Brain Injury, June 2009; 23(6): 535–547

A preliminary investigation of the brain injury family intervention:

Impact on family members

JEFFREY S. KREUTZER1,2,3, TARYN M. STEJSKAL1, JESSICA M. KETCHUM4,

JENNIFER H. MARWITZ1, LAURA A. TAYLOR5, & JENNIFER C. MENZEL6
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1
Department of Physical Medicine and Rehabilitation, 2Department of Neurological Surgery, 3Department of
Psychiatry, 4Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA, 5Village Family
Psychiatry, Richmond, VA, USA, and 6Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond,
VA, USA

(Received 23 September 2008; revised 25 February 2009; accepted 26 March 2009)

Abstract
For personal use only.

Primary objective: To evaluate the benefits of the Brain Injury Family Intervention (BIFI) for families of persons with
acquired brain injury and identify factors related to outcomes.
Research design: Pre-test, post-test design with outcomes measured immediately after and 3 months following intervention.
Methods and procedures: Family members and survivors participated in five 2-hour sessions over 10 weeks which included
discussions of typical effects of brain injury, coping with loss and change, managing stress and intense emotions, effective
problem-solving, setting reasonable goals and taking care of one’s self. Guided by principles of family systems theory (FST)
and cognitive behaviour therapy (CBT), the manualized treatment included educational, skill building and psychological
support components.
Main outcomes and results: Analysis of data derived from family members indicated a greater number of met needs and
perceptions of fewer obstacles to receiving services post-treatment and at 3 months follow-up. Before and after treatment,
unmarried caregivers reported more unmet needs. Family members of persons with longer acute care lengths of stay
reported more unmet needs and greater perceived obstacles to services. Post-treatment differences in family members’
psychological distress, satisfaction with life and functioning were not identified.
Conclusions: The investigation provided evidence that family members benefit from interventions designed to meet their
unique needs after brain injury. Uncertainties remain about the benefits of intervention to general family functioning and
life satisfaction.

Keywords: Family interventions, support systems, therapy

Introduction of survivors’ and family members’ needs. Briefer

A number of researchers have expressed concern
that rehabilitation lengths of stay are decreasing
[1–3], especially with reduced reimbursement from
managed care companies and Health Maintenance
Organizations (HMOs). Shortened hospital stays
necessitate a greater in-hospital focus on physical
and functional goals and fewer opportunities for
rehabilitation staff to address the full spectrum
rehabilitation stays also allow less time for neurobe-
havioural recovery and discharge planning. Nine of
every 10 patients are being discharged to home [2],
leaving relatives to assume primary caregiving
responsibilities for years after the injury. Family
members’ responsibilities typically include helping
survivors manage activities of daily living, appoint-
ments, finances and medications. Family members

Correspondence: Jennifer H. Marwitz, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA.
Tel: 804-828-3704. Fax: 804-828-2378. E-mail: jhmarwit@vcu.edu
ISSN 0269–9052 print/ISSN 1362–301X online ß 2009 Informa Healthcare Ltd.
DOI: 10.1080/02699050902926291
 536 J. S. Kreutzer et al.
also help arrange for socialization and recreational
activities and often serve as survivors’ primary source
of emotional support.
Despite rehabilitation staff members’ best efforts
to educate and prepare families, many report feeling
overwhelmed and ill-equipped to provide for survi-
vors’ complex and dynamic long-term needs [4–6].
Recent research indicates a family’s ability to cope in
the face of stressors influences the quality of support
they can provide to the person with the injury and,
consequently, the extent of the survivor’s neurobe-
havioural recovery [7, 8]. Earlier discharge also
leaves family members with little time to personally
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recover from the emotional shock triggered by the
initial injury.
The impact of brain injury on families has been
well documented. For example, a variety of research-
ers have reported high rates of psychological distress,
namely anxiety and depression among caregivers in
the acute and post-acute phases of injury [9–17].
Many researchers have documented disruptions in
family functioning [18, 19] as manifested by less
effective coping, problem-solving and communica-
tion [20, 21]. An extensive body of literature on
family needs indicates that family members rate the
For personal use only.
needs for information and emotional support
[22, 23], early intervention and advocacy [24] and
community reintegration [25] as very important.
However, many important needs are identified as
unmet [23, 26]. Investigators have reported detri-
ments to life satisfaction when families hold percep-
tions that services are unavailable, unaffordable and
inaccessible [27].
In summary, research has indicated that TBI has
long-term adverse consequences for family mem-
bers, especially primary caregivers. Many agree that
family members are adversely affected by brain
injury and are likely to benefit from treatment
[28, 29]. However, few investigators have developed
evidence-based interventions for survivors and their
family members, leaving important unanswered
questions. A comparative review of family interven-
tion studies (see Table I) indicates both differences
and similarities. In every case, intervention included
family members, but in most cases survivors were
not included. Treatment delivery methods varied
greatly, with some focused on groups of family
members, others using individual counselling
sessions in-person or by telephone and some pro-
viding informational websites. Many interventions
provided combinations of education and psycholog-
ical support while others focused on skills such
as behaviour management and problem-solving.
Investigators’ findings were often equivocal, with
some providing evidence of reduced psychological
distress and improved problem-solving skills follow-
ing intervention.
In summary, there is little doubt that brain injury
has adverse long-term consequences for family
members and survivors. Unfortunately, recent
reviews of the literature conclude that there is a
dearth of scientifically rigorous empirical research on
family interventions [30]. This manuscript has three
main purposes. First, a detailed description of the
Brain Injury Family Intervention (BIFI), a manua-
lized treatment for survivors and caregivers, is
provided. Secondly, information regarding care-
givers’ well-being, needs, perceived obstacles to
receiving services and family functioning before
and after treatment is described. Thirdly, limitations
of the present investigation, clinical implications and
directions for future research are discussed.
Methods
Participants
Of 79 families that initially enrolled in the BIFI,
53 completed all sessions and assessments. Divorce,
separation, moving out of state, severe illness and
transportation difficulties were the reasons most
commonly cited by participants for discontinuation.
Families that did not complete the programme were
compared to those that did on variables including
caregiver relationship to patient, age, ethnicity,
gender, education and patient’s length of hospital
stay and time post-injury. No differences were
found, with the one exception of caregiver age.
Younger caregivers were less likely to complete the
programme. The final sample included 53 persons
with acquired brain injury (ABI) and their family
members. The only two exclusion criteria were
active psychosis or suicidal intent and no partici-
pants were excluded.
With a mean age of 40.73 (SD ¼ 16.52), persons
with ABI were primarily male (58%), Caucasian
(83%) and married (57%). With regard to cause of
injury, the majority had sustained a traumatic brain
injury (87%). Among persons with TBI, the per-
centage with mild (admission GCS 13–15), moder-
ate (GCS 9–12) and severe (GCS 3–8) injury was
47%, 13% and 40%, respectively. Motor vehicle
accidents were the primary cause of injury (52%),
with a smaller number injured by motorcycle or
bicycle accidents (10%), falls (14%) and blunt
objects (11%). The remaining participants (13%)
included individuals with aneurysm, brain abscess,
stroke, encephalitis, epilepsy or hypoxia. Additional
information regarding injury characteristics is pro-
vided in Table II. Data was collected on ancillary
services received at the time of intervention and a
majority of patients were receiving none.
Psychological, psychiatric and vocational services
 Family intervention after brain injury 537

Table I. Comparative review of family intervention research studies.

Intervention delivery Caregiver intervention

Reference n method Recipient Intervention purpose benefits

[68] 19 group; in-person; three 5-
hour sessions over 3
weekends; manualized
[64] 91 group; in-person, on site vs family members
telephone; ten 1.5–
2.0 hour sessions over 10
weeks; not manualized
[65] 33 individual; off site; two
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family members psychological support,
education
psychological support
family members psychological support,
No significant changes in
coping ability, self-
esteem, or life-
satisfaction.
Improvements in psycho-
logical distress for both
treatment groups but no
improvements in family
functioning or burden
for either.
No improvements in psy-

follow-up telephone education via informa- chological distress.

calls over 5 weeks; not tion booklet
manualized
[63] 56 individual; on site in person family members psychological support, Intervention reduced
and off site, post-dis- education burden levels, improved
charge by telephone; satisfaction with care-
sessions varied in length giving and increased
for a period up to 16 perceptions of caregiving
months; not manualized competency.
[66] 27 individual; in-person, home family members, behavioural management, No significant changes in
and community setting; survivors problem-solving skills perceived stress or
2 hour education ses- training psychological distress.
sions provided weekly
over 4 weeks to all par-
For personal use only.

ticipants; behavioural
intervention group com-
pleted additional 2 hour
sessions weekly for 8
weeks; not manualized
[67] 41 survivor and family family members, education No significant changes in
member groups, in- survivors psychological distress,
person; eight, 2.5-hour coping or self-esteem.
sessions over 8 weeks;
not manualized
Rivera (2008) [61] 67 individual; 12 monthly ses- family members problem-solving skills Positive treatment impact
sions over 1 year, four training on psychological dis-
in-home, eight by tele- tress/depression, health,
phone; not manualized dysfunctional problem-
solving styles. No impact
on caregiver life satis-
faction, burden or con-
structive problem-
solving styles.
Present study 53 individual; on-site; five 1.5– family members, psychological support, Increases in met family
2 hour sessions delivered survivors education, skills training needs and perceived
over 10 weeks; access to services. No
manualized impact on psychological
distress, family func-
tioning, satisfaction with
life.

were most often reported, with fewer than 20%
receiving such services.
Family members included persons described by
survivors as a family relation, a partner, a significant
other or friend. When more than one family mem-
ber was available, data was obtained from the one
person identified by the patient as providing the
majority of care. Ranging in age from 22–72, with a
mean of 50.22 years (SD ¼ 12.52), the majority of
participating family members were spouses and
female. Other participants included siblings and
adult children. Table III provides detailed informa-
tion regarding educational level, employment status
and marital status.
 538 J. S. Kreutzer et al.

Table II. Injury characteristics (n ¼ 53). Table III. Caregiver information at intake.

Mean Median SD Range n ¼ 53 Percentage

Acute care length 14.4 7 18.28 0–80 Relation to survivor

of stay (days) Spouse 29 55%
Rehabilitation length 27.8 18 26.23 0–121 Parent 15 28%
of stay (days) Sibling 3 5%
Months post-injury 38.6 12.8 50.79 1.6–185 Adult child 2 4%
Length of unconsciousness 3.5 0.0 9.51 0–47 Boyfriend/girlfriend 2 4%
(days)* Other relative 2 4%
Admission Glasgow 10.4 12 4.72 3–15 Female gender 35 66%
Coma Scale* Married 44 83%
Education level
*For participants with TBI. Less than high school 3 6%
High school graduate/some college 28 52%
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College degree or greater 22 42%

Intervention structure and content Employment status
Competitively employed 35 66%
The Brain Injury Family Intervention (BIFI) is a Not competitively employed 18 34%
structured treatment designed to meet the needs
most commonly identified by family members and
survivors. The intervention was conceived to
improve survivors’ and family members’ psycholog-
and the family as a whole. The impact of brain injury
ical well-being, life satisfaction, access to services
on patients has been well documented. Researchers
and enhance family functioning [31]. The BIFI is
have also identified a profound impact on family
implemented over the course of five 90–120 minute members, especially primary caregivers [36, 37]. As
sessions. During each session, two or three topics are such, the BIFI is delivered jointly to family members
For personal use only.

addressed, as delineated in Table IV. The 11 topics
are covered in the same sequence with each family.
The BIFI was constructed such that sessions were
logically organized to achieve the greatest therapeu-
tic impact. Earlier sessions focus on the needs and
concerns most frequently identified during inter-
views conducted with family members and within
the literature. Later sessions reinforce and build
upon the foundation of knowledge and skills learned
in earlier sessions. Each session begins with an
overview of topics and concludes with a summary
and homework assignments.
Clinicians depend on the BIFI manual [32] to
deliver the intervention systematically and effi-
ciently. For each topic covered in each session, the
manual delineates goals, materials needed and, if
necessary, accommodations for disability. Using a
step-by-step approach, the manual provides the
clinician with detailed scripts for each module,
instructions, therapeutic activities and homework.
Bibliotherapy also serves as a helpful complement.
Fact sheets, guides and supplementary readings from
the book Getting Better and Better after Brain Injury:
A Guide for Family, Friends, and Caregivers [33] were
provided and reviewed by participants during treat-
ment sessions and for homework.
The BIFI incorporates principles of family systems
theory (FST [34, 35]) and utilizes family therapy
techniques. A primary postulate of FST is that
families are interconnected systems. The actions,
communications and feelings of each family member
typically influence those of other family members
and survivors. To strengthen family systems, the
BIFI relies heavily on family therapy techniques
including empathic reflections, validation, reframing
and normalization of common concerns.
Cognitive Behavioural Theory (CBT [38]) is
predicated on the idea that a person’s cognitions
influence his or her emotions and behavior [39].
Change in one area is thought to produce related
changes in the other areas of functioning. Recent
research studies have substantiated the benefits of
CBT after brain injury [40–43]. As such, CBT
techniques have been adapted and incorporated in
the BIFI to improve cognitive, emotional and
behavioural functioning. Educational techniques
are used to inform participants about common
injury sequelae and recovery. Psychological support
techniques are used to help participants recognize
their feelings and improve their emotional well-
being. Skills training techniques are used to improve
problem-solving, communication and emotional
control.
The BIFI also makes significant use of the
technique, collaborative self-examination, developed
by Kreutzer and Taylor [32]. Injury typically causes
rapid and dramatic changes in the lives of survivors
and family members. Family members are often
uncertain about their feelings, capabilities, concerns
and plans for the future. Survivors often harbour
similar uncertainties which are compounded by
impaired self-awareness. Using collaborative self-
examination, each family member shares their
perspectives about events, one another’s behaviour
 Family intervention after brain injury 539

Table IV. Overview of BIFI sessions and topics.

Session Topic Objective(s)

I. Effects of brain injury on the
survivor and family
II. Understanding recovery
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What is normal after brain injury?
Brain injury happens to the whole family
Emotional and physical recovery are two
different things
Recognize, understand and appreciate
common injury consequences; recognize
each family member’s point of view about
the injury’s effects
Improve communication and recognition
that each family members’ responsibil-
ities, life plans and feelings about the
future have been significantly changed
Appreciate expectations for improvement
and clearly understand the differences
between emotional and physiological
recovery

Mastering the art of patience Appreciate the benefits of patience and

III. Solving problems and setting
goals
IV. Managing stress and intense
emotions
For personal use only.
Coping with loss and change
Setting reasonable goals
Solving problems effectively
Managing stress effectively
master the skill of overcoming impatience
Identify and implement strategies to better
cope with loss and change
Understand the characteristics and dangers
of unrealistic goals and take steps to set
more reasonable and achievable goals
Identify obstacles to solving problems effec-
tively; learn and apply a framework of
strategies for efficient problem-solving
Identify current stress levels and recognize
personal ‘red flags’ which signal stress;
employ strategies for managing stress
effectively

Managing intense emotions Recognize communication obstacles and the

V. Strategies for optimal recovery
Taking care of yourself
Focusing on gains and accomplishments
Most important lessons learned and where to
go from here
importance of communication; employ
strategies to effectively manage frustra-
tion, anger and other intense emotions
Recognize the adequacy and importance
of self-care; take steps to better care for
one’s self
Realize the strong relationship between
thoughts and feelings; better recognize
strengths and progress
Recognize and communicate the most
important things learned during the
course of intervention

and their interactions with one another, encouraging
perspective taking, self-monitoring and enhanced
awareness. Collaborative self-examination chal-
lenges family members’ perceptions of themselves
and provides an opportunity for each person to
understand how others perceive them. When imple-
menting the technique, family members are asked to
answer standardized questions to illuminate infor-
mation about their perspective. Then, family mem-
bers are asked to communicate their perspective
while others listen. All family members are reminded
that they do not have to agree. The discussion is
meant to facilitate understanding, encourage discus-
sion, improve family members’ communication skills
and enhance support for one another. Through the
use of collaborative self-examination, family mem-
bers are encouraged to recognize and stop using
approaches that do not work or make things worse.
Family members are also assisted in recognizing
and making greater use of approaches that work well
and make their lives better.
All clinicians conducting the BIFI treatment were
doctoral level psychologists who received training
from the first author. Initially, clinicians carefully
studied the treatment manual and observed the
first author providing a course of sessions. Next,
therapists were observed and given feedback.
Clinicians met weekly for supervision with the first
author. At the end of each session, participants
completed feedback forms indicating their percep-
tion of the extent to which session goals were
achieved and their overall satisfaction with the ses-
sion and the material presented. Completed
forms indicated a high level of satisfaction and
that the goals delineated in the manual were
consistently achieved.
 540 J. S. Kreutzer et al.
Measures
. Family Needs Questionnaire (FNQ): The FNQ is
a widely used 40-item self-report questionnaire
developed to measure family members’ perceived
needs after a family member sustains a brain
injury [44–48]. The items were designed to
address diverse psychosocial and educational
needs apparent in the acute and post-acute
phases after injury. Family members rate the
extent to which needs are perceived as important
on a scale ranging from 1 ¼ not important to
4 ¼ very important. Respondents also rate the
degree to which they perceive that each need has
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been met (not met, partly met or met). Content
and construct validity as well as internal consis-
tency has been established (Spearman-Brown
split-half reliability of 0.75) [22]. A later factor
analytic investigation [49] revealed six indepen-
dent factors comprising six scales: Health
Information, Emotional Support, Instrumental
Support, Professional Support, Community
Support Network and Involvement with Care.
Internal consistency for individual factors was
indicated by Chronbach’s alpha’s ranging from
For personal use only.
0.78–0.89. The proportion of needs described as
met (converted to a 10-point scale) was the
primary family outcome measure for the present
study.
. Service Obstacles Scale (SOS): The SOS [50] was
developed to evaluate individuals’ and caregivers’
perceptions of brain injury services in the com-
munity with regard to quality and accessibility.
The six-item scale solicits information regarding
obstacles to receiving brain injury services, knowl-
edge of and availability of resources and satisfac-
tion with the quality of care. Items are rated on
a seven-point Likert-type scale ranging from
1 ¼ strongly disagree through 7 ¼ strongly agree.
Lower scores denote greater access and satisfac-
tion with services. The SOS has three main
components: (1) satisfaction with treatment
resources; (2) finances as an obstacle to receiving
services; and (3) transportation as an obstacle to
receiving services. A recent regional needs assess-
ment study provided evidence of the SOS’s
validity [51]. The total score for items relating
to satisfaction with treatment resources served as
a primary outcome measure in the present
investigation.
. Family Assessment Device (FAD): The FAD is a
60-item questionnaire designed to assess diverse
aspects of family functioning [52, 53]. A number
of investigators have used the measure to charac-
terize families after brain injury. For example,
a number of researchers have also utilized the
FAD to assess family functioning after brain
injury [7, 54–56]. The present investigation only
utilized items from the 12-item General
Functioning Scale, developed to characterize
overall family functioning. Items are rated on a
scale ranging from 1–4, indicating ‘strongly agree’
to ‘strongly disagree’. Some items are reverse-
coded, with lower scores indicative of more
optimal functioning.
. Brief Symptom Inventory-18 (BSI-18): The BSI-18
[57] is an 18 item self-report instrument designed
to quantify psychological distress in the general
population. Increasingly, the measure has been
used to quantify family members’ distress after
brain injury [58, 59]. The instrument is a
psychometrically sound [60], abbreviated version
of the SCL-90-R [57]. Frequency ratings for
items in three primary symptom dimensions are
added to yield scores for Somatization,
Depression and Anxiety. The Global Severity
Index (GSI) reflects the sum of scores for the
three primary symptom dimensions. T-scores for
each dimension and the GSI are calculated based
on community norms.
. Satisfaction With Life Scale (SWLS): The SWLS
[43] is a measure of global life satisfaction
comprised of five statements scored on a Likert
scale such that 1 ¼ Strongly disagree and
7 ¼ Strongly agree. The measure has been used
by a number of researchers to characterize
caregivers post-injury [58, 61]. Lower scores
indicate lower levels of life satisfaction.
Normative data are available and the scale shows
good convergent validity with other scales
and with other types of assessments of subjective
well-being [62]. The SWLS has shown sufficient
sensitivity to detect changes as a result of clini-
cal interventions and has good discriminant
validity [62].
Procedure
Participants were recruited from a variety of sources
and included persons with neurobehavioural pro-
blems referred by rehabilitation providers, advocacy
organizations and agencies. Screening, assessment
and intervention were centralized in an outpatient
rehabilitation clinic attached to a major medical
centre. During the initial intake session, project staff
provided information about the research pro-
gramme, confirmed eligibility and interest in parti-
cipation, identified the primary family member and
obtained informed consent from all participants
in each family.
On giving informed consent, the individual with
TBI and primary family member were given baseline
assessment materials to complete. One therapist
worked with each family through completion of the
 Family intervention after brain injury 541

intervention. The five 90–120 minute sessions were
scheduled over a 10-week period. Participants were
asked to review and discuss materials and complete
worksheets between sessions. Post-treatment data
was collected following completion of the fifth
session. Three month follow-up data was collected
10–14 weeks following the last session.
Data analysis
Descriptive statistics including means, standard
deviations and proportions were computed for
variables relating to injury and caregiver character-
istics. Means and standard errors were calculated for
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p < 0.2. Interactions between evaluation interval,
scales and each covariate were considered to deter-
mine if the changes over time varied in relation to
demographic and injury characteristics. Insignificant
covariates and interaction effects were subsequently
removed if p  0.05. To control the type I error rate,
Bonferroni adjustments for multiple comparisons
were utilized.
An alternative to MANOVA, mixed-effects
models have the advantage of accounting for
correlated data by assuming specific variance–covar-
iance structures. The mixed-effects model also has
the advantage of simultaneously modelling, within

each subject, correlations in measures across time as

the five outcome measures. Repeated measures
well as across scales. Participants with missing data
mixed models were used to model the means of
can be examined and need not be excluded from
each outcome measure over time. For all models, an
analysis. Furthermore, modelling more data together
autoregressive variance–covariance structure was
increases statistical power and decreases standard
chosen to model the correlations in observations
errors of estimates.
over time within subjects. Models for measures with
multiple scales (e.g. BSI, FNQ) also utilized an
unstructured variance–covariance structure to
account for the correlation between scales. Results
The initial models for each outcome measure were
Family needs
examined to determine if there were changes in
For personal use only.

scores over time without adjusting for covariates.
When there was evidence of at least a marginal
amount of change in scores (p-value < 0.20), an
adjusted model was fit to more accurately model the
means. The variables considered for adjustment
included caregiver characteristics such as relation
to survivor (spouse, parent, other), age, gender,
ethnicity (minority, non-minority) and marital status
(married/cohabitating, not married) and survivor
characteristics including age and acute care length
of stay. The adjusted models were initially fit in a
forward stepwise fashion, entering covariates with
Means and standard errors for the six FNQ scales
are detailed in Table V. A single repeated measures
mixed model was used to model the six FNQ scales
over time, assuming an autoregressive structure
across the visits and an unstructured structure
across the domains. Changes in the FNQ over time
were not significantly different across the six scales
(p ¼ 0.4913). Regardless of scale, scores changed
significantly over time (F(2, 81) ¼ 8.97, p ¼ 0.0003).
Using a Bonferroni correction ( ¼ 0.0083) for post-
hoc comparisons, significant increases in met needs
over time were evident for Health Information

Table V. Means and standard errors for outcome measures before and after treatment.

Pre-treatment Post-treatment 3 Month follow-up

Measure Mean (SE) Mean (SE) Mean (SE)

Family Needs Questionnaire*

Health Information 5.25 (0.43) 7.09 (0.44) 7.63 (0.50)
Emotional Support 3.72 (0.47) 5.31 (0.47) 5.32 (0.54)
Instrumental Support 3.40 (0.51) 4.75 (0.51) 4.90 (0.59)
Professional Support 3.55 (0.51) 5.72 (0.52) 6.25 (0.59)
Community Support 3.75 (0.49) 4.80 (0.49) 5.81 (0.56)
Care Involvement 5.09 (0.58) 6.58 (0.58) 7.64 (0.67)
Family Assessment Device 23.71 (0.85) 23.83 (0.87) 23.59 (0.95)
Service Obstacles Scale 14.60 (0.73) 12.26 (0.77) 10.30 (0.87)
Brief Symptom Inventory-18
Somatic 51.82 (1.40) 51.71 (1.44) 51.69 (1.62)
Depression 54.19 (1.35) 51.10 (1.38) 53.40 (1.56)
Anxiety 54.61 (1.32) 52.15 (1.35) 53.24 (1.52)
Global Severity Index 54.65 (1.37) 52.14 (1.41) 53.48 (1.59)
Satisfaction with Life Scale 21.45 (1.06) 22.29 (1.06) 21.45 (1.13)

*FNQ scale score values were transformed to a 10-point scale.

 542 J. S. Kreutzer et al.

(p ¼ 0.0002), Professional Support (p ¼ 0.0002) and
Care Involvement (p ¼ 0.0083) needs, but not for
Emotional Support (p ¼ 0.0104), Instrumental
Support (p ¼ 0.0506) or Community Support
(p ¼ 0.0147).
Subsequently, an adjusted model was fit that
included main effects for time (F(2, 78) ¼ 9.05,
p ¼ 0.0003), FNQ scale (F(5, 240) ¼ 12.71,
p < 0.0001), caregiver marital status (F(1, 46) ¼
12.11, p ¼ 0.0011) and acute LOS (F(1, 46 ¼ 7.52,
p ¼ 0.0087), as well as an interaction effect for time
by domain (F(10, 379) ¼ 1.06, p ¼ 0.3941). After
adjusting for caregiver marital status and acute LOS,
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analysis did not provide evidence of differences
between post-treatment and 3 month follow-up
scores.
Regarding caregiver marital status, FNQ scores
were significantly higher for married caregivers than
non-married caregivers by 2.253 units (95%
CI ¼ 0.950, 3.556), irrespective of scale or evalua-
tion interval (i.e. pre-treatment, immediate post-
treatment, 3 months follow-up). Additionally, a
10-day increase in acute LOS was associated with
a 0.38 unit decrease (95% CI ¼ 0.10, 0.66) in FNQ
score, irrespective of scale or evaluation interval.
There was no evidence of interaction effects for

the FNQ changes over time were not significantly FNQ scale, evaluation interval and the covariates
different among the six scales. All six FNQ scales (e.g. marital status, acute care LOS).
showed significant changes over time.
Using a Bonferroni correction ( ¼ 0.0083) for Family functioning
post-hoc comparisons, changes over time were
A single repeated measures mixed effects model was
significant for the Health Information (p ¼ 0.0002),
used to model the FAD scores over time, assuming
Emotional Support (p ¼ 0.0069), Professional
an autoregressive structure across the visits. Scores
Support (p ¼ 0.0002) and Care Involvement
did not change significantly over time (F(2, 80) ¼
(p ¼ 0.0083) scales. Significant changes were not
0.05, p ¼ 0.9486). Means and standard errors are
observed for the Instrumental Support (p ¼ 0.1336)
presented in Table V. Since there was not evidence
or Community Support (p ¼ 0.0171) scales.
of changes in family functioning over time
For personal use only.

For the Health Information, Emotional Support,

Professional Support and Care Involvement scales,
changes over time were further examined using a
Bonferroni correction ( ¼ 0.0167). As indicated in
Table VI, significant pre- to post-treatment increases
were identified for Health Information, Emotional
Support and Professional Support needs, but not for
Care Involvement. Comparisons between pre-treat-
ment and 3 month follow-up data revealed signifi-
cant increases for the four scales. The data presented
in Figure 1 provides evidence that treatment benefits
may continue to accrue for several months beyond
completion of formal intervention. However,
(p ¼ 0.9486 > 0.20), an adjusted model was not fit.
Service obstacles
A single repeated measures mixed effects model was
used to model the total SOS scores over time,
assuming an autoregressive structure across the
visits. Scores changed significantly over time (F(2,
78) ¼ 8.58, p ¼ 0.0004). Mean values and standard
errors are presented in Table V. Using a Bonferroni
correction ( ¼ 0.0167) for post-hoc comparisons,
significant pre- to post-treatment (p ¼ 0.0062) and
pre-treatment to 3 month follow-up (p ¼ 0.0001)

Table VI. Adjusted FNQ score increases: mean, standard error, 95% confidence intervals and associated p-values.

Mean increase SE 95% CI p-value

Health information
Pre–post-treatment 1.743 0.490 (0.842, 2.878) 0.0004
Post–3 month follow-up 0.523 0.535 (0.568, 1.698) 0.3286
Pre–3 month follow-up 2.267 0.596 (1.184, 3.665) 0.0002
Emotional support
Pre–post-treatment 1.611 0.543 (0.585, 2.612) 0.0032
Post–3 month follow-up 0.063 0.592 (1.078, 1.175) 0.9156
Pre–3 month follow-up 1.674 0.660 (0.414, 2.881) 0.0116
Professional support
Pre–post-treatment 2.106 0.591 (1.006, 3.327) 0.0004
Post–3 month follow-up 0.562 0.645 (0.769, 1.816) 0.3844
Pre–3 month follow-up 2.668 0.717 (1.279, 4.101) 0.0002
Care involvement
Pre–post-treatment 1.431 0.675 (0.157, 2.842) 0.0346
Post–3 month follow-up 1.087 0.736 (0.436, 2.550) 0.1403
Pre–3 month follow-up 2.519 0.823 (0.918, 4.195) 0.0024
 Family intervention after brain injury 543

3
mixed model was used to model the four BSI-18
Pre-Post Post-3 Months
scales over time, assuming an autoregressive struc-
2.5
ture across evaluation intervals and an unstructured
structure across the scales. Analysis indicated
Mean Increase

2
that BSI-18 scale scores did not change significantly
1.5 over time, (F(2, 81) ¼ 1.49, p ¼ 0.2318) and there
were no significant differences between scales
1
(F(6, 243) ¼ 1.25, p ¼ 0.2792). Since there was not
0.5
evidence that the BSI changed significantly over time
(p ¼ 0.2318 > 0.20), an adjusted model was not fit.
0 A single repeated measures mixed model was used
Health Emotional Instrumental Professional Community Care
Information Support Support Support Support Involvement to model the caregiver SWLS scores over time,
assuming an autoregressive structure across the
Figure 1. Mean post-treatment changes in met needs.
Brain Inj Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/14/13

visits. Caregiver SWLS scores did not change

significantly over time (F(2, 82) ¼ 1.33,
p ¼ 0.2694). Means and standard errors are provided
Table VII. Adjusted SOS score decreases by acute care length of in Table V.
stay: mean, standard error, 95% confidence intervals and
associated p-values.
Discussion
Mean
decrease SE 95% CI p-value** Family intervention researchers have examined dif-
ferent types of outcomes, yet most studies have not
1 day acute care* yielded evidence of treatment benefits. Investigations
Pre–post-treatment 4.02 1.04 (1.95, 6.09) 0.0002
of benefits to psychological distress, problem-solving
Post–3 month follow-up 1.36 1.16 (0.96, 3.68) 0.2455
and burden have generated equivocal findings
For personal use only.

Pre–3 month follow-up 5.38 1.32 (2.76, 8.03) 0.0001

19 days acute care*
Pre–post-treatment 1.87 0.86 (0.16, 3.59)
Post–3 month follow-up 1.91 0.95 (0.01, 3.81)
Pre–3 month follow-up 3.78 1.08 (1.63, 5.93)
*1 and 19 day length of stay values correspond to 1st and 3rd
quartiles.
**post hoc comparisons are made in reference to a Bonferroni
correction ( ¼ 0.0083).
decreases were identified. The post-treatment to
3 month follow-up (p ¼ 0.0428) decrease was
nominal.
With evidence of significant SOS changes over
time, an adjusted model was built to account for
caregiver and survivor characteristics. The model
included main effects for time (F(2, 74) ¼ 10.26,
p ¼ 0.0001), acute LOS (F(1, 74) ¼ 1.87,
p ¼ 0.1779) and the interaction effect (F(2,
74) ¼ 3.55, p ¼ 0.0338). Table VII provides infor-
mation regarding the interaction between evaluation
interval and acute LOS. Comparisons are made at
first (i.e. 1 day) and third (i.e. 19 days) quartile
LOS values. In comparison to family members of
participants with longer lengths of stay, family
members of participants with shorter stays showed
greater improvements pre- to post-intervention and
pre-intervention to 3 month follow-up.
Family members’ distress and life satisfaction
Means and standard errors for BSI-18 scales are
provided in Table V. A single repeated measures
[61, 63–67]. No investigators have identified signif-
0.0325 icant improvements in post-intervention family
0.0487 functioning, life satisfaction, coping or self-esteem
0.0008
[61, 64, 67, 68]. On a positive note, family
participants in the present investigation showed a
greater number of met family needs and perceived
fewer obstacles to obtaining services following the
BIFI. Post-hoc analyses suggested that treatment
benefits continued to accrue for at least 3 months
beyond the cessation of treatment. These findings
are unique in that other researchers have not
examined how intervention affects family needs or
perceptions of access to services.
The present investigation was also unique in using
covariance analyses to identify factors that influ-
enced treatment. There was no indication that
caregivers’ relationship to survivor, gender, age or
ethnicity related to treatment. Nor was there evi-
dence that survivors’ age influenced treatment out-
come. On the other hand, caregivers’ marital status
and survivors’ length of hospitalization were identi-
fied as significant covariates. With regard to marital
status, married caregivers reported more met needs
than unmarried caregivers. The higher rate of met
needs was evident before and after treatment.
With regard to length of stay, caregivers of survivors
with longer hospitalizations reported fewer met
needs. Researchers have only begun to examine the
impact of brain injury on marriages and factors that
influence marital stability. Findings from the
present investigation suggest that marriage provides
important supports for caregivers. With regard to
 544 J. S. Kreutzer et al.
perceived obstacles to receiving services, survivors’
acute care length of stay was the only significant
covariate. Families of survivors with longer hospital-
ization lengths reported more obstacles to receiving
services. The findings for marital status and service
accessibility are not surprising and they fit with the
notion that adjustment is more difficult for unmar-
ried persons and caregivers of survivors with more
severe injury. Clearly these findings should be
viewed as preliminary and more research is needed
to delineate factors influencing treatment success.
The present investigation also examined post-
treatment changes in psychological distress, family
Brain Inj Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/14/13
functioning and life satisfaction. Among the seven
previous family intervention studies reviewed, only
Brown et al. [64] examined impact on family
functioning. As in the present investigation, Brown
et al. utilized the Family Assessment Device and
significant treatment effects were not observed.
Acorn [68] used the Life Satisfaction Index [69]
and Rivera [61] used the Satisfaction with Life Scale
(SWLS [43]) to measure caregivers’ satisfaction with
life. As in Rivera’s investigation, the present inves-
tigation also utilized the SWLS. Non-significant
findings were reported in all three investigations.
For personal use only.
A majority of family intervention studies have
included a psychological support component and
findings have been equivocal. Brown et al. [64] and
Rivera et al. [61] identified treatment-related psy-
chological distress reductions. Brown et al. relied
upon the Profile of Mood States [70] and Rivera
et al.’s participants completed the CES-D [71].
As reported by Morris [65], Carnevale et al. [66] and
Sinnakaruppan et al. [67], the present investigation
did not identify treatment-related reductions in
distress. Morris and Sinnakaruppan et al. both
utilized the HADS to measure distress. Differential
findings regarding psychological distress seem unre-
lated to intervention delivery method, recipient or
purpose. Instead, differential findings may be attrib-
utable to the differential sensitivity of outcome
measures. Equivocal findings may also indicate that
smaller samples did not provide sufficient statistical
power. The samples used by Brown et al. (n ¼ 91)
and Rivera et al. (n ¼ 67) were larger than those in all
the other investigations.
In fact, sample size may be one of the salient
factors distinguishing studies that have shown
treatment-related benefits from those that have not.
The four studies [65–68] with the smallest sample
sizes showed no treatment benefit. Sample sizes
ranged from 19–41. Including the present investiga-
tion, the four studies with greater than 50 partici-
pants provided evidence of treatment-related
benefits [61, 63, 64].
Unfortunately, comparing the benefits of different
interventions has been difficult because
methodologies vary widely. Some have provided
treatment to groups while others have provided
individual treatment. In some cases treatment has
been delivered by telephone and in other cases in
person. Standardization of treatment has been
difficult, with most providers not relying on a
treatment manual. Treatment has been provided in
hospitals, homes, clinics and other community-based
settings. Some interventions have included survivors,
though most have not. There has been great vari-
ability in the frequency and duration of treatment,
with some investigators delivering treatment for less
than 1 month and others for over 1 year. Finally,
interventions have been developed for varying
purposes. Most investigators have included a psy-
chological support component and an educational
component. A relatively small number have focused
on skill building. The present investigation is the first
to incorporate all three components, education,
psychological support and skill building.
Investigations have also utilized widely varying
outcome measures, even when measuring the same
construct. Variation in measures utilized to quantify
psychological distress and coping are most impress-
ive. For example, two investigators examined care-
givers’ coping [67, 68] and each relied on a different
measure. The Satisfaction With Life Scale, Family
Assessment Device, HADS and the Rosenberg Self-
Esteem Scale were each used in two research studies.
Unfortunately, no measures have been used in more
than two studies.
The findings of the present investigation must be
interpreted within the context of several method-
ological limitations. First, a control group was not
utilized, leaving questions about factors underlying
treatment benefits. Self-report measures were uti-
lized and outcome data was not derived from
standardized observational methods or interviews.
Some might suggest that a combination of observa-
tional and self-report measures is optimal. The
sample was relatively small, raising questions about
statistical power and representativeness. Data was
collected at a single centre, perhaps adding to
questions about generalization from findings.
Treatment spanned five sessions over a 10-week
period, leaving uncertainties about optimal treat-
ment intensity, duration and frequency. The data
provided support for the durability of treatment
effects, but there are questions about durability
beyond 3 month follow-up.
Without a doubt additional research is needed.
Ideally, future studies should include a combination
of well-validated measures, especially tools
developed for brain injury populations and shown
to be treatment sensitive. Inclusion of a control group
will enable researchers to draw firmer conclusions
about factors underlying treatment benefits. Wait-list

controls may be preferred to no-treatment controls
because of ethical concerns about withholding treat-
ment entirely. Multi-centre studies with larger sam-
ples will increase statistical sensitivity and reduce the
likelihood of Type II error. Comparing treatments
with varying frequency and duration and including
longer-term follow-up will help ascertain the ideal
treatment regimen and the longevity of treatment
benefits. Finally, the present investigation focused on
data derived from caregivers. More research is
needed to identify the benefits of the BIFI and
other treatments for survivors.
In conclusion, analysis of data derived from the
Brain Inj Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/14/13
present investigation provides evidence that a man-
ualized intervention which includes education,
skill building and psychological support components
has benefits for family members in a post-acute
setting. Caregivers of persons with more severe
injuries, as measured by hospital length of stay,
reported more unmet needs and perceived more
obstacles to receiving services before and after injury.
However, analysis indicated similar intervention
benefits for families regardless of injury severity.
The quantitative data was complemented by quali-
tative data, indicating that the intervention helped
For personal use only.
family members learn about the nature of injury,
improve communication and enhance problem-sol-
ving skills. Many family members also reported that
the BIFI helped them recognize how the injury had
affected them personally and the family as a whole. In
fact, 100% of family members reported that they
would recommend the programme to others.
The literature clearly provides evidence that family
members have a critical role in survivors’ rehabilita-
tion, yet they are adversely impacted as well.
The present investigation provides evidence that the
BIFI effectively addresses family members’ needs,
alleviates obstacles to receiving services and has a
positive impact on family members’ lives.
Acknowledgement
Supported by grants H133A070036 and
H133P040006 from the National Institute on
Disability and Rehabilitation Research, United
States Department of Education.
Declaration of interest: The authors report
no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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