NeuroRehabilitation 40 (2017) 545–552 545

DOI:10.3233/NRE-171441
IOS Press

Impact of the Brain Injury Family

Intervention (BIFI) training on rehabilitation
providers: A mixed methods study
Cara Meixnera,∗ , Cynthia R. O’Donoghueb and Vesna Harta
a Department of Graduate Psychology, James Madison University, Harrisonburg, VA, USA
b Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, VA, USA

Abstract.
BACKGROUND: The psychological impact of TBI is vast, leading to adverse effects on survivors and their caregivers.
Unhealthy family functioning may be mitigated by therapeutic strategies, particularly interdisciplinary family systems
approaches like the well-documented Brain Injury Family Intervention (BIFI). Little is known about the experience of
providers who offer such interventions.
OBJECTIVE: This mixed methods study aims to demonstrate that a structured three-day training on the BIFI protocol
improves providers’ knowledge and confidence in working with survivors and families, and that this outcome is sustainable.
METHODS: Participants were 34 providers who participated in an intensive training and completed a web-based survey
at four points of time. Quantitative data were analyzed via Wilcoxon signed-rank tests and binomial test of proportions.
Qualitative data were analyzed according to rigorous coding procedures.
RESULTS: Providers’ knowledge of brain injury and their ability to conceptualize treatment models for survivors and their
families increased significantly and mostly remain consistent over time. Qualitative data point to additional gains, such as
understanding of family systems.
CONCLUSIONS: Past studies quantify the BIFI as an evidence-based intervention. This study supports the effectiveness
of training and serves as first to demonstrate the benefit for providers short- and long-term.

Keywords: Brain injury, family systems, BIFI, mixed methods

1. Introduction to be approximately 2.5 million (CDC, 2014), mak-

Today’s rehabilitation providers will work with
multiple clients and families who have survived brain
injuries and endure significant longitudinal conse-
quences. A traumatic brain injury (TBI), caused by a
“bump, blow, or jolt” (CDC, 2014, p. 15) to the head,
disrupts the normal function of the brain leading to
short- and long-term sequelae – cognitive, behavioral,
affective, and somatic. In spite of limitations to data
collection and reporting, the Centers for Disease Con-
trol and Prevention (CDC) estimate TBI incidences
∗ Address
for correspondence: Cara Meixner, Department of
Graduate Psychology, James Madison University, MSC 4603,
1251 Carrier Drive, Harrisonburg, VA 22807, USA. Tel.: +1 540
568 4846; Fax: +1 540 568 4990; E-mail: meixnecx@jmu.edu.
ing it a leading cause of death and disability in the
United States.
Given the nuanced neurochemistry and mecha-
nisms of the brain, no two injuries are alike, and
the locus of injury may not always predict a sur-
vivor’s success in the recovery process. For instance,
a high-school athlete who sustained what seemed
to have been a mild concussion may withstand per-
sistent learning and memory challenges, struggling
to fulfill school obligations. A middle-aged woman
who appeared to have recovered quickly from a car
accident may be plagued with long-term sleep distur-
bances, depression, and light sensitivity. A returning
war veteran who survived a blast-related injury may
vacillate in his symptoms, appearing rational and well

1053-8135/17/$35.00 © 2017 – IOS Press and the authors. All rights reserved
546 C. Meixner et al. / Impact of the BIFI training on providers
adjusted for weeks, only to later experience sustained
periods of irrational behavior punctuated by impul-
sivity, anxiety, and rage.
The psychological impact of TBI is vast, leading
to an array of adverse effects on the survivor and
his loved ones. While “the return to work, school,
and other pre-injury activities after TBI are key ele-
ments for life satisfaction” (CDC, 2014, p. 18), it is
often the case that these goals are untenable given
the pronounced long-term outcomes of brain injury.
This promulgates caregiver stress; numerous studies
have demonstrated that families caring for a loved one
with TBI face increased psychological distress and
unhealthy family functioning (Anderson, Parmenter,
& Mok, 2002; Kreutzer, Gervasio, & Camplair, 1994;
Livingston, Brooks, & Bond, 1985; Norup, Welling,
Qvist, Siert, & Mortensen, 2012; Perlesz, Kinsella,
& Crowe, 2000; Schönberger, Ponsford, Olver, &
Ponsford, 2010).
While research documents the need for thorough
education on brain injury (Meixner, O’Donoghue, &
Witt, 2013), no studies have investigated the dif-
ficulties that rehabilitation providers face when
working with survivors of brain injury and their fami-
lies. Comprehensive interdisciplinary family systems
approaches do work for survivors and families, so
engagement in specialized training may improve
providers’ knowledge of brain injury and their effi-
cacy in working with survivors and their loved ones
both short-term and longitudinally. Through a mixed
methods design, this research investigates this phe-
nomenon, paving paths for novel, person-centered
intersections between the fields serving persons with
brain injury.
2. Literature review
A preview of the empirical literature on family
rehabilitation and intervention, with attention to the
barriers affecting access to rehabilitative services for
survivors of brain injury and their families, provides
the backdrop for this investigation.
2.1. The need for family rehabilitation
and intervention
In the current literature, studies have explored the
effectiveness of various therapeutic interventions for
persons with TBI. Generally, the long-term goals of
these interventions are to improve survivors’ mental
and cognitive functioning and to help them regain
functional independence. In a review of randomized
control studies of various interventions, comprehen-
sive interdisciplinary approaches were found to be
most effective in the recovery of cognitive function-
ing (e.g., attention, memory, executive functioning,
communication) and functional independence for
post-acute patients (Lu, Gary, Neimeier, Ward, &
Lapane, 2012). Integrally, comprehensive interdisci-
plinary approaches were associated with lower rates
of depression (Bombardier et al., 2009), increases
in cognitive and memory functioning (Vanderploeg
et al., 2008), and increases in functional indepen-
dence (Powell, Heslin, & Greenwood, 2002).
In spite of the effectiveness of comprehensive inter-
disciplinary approaches, none of the previous studies
involved family caregivers of a survivor of TBI.
Family members care for nine of 10 persons with
TBI (Kreutzer et al., 2009), playing a pivotal and
essential role in the rehabilitation process. Yet fam-
ily caregivers of persons with brain injury are under
pronounced stress; Kreutzer et al. (1994) found that
47% of caregivers reported significant distress on the
Brief Symptom Inventory (DeRogatis, 1993). Fur-
ther, those family members caring for loved ones with
grave communicative or social impairments experi-
ence more severe physiological distress than those
who care for individuals with more mild deficits
(Anderson et al., 2002). In a study of 45 families
of individuals with TBI, caregivers reported sig-
nificantly higher depression and anxiety symptoms
compared to a normed sample (Norup et. al, 2012).
Norup et al. also discovered significantly lower qual-
ity of life scores (i.e., emotional impact, vitality,
social function, and mental health) in families coping
with TBI.
Without support, these challenges persist. In a
longitudinal study of families affected by TBI,
depression and anxiety remained present in care-
givers at two, five, and seven years post event
(Brooks, Campsie, Symington, Beattie, & McKinlay,
1986; Brooks, McKinlay, Symington, Beattie, &
Campsie, 1987; Schönberger et al., 2010). Addition-
ally, families of persons with TBI often reported
unhealthy family functioning. Applying the Fam-
ily Assessment Device (FAD) (Epstein, Baldwin, &
Bishop, 1983) as the measure, a longitudinal study
demonstrated increased levels of dysfunction in
problem-solving, communication, affective involve-
ment, and general functioning in family caregivers
(Schönberger et al., 2010). Caregivers of persons
with TBI scored significantly lower on the gen-
eral functioning subscale of the FAD compared to
 C. Meixner et al. / Impact of the BIFI training on providers
a non-medical sample (Kreutzer et al., 1994). Simi-
larly, social and marital functioning in couples coping
with TBI has been shown to decline in the year fol-
lowing the injury (Livingston et al., 1985).
Because caregivers experience significant distress
following the brain injury of a family member, an
intervention that attends to both the survivor and his
family might be more beneficial than individual ther-
apy alone.
2.2. The Brain Injury Family Intervention (BIFI)
The Brain Injury Family Intervention (BIFI)
is a comprehensive, evidence-based intervention
designed to improve the lives of persons with TBI
and their families. With underpinnings in cogni-
tive behavioral therapy (CBT) and family systems
theory, the BIFI is implemented by counselors, psy-
chologists, social workers, nurses, and rehabilitation
therapists. The BIFI consists of five 90–120 minute
sessions in which survivors and their families system-
atically engage with 12 topical areas around which
there are provided scripts, goals, intervention activ-
ities, and homework (Kreutzer, Kolakowky-Hayner,
Demm, & Meade, 2002; Kreutzer et al., 2009).
The goal of the BIFI is to educate families on the
physical and cognitive changes associated with TBI
and how to cope effectively with these changes both
for the family and the client. Families who engaged
with the BIFI reported statistically significant gains in
the areas of health information, professional support,
emotional support, and care involvement (Kreutzer
et al., 2009).
The BIFI is founded upon well-researched thera-
peutic techniques, including family systems theory,
cognitive behavioral therapy (CBT), and collabora-
tive self-examination (Kreutzer et al., 2009). Family
systems theory suggests that healthy family function-
ing is achieved when each member of a family system
functions independently and also interacts positively
within the group (Gan, Campbell, Gemeinhardt, &
McFadden, 2006). In an assessment of family sys-
tem functioning following a member’s brain injury,
very few of the families studied engaged in normal
or healthy family functioning (Gan et al., 2006). An
in-depth analysis of unhealthy family functioning
revealed particular problems in the areas of prob-
lem solving and coping with new roles for family
members (Gan et al., 2006). The BIFI endeavors
to improve family functioning by addressing empa-
thy, respect, and validation within the family system
(Kreutzer et al., 2009).
547
Additionally, the BIFI applies CBT as a cata-
lyst for change. CBT assumes that cognition affects
behavior, and behavioral changes can be achieved
by changing cognition (Konnert, Dobson, & Stel-
mac, 2009). In a meta-analysis of 16 controlled
studies, CBT was found to be effective in reduc-
ing depression and anxiety symptoms long-term in
populations suffering from posttraumatic stress dis-
order, panic disorder, and adult unipolar depression
(Bulter, Chapman, Forman, & Beck, 2006). Depres-
sion and anxiety symptoms have been observed in
both survivors of TBI and their families (Fleminger,
Oliver, Williams, & Evans, 2010; Kreutzer et al.,
1994; Norup et al., 2012). Waldron, Casserly, and
O’Sullivan (2012) found a significant improvement
in using CBT to treat anxiety and depression for per-
sons who have an acquired brain injury. It is suggested
that guided self-talk helps clients with TBI manage
frustration and increase self-regulation of their moods
and emotions (Mateer, Sira, & O’Connell, 2005).
In the BIFI approach, CBT is used to implement
emotional reframing to better cope with negative
emotions and skill-training techniques to improve
problem solving and communication (Kreutzer et al.,
2009).
Implemented in conjunction with family systems
theory and CBT, the collaborative self-examination
technique developed by Kreutzer and Taylor (2004)
allows family members to express their feelings and
opinions about life events, and it encourages fam-
ily members to take the perspective of other family
members to promote understanding and communica-
tion within the family system (Kreutzer et al., 2009).
The technique was developed to help families cope
with the rapid changes the family system endures
following a TBI (Kreutzer et al., 2009).
To date, the BIFI has been associated with positive
outcomes for families and persons with TBI. Using
the Family Needs Questionnaire, developed to quan-
tify the perceived needs of families before and after
the BIFI (Serio, Kreutzer, & Witol, 1997), significant
gains were found in the areas of health informa-
tion, emotional support, professional support, and
involvement in care (Kreuzter et al., 2009). These
findings suggest that the BIFI met the needs of fam-
ily members and reduced perceived barriers to service
(Kreutzer et al., 2009). In a mixed methods inves-
tigation, researchers used the Learning Survey to
assess the attainability of each goal set forth in the
BIFI sessions (Kreutzer, Stejskal, Godwin, Powell, &
Arango-Lasprilla, 2010). Results revealed that both
families and persons with TBI found the interven-
548 C. Meixner et al. / Impact of the BIFI training on providers
tion sessions to be helpful and important (Kreutzer
et al., 2010). The results also suggest that the goals
set forth during the intervention were met (Kreutzer
et al., 2010).
2.3. Barriers to accessing services
Many survivors of TBI and their families do
not receive the therapies and services they require,
despite available interventions like the BIFI. This
situation is even more complex when persons with
TBI experience comorbid mental health concerns. To
better understand this phenomenon, Meixner et al.
(2013) conducted an explanatory mixed methods
study of service providers. In phase one of the study, a
survey questionnaire was distributed to 226 providers
with 110 respondents (49% response rate). Phase two
involved focus group interviews, designed to inves-
tigate further the findings from the first part of the
study.
The findings pointed to various, interrelated bar-
riers to services, among them the self, the family,
stigma, professional issues, training/education, sys-
tem resources, and funding (Meixner et al., 2013).
Relevant to this research study are two barriers – the
family, which is often stressed to “provide care and
gate keeping for a loved one who is in crisis” (p. 382)
and a dearth of training and education on brain injury
for rehabilitation providers. According to the survey
results, 58% of the respondents had never attended
a specialized training session on working with indi-
viduals with TBI and 52% of the providers surveyed
reported that they did not feel confident in their abil-
ities to work someone with a TBI (Meixner et al.,
2013).
While a multitude of research studies focus on
survivors of TBI and their families, no research to
date highlights the difficulties that providers may face
when working with this population. Absent appropri-
ate education and training, however, few providers are
confident in their work with survivors of brain injury
(Meixner et al., 2013). As studies do demonstrate the
efficacy of a comprehensive, interdisciplinary family
systems approach like the BIFI, it stands to rea-
son that training in this intervention could increase
confidence and, in turn, fulfill an integral need for sur-
vivors and their loved ones. The current study aims
to demonstrate that providing a structured three-day
training on the BIFI protocol will improve providers’
knowledge and confidence in working with persons
with TBI and their families, and that this outcome is
sustainable.
3. Methodology
The primary aim of this mixed methods study was
to investigate the short and long-term impact of the
BIFI training on providers’ knowledge and confi-
dence outcomes. Research questions were as follows:
(1) is there a difference in foundational knowledge of
brain injury (e.g., functional neuroanatomical issues,
neurobehavioral problems, impact on the survivor
and family system)? (2) Is there a difference in
confidence to conceptualize treatment models for
survivors and their families? (3) Does the BIFI train-
ing maintain its effectiveness over time? The study
was approved for human subjects by the Institutional
Review Board of the university within which the
researchers serve as faculty.
3.1. Participants
Participants included a convenience sample of
34 providers of therapeutic services (i.e., licensed
professional counselors, neuro/psychologists, social
workers, case workers) across a region defined as
rural by the Office of Rural Health Policy (HRSA,
2013). A prior study on this population (Meixner
et al., 2013) validated the need for provider train-
ing and education given two factors: an absence of
integrated services for persons with brain injury and
the small number of professionals who work routinely
with survivors and their families. Thus, the intensive,
expert-led training educated a self-selecting group
of providers on brain injury, also teaching them to
administer the BIFI protocol to survivors of brain
injury and their families. Inclusion criteria for admis-
sion into the training were as follows: individuals
must be employed at the time of training in a men-
tal health or health care position wherein therapeutic
services are provided to families or survivors of brain
injury.
3.2. Measures
A web-based evaluation instrument was developed
by a team of content and measurement experts to
measure and explore participants’ knowledge and
confidence related to the BIFI training objectives.
Each of the items, made explicit in the results section,
mapped to facets of the training curriculum and were
amenable to a dependent samples design. In addition,
open-ended responses were elicited to (1) provide
qualitative, explanatory support to the quantitative
measures and (2) explore participants’ perceptions
 C. Meixner et al. / Impact of the BIFI training on providers 549

of how what they learned would be applied to their
professional settings.
Participants were asked to complete the online
instrument at four time points: pre-training (T1),
one day post-training (T2), 90 days after the train-
ing program (T3), and two years post-training (T4).
Thirty-four (34) participants completed T1 and T2,
18 participants completed T3, and nine participants
completed T4. Given the longitudinal nature of the
study and the need to match participants over time,
attrition by T4 was anticipated. While 11 matched
cases were presented across T1, T2, and T3, only
three matched cases were presented across all four
points of data collection. Thus, data from T4 are
insufficient to merit discussion in this paper.
3.3. Data analysis
The quantitative data were analyzed using SPSS.
Wilcoxon signed-rank tests, a nonparametric alter-
native to the dependent samples T tests, were used
to determine whether there is a significant differ-
ence in the total ranks of two related groups across
items corresponding to participants’ understanding
and confidence. The researchers also conducted
a binomial test of the proportion of respondents
who increased in their knowledge of brain injury
(e.g., etiology, impact, etc.) across time. All
quantitative data are summarized in Table 1.
The qualitative data were transcribed and initially
coded by hand, then imported into NVIVO 10 for cod-
ing, aggregation, and analysis. Data were themed by
two members of the research team according to a
consensus procedure, which limits bias and assures
credibility of findings.
4. Results
Wilcoxon signed-rank tests compared two depen-
dent conditions. As an immediate result of BIFI
Table 1
Impact of BIFI training on confidence and knowledge over time
Confidence Domain:
Ability to conceptualize treatment models for survivors and their families
Knowledge Domains:
Foundational knowledge of brain injury
Understanding of how brain injury affects the family system
Understanding of how brain injury impacts survivors’ ability to maintain employment
Knowledge of areas most damaged by DAI
Knowledge of commonly reported neurobehavioral problems
Knowledge of commonly reported emotional reactions
Knowledge of theoretical models appropriate for working with families
Knowledge of the grading system for concussions
training, participants’ understanding of how brain
injury affects the family system was significantly
higher after the intervention than prior to the training
(z = –2.75, p < 0.01, r = –0.59). Participants’ under-
standing of how brain injury impacts survivors’
ability to maintain stable employment was also sig-
nificantly higher at T2 (z = –2.25, p < 0.05, r = –0.48).
Critically, participants were significantly more con-
fident in their abilities to conceptualize treatment
models for families (z = –2.89, p < 0.005, r = –0.61).
In comparing T2-T3, participants’ understanding of
how brain injury impacts family systems and sur-
vivors’ ability to maintain stable employment did not
change significantly in the period of 90 days fol-
lowing the training. Further, participants remained
confident in their ability to conceptualize treatment
models for families.
As an immediate result of BIFI training (T1-T2),
participants’ knowledge also increased significantly
as measured by binomial tests of proportions: the
areas of the brain most damaged by diffuse axonal
injury (p = 0.012), commonly reported neurobe-
havioral problems (p = 0.012), commonly reported
emotional reactions (p = 0.012), and theoretical mod-
els appropriate for working with families after brain
injury (p = 0.001). The following items did not sig-
nificantly change as an immediate result of the BIFI
training: foundational knowledge of brain injury
(p = 0.227) and knowledge of the grading system for
concussions (p = 0.065). When binomial tests of pro-
portions were conducted between T2-T3, findings
reveal that participants’ knowledge of brain injury
remains consistent, only decreasing significantly in
one area: participants’ knowledge of the commonly
reported emotional reactions of families living with
a survivor of brain injury (p = 0.012).
At T2 and T3, participants were asked to respond
to two open-ended items. The first elicited insight on
the three most important components of knowledge
participants gained from BIFI training. The second
T2-T1 T3-T2
T2>T1 T3 = T2
T2-T1 T3-T2
T2 = T1 T3 = T2
T2>T1 T3 = T2
T2>T1 T3 = T2
T2>T1 T3 = T2
T2>T1 T3 = T2
T2>T1 T3<T2
T2>T1 T3 = T2
T2 = T1 T3 = T2
550 C. Meixner et al. / Impact of the BIFI training on providers
queried respondents for the ways they intend to
or have applied their learning to practice. At T2,
the following categories emerged as integral: under-
standing and application of family systems (e.g.,
“learning ways to live with TBI patients and how
family dynamics change around situation”), informa-
tion on TBI diagnosis (e.g., “familiarity with Glasgow
Coma Scale, grades for concussions”), and general
treatment/intervention strategies (e.g., “integration
of family systems and CBT”). These areas were mir-
rored in the T3 qualitative findings.
At T2, participants provided a broad list of appli-
cations for the training: raising awareness (in self,
others, and clinical settings), providing resources
to families (psychoeducation), integrating CBT and
family systems therapy, involving family members in
treatment, and applying their learning to other popu-
lations. For those individuals at T3 who had worked
with persons with brain injury since the training, the
following themes were noted: increased ability to
work effectively with clients with TBI and developed
ability to normalize challenges faced by individuals
and their families. Those individuals who had not
worked in this milieu since T2 reported that they
had shared information with colleagues or supervi-
sors and still planned to apply their knowledge in the
future.
5. Limitations
Limitations subsist in non-experimental studies;
although a rigorous time series design was employed,
there was not a control group against which to compare
outcome data with those who engaged in the training.
Further, individuals who attended the three-day train-
ing may constitute a self-selecting group of providers
more motivated to work with survivors and their fami-
lies than others. A fidelity study was not conducted on
the training protocol itself, so it is plausible that lack of
change in certain domains is attributable to pedagogy
or content – not to the participants’ actual develop-
ment. Finally, a potential project limitation includes
whether these findings generalize beyond a rural, geo-
graphically disperse locus. Replication with a larger
and more diverse sample size is encouraged.
6. Discussion
Medical advances, particularly in the area of neu-
rotrauma, have led to decreased mortality rates for
survivors of brain injury. During the acute phase,
individuals with brain injury often endure coma,
craniotomy, and polytrauma before transitioning
into inpatient or outpatient rehabilitation hospitals.
Beyond the post-acute phase, however, the medi-
cal and therapeutic trajectory is often unknown or
highly varied across patients. Long-term, survivors
and their families need access to cost-effective, inte-
grative services that address ongoing symptoms and
sequelae – somatic, psychological, psychiatric, and
physical. Individual and family interventions with
attention to the idiosyncrasies of neurotrama – such
as that provided through the BIFI – are integral and
central.
Past studies quantify BIFI as an impactful,
evidence-based intervention for survivors and their
families. The findings of this study support the
effectiveness of the BIFI training program for reha-
bilitation providers who work with individuals with
brain injuries and their families. This study serves as a
first to demonstrate the benefit both for and from ser-
vice providers’ perspectives. Regardless of whether
rehabilitation providers implement the BIFI protocol,
the longitudinal positive outcomes of training and
reported participant confidence point to the impor-
tance of training and education. Providers are more
confident in their ability to conceptualize treatment
models for survivors of brain injury and their fam-
ilies. They also understand and retain the nuances
of brain injury – how it affects the brain and its
impact on families and survivors (e.g., employment,
neurobehavior, emotions). It is curious that knowl-
edge of the frequently reported emotional reactions
of families living with a survivor of brain injury
decreased when comparing T3 to T2 as heightened
sensitivity to the emotional aspects surrounding TBI
for affected families would be more the expecta-
tion. This finding may merit further investigation.
While the quantitative findings point to no change
in participants’ base knowledge of brain injury
and the grading system, the qualitative results sig-
nify great gains related to understanding the TBI
diagnosis.
An analysis of open-ended questions reveal
applications that benefit rehabilitation and neurore-
habilitation providers, especially those who plan
to integrate brain injury into curricula, courses,
and trainings. Pedagogically robust and well-aligned
trainings not only raise awareness of the self and
others in relation to brain injury, but they can also:
provoke ideas on resource integration, model meth-
ods of theoretical parsimony (e.g., CBI and family
systems), and contextualize ways to see survivors
 C. Meixner et al. / Impact of the BIFI training on providers
and their families as partners in a systemic process
of recovery.
Acknowledgments
The authors acknowledge the contributions of
Dr. Jeffrey S. Kreutzer and Dr. Emilie Godwin,
co-developers of Brain Injury Family Intervention
Therapy, Virginia Commonwealth University, Rich-
mond, VA, USA. The authors acknowledge the work
of Julia Teague, Department of Communication Sci-
ences and Disorders, James Madison University,
Harrisonburg, VA, USA.
Conflict of interest
There are no declarations of interest. That is,
no people or organizations have a financial interest
(direct or indirect) in this subject or study.
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