.

Author Response

The authors would like to thank the reviewer for reviewing our manuscripts and for their helpful comments.  We have taken on board all the feedback and revised the Manuscript accordingly.  Please see below for more details about how we have addressed each comment.  

Comment: Upon examining the participant group (Table 1), it is evident that a significant portion of the participants (P1, P5, P7, P8, P9, P11) work in health or social care fields, such as auxiliary nurse, educator, trainee psychologist, and youth worker. This suggests that the participants may possess an above-average awareness or professional jargon regarding concepts like "illness," "care," and "psychological safety." The potential impact of this "professional bias" on the results should be discussed more explicitly in the Limitations section . 

Response: We have noted this in the discussion.  

 

Comment: The footnote under Table 1 states that the participant coded P7 was excluded from the final analysis due to incomplete data. However, there is no explanation regarding the reason for or the process of this data loss within the text of the "Participants" or "Procedure" sections. For the sake of transparency, this situation should be briefly explained within the main body of the text. 

Response: The interview protocol for P7’s interview was not correctly followed. An error was made with one question being missed. Therefore, P7’s data was not included in the thematic analysis. We have added this explanation into the main body of text in the recruitment & procedure section.  

 

Comment: In the Implications section, 452–460 lines discuss "technology-enhanced approaches" and "AI-driven interventions". However, the study's findings are based entirely on participants' "embodied and relational" experiences, and no theme related to technology use emerged from the data. This paragraph appears disconnected from the study's main theme and seems like a forced addition. It is recommended that this section be removed or organically linked to the study's findings (e.g., how digital interventions might align with participants' desire for isolation ). 

Response: We have removed this paragraph.   

 

Comment: There are minor spelling and grammatical errors throughout the manuscript. For example, in line 195, there is a spacing error in the word "co mpassionthe". Additionally, in line 432, the sentence "They suggest that psychological safety—particularly in the context of illnesses shaped by..." appears to have a missing predicate or a structural flaw; a correction such as "illnesses is shaped by" may be required. 

Response: Thank you, we have amended these errors.  

 

Comment: The study sample consists of 11 individuals, 10 of whom are female. Although the authors have noted this as a limitation, the potential for neurobiological or sociocultural differences in the perception of "safety" between genders is a topic discussed in the literature (particularly within Polyvagal Theory). In the Discussion section, providing a more in-depth interpretation of the relationship between the findings (especially the "Responsibility and Internalised Guilt" theme ) and gender roles (e.g., the caregiving role) would strengthen the study.  

Response: We have included a sentence to the discussion noting this.  

 

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

accept

Author Response

Comment: They had only 11 subjects, most of whom were women who worked in the health professions. I would recommend the authors substantially expand their subject pool number, gender, and profession of the subjects.

Comment: Though the authors have made several corrections, they have not adequately addressed two major criticisms: 1) The small number of subjects, and 2) the unrepresentativeness of the study sample.  If the authors rewrite the paper to emphasize that their study results apply not to the general population but to female health professionals, then their paper could be considered for publication.  Or if the authors can provide a justification for why their study sample is not unrepresentative, that would serve as sufficient justification.

Authors Response: The sample size is in keeping with the research aims and methodology for a qualitative research design (see refs below). The study initially aimed to recruit approximately ten participants to allow for in-depth qualitative analysis while ensuring a range of illness experiences informed by guidance from Namey et al., who highlight that focused, smaller samples are effective in qualitative research when participants share common, lived experiences. This size was deemed appropriate to allow for in-depth exploration of individual perspectives while maintaining a manageable volume of data for rigorous analysis. Additionally, a smaller sample ensured that the unique voices of participants could be closely examined and accurately represented, aligning with the study’s aim to amplify patient experiences.  

Namey, E.; Guest, G.; McKenna, K.; Chen, M. Evaluating Bang for the Buck: A Cost-Effectiveness Comparison Between Individual Interviews and Focus Groups Based on Thematic Saturation Levels. Am. J. Eval. 2016, 37, 425–440. [CrossRef]   Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.    Braun, V., & Clarke, V. (2024). A critical review of the reporting of reflexive thematic analysis in Health Promotion International. Health Promotion International, 39(3), daae049.    Clarke, V., & Braun, V. (2017). Thematic analysis. The Journal of Positive Psychology, 12(3), 297-298.   Braun, V., Clarke, V., Hayfield, N., Davey, L., & Jenkinson, E. (2023). Doing reflexive thematic analysis. In Supporting research in counselling and psychotherapy: Qualitative, quantitative, and mixed methods research (pp. 19-38). Cham: Springer International Publishing.

Further, in response to these additional comments we have added the following text to the discussion section. 

The study sample was predominantly female and included a high proportion of health professionals, which limits the transferability of the findings to other populations. These characteristics shape how illness is experienced, interpreted, and narrated. However, this specificity also enabled in-depth exploration of illness experience within a group characterised by high health literacy and professional caregiving identities. As with all qualitative research, the findings should be understood as contextually situated rather than representative of the general population.

Future research could extend this work by exploring illness experiences in more diverse and gender-balanced samples, including participants from non-health professional backgrounds, to examine how illness is understood and negotiated across different social and occupational contexts.