Nursing Journal Article Report and Critique Example

Article Report and Critique

Journal Article: BITTEN at the Bedside: An Application Guide for Nurse Practitioners
Authors: Chrystal L. Lewis, Emma C. Lathan, Candice N. Selwyn, Gabrielle A. Agnew, Sean D. McCabe, Margaret E. Gigler, Jennifer Langhinrichsen-Rohling – https://doi.org/10.1016/j.nurpra.2020.12.006

Introduction

Healthcare encounters are fundamentally shaped by patients’ previous experiences within the medical system, yet healthcare providers often lack systematic frameworks for assessing and responding to these historical influences. As nursing students preparing to enter clinical practice, understanding how past medical trauma affects current patient care is essential for providing compassionate, effective treatment. Lewis et al. (2021) address this critical gap in their article “BITTEN at the Bedside: An Application Guide for Nurse Practitioners,” published in The Journal for Nurse Practitioners. The authors introduce the BITTEN theoretical framework as a tool for implementing trauma-informed care in clinical practice.

This analysis examines Lewis et al.’s (2021) presentation of the BITTEN framework, evaluating both the conceptual contributions and methodological limitations of their approach. While the framework offers valuable guidance for recognizing healthcare-related trauma and fills a genuine gap in practical clinical tools, significant limitations in research methodology, the absence of empirical validation, and the lack of systematic evaluation restrict its immediate clinical applicability. The purpose of this critique is to assess the framework’s potential contribution to nursing practice while identifying critical areas requiring further development and rigorous research validation before widespread implementation.

Here’s how to write an Article Critique in APA Format

Summary

Research Purpose and Theoretical Foundation

The primary purpose of Lewis et al.’s (2021) article is to introduce and demonstrate the practical application of the BITTEN theoretical framework within routine nurse practitioner encounters. The BITTEN model represents a comprehensive acronym encompassing six key assessment domains: Betrayal history by health-related institutions; Indicator for health care engagement; Trauma symptoms related to health care; Trust in health care providers; Expectation of patient; and Needs of patient (Lewis et al., 2021). The authors position this framework as a patient-centered approach designed to help healthcare providers systematically recognize and respond to patients’ previous negative medical experiences while actively working to prevent retraumatization during current and future healthcare encounters.

Bitten Model Explained

The theoretical foundation of BITTEN builds upon established trauma-informed care principles, acknowledging that patients with complex medical conditions often accumulate multiple negative or traumatic experiences throughout their diagnostic and treatment journeys (Lewis et al., 2021). These experiences may include repeated dismissal of symptoms, misunderstanding by healthcare providers, invasive medical procedures without adequate explanation, prolonged diagnostic delays, and systemic barriers that contribute to institutional betrayal. The framework specifically addresses the heightened vulnerability of patients with stigmatized conditions, such as fibromyalgia, chronic fatigue syndrome, or mental health disorders, who face increased risk of dismissal and inadequate care due to provider bias and systemic discrimination.

Methodology and Research Approach

Rather than presenting empirical research findings based on systematic data collection and analysis, Lewis et al. (2021) employ a descriptive case study methodology to demonstrate the practical application of the BITTEN framework. The authors utilize a composite case study based on clinical experience, featuring a hypothetical patient with fibromyalgia who has experienced a prolonged diagnostic journey characterized by multiple negative healthcare encounters spanning several years and multiple healthcare providers. The selection of fibromyalgia as the exemplar condition was deliberate, given the well-documented stigma associated with this diagnosis and the increased likelihood of institutional betrayal experienced by patients with this condition (Lewis et al., 2021).

The case study methodology allows the authors to illustrate each component of the BITTEN framework systematically, demonstrating how nurse practitioners can integrate these assessment domains into routine clinical encounters. The approach includes step-by-step guidance for implementing each assessment component, potential conversation starters for sensitive topics, and strategies for building therapeutic relationships with patients who have experienced healthcare trauma. However, this approach lacks the empirical rigor typically expected in nursing research, as it does not include systematic data collection, statistical analysis, control groups, or validation of the framework’s effectiveness through measurable patient outcomes.

Framework Components and Clinical Application

The BITTEN model operationalizes trauma-informed care through six interconnected assessment domains that can be systematically integrated into standard clinical encounters. The Betrayal component focuses on identifying patients’ experiences of institutional betrayal, including dismissal of symptoms by healthcare providers, inadequate pain management or treatment delays, insurance denials or coverage limitations, and systemic barriers to accessing appropriate care (Lewis et al., 2021). This domain requires providers to actively listen for indicators of past negative experiences and validate patients’ feelings of betrayal or mistrust.

The Indicator domain examines behavioral and emotional cues that suggest past healthcare trauma, such as hypervigilance during examinations, excessive apologizing for seeking care, reluctance to engage with providers, physical tension or guarding behaviors, and expressions of hopelessness about treatment effectiveness (Lewis et al., 2021). The Trauma component specifically assesses symptoms related to healthcare experiences, including medical PTSD symptoms, avoidance behaviors related to medical settings, physiological responses to medical procedures, and emotional distress triggered by healthcare encounters.

Trust assessment constitutes a critical component, evaluating patients’ current confidence levels in healthcare providers and systems, their willingness to share sensitive information, and their expectations about provider responsiveness and competence (Lewis et al., 2021). The Expectation domain explores patients’ anticipated outcomes from healthcare encounters, which may be influenced by previous disappointments, negative experiences, or unrealistic hopes for immediate solutions. Finally, the Needs component addresses both immediate healthcare requirements and broader psychosocial needs that may have developed as a result of past healthcare trauma, including needs for validation, control, predictability, and emotional support.

Key Findings and Authors’ Conclusions

Through their detailed case study application, Lewis et al. (2021) demonstrate that systematic implementation of the BITTEN framework can potentially enhance provider awareness of patient vulnerability and improve care delivery for individuals with complex medical histories. They argue that nurse practitioners are ideally positioned to implement this approach given their holistic training, emphasis on patient-centered care, extended appointment times, and focus on therapeutic relationships. The framework provides specific guidance for recognizing trauma indicators, validating patient experiences, and developing responsive care plans that acknowledge and address previous negative experiences while promoting healing and trust.

The authors conclude that increased awareness of institutional betrayal risk and trauma history can significantly improve healthcare providers’ understanding of patient needs and expectations, potentially leading to better therapeutic relationships, improved patient satisfaction, and enhanced care outcomes (Lewis et al., 2021). They emphasize that while their case study focused specifically on fibromyalgia, the BITTEN framework has broad applicability across various medical conditions and patient populations, particularly those who have experienced systemic healthcare disparities, stigmatization, or marginalization. The authors suggest that implementation of this framework could reduce patient retraumatization, improve provider-patient communication, and enhance overall quality of care for vulnerable populations.

Critical Analysis

Comprehensive Methodological Evaluation

Fundamental Study Design Limitations

The most significant and problematic limitation of Lewis et al.’s (2021) article lies in its fundamentally flawed methodological approach. While the authors present BITTEN as a theoretical framework worthy of immediate clinical implementation, they provide absolutely no empirical evidence supporting its effectiveness, validity, reliability, or safety. As nursing students learning to evaluate research quality and evidence-based practice principles, this represents a critical flaw that severely undermines the framework’s credibility and clinical applicability. The complete reliance on a single hypothetical case study, while useful for illustration purposes, cannot substitute for rigorous evaluation of the framework’s impact on patient outcomes, provider satisfaction, implementation feasibility, or healthcare delivery quality.

The descriptive case study methodology, though appropriate for demonstrating practical application and theoretical concepts, lacks the scientific rigor necessary to establish the framework’s clinical utility, effectiveness, or safety. According to Polit and Beck (2021), effective nursing interventions require systematic evaluation through well-designed studies that can demonstrate both efficacy and safety before widespread adoption. The absence of pilot testing, preliminary validation studies, systematic outcome evaluation, or any form of empirical assessment severely limits the scientific credibility of Lewis et al.’s (2021) recommendations for clinical implementation.

Critical Sampling and Generalizability Concerns

The composite nature of the presented case, while protecting patient confidentiality, raises serious questions about the authenticity, representativeness, and generalizability of the scenarios described (Lewis et al., 2021). The authors provide no information about how the composite case was developed, what clinical experiences informed its creation, whether it represents typical patient experiences, how many actual patients contributed to the composite, or how it might generalize to broader patient populations with different demographics, cultural backgrounds, or clinical presentations.

This limitation is particularly concerning given nursing’s emphasis on evidence-based practice and the need for interventions that can be applied safely and effectively across diverse patient populations. The exclusive focus on fibromyalgia patients, while appropriate for demonstrating the framework’s application to stigmatized conditions, severely limits understanding of how BITTEN might work with other patient populations, different age groups, various cultural backgrounds, or alternative clinical presentations. Nursing practice requires interventions that have been validated across various clinical situations, patient demographics, and healthcare settings.

Absence of Data Collection and Analysis Methods

Lewis et al. (2021) provide no systematic approach to data collection, analysis, or evaluation, which represents a fundamental gap from a nursing research perspective. The article lacks critical information about the development process for the BITTEN framework, including whether it was derived from systematic literature review, expert consensus methods, empirical observation of patient-provider interactions, or evidence-based analysis of existing trauma-informed care approaches. This significant gap makes it extremely difficult to assess the framework’s theoretical foundation, scientific validity, or potential for successful implementation.

Furthermore, the authors provide no discussion of how the framework’s effectiveness might be measured, what outcome indicators would be appropriate, how implementation barriers might be identified and addressed, or what training and resources would be required for successful adoption. These omissions represent serious methodological flaws that limit the framework’s practical applicability in evidence-based nursing practice.

Ethical Considerations and IRB Approval

A particularly concerning omission in Lewis et al.’s (2021) work is the complete absence of discussion regarding ethical considerations in framework development and implementation. The authors provide no information about institutional review board (IRB) approval for framework development, ethical review of the systematic inquiry into patient trauma history, or consideration of potential harm that might result from systematic trauma assessment without proper safeguards. Given that the framework explicitly involves probing into patients’ past traumatic experiences, the lack of ethical oversight and safety protocols represents a significant concern for patient safety and professional responsibility.

The systematic inquiry into trauma history, while potentially beneficial, carries inherent risks of retraumatization, emotional distress, or psychological harm, particularly for vulnerable patients with complex trauma histories. The absence of ethical guidelines, safety protocols, or harm mitigation strategies represents a serious oversight that could impact patient well-being and provider liability.

Comprehensive Content Quality Assessment

Literature Integration Strengths and Limitations

Despite significant methodological limitations, Lewis et al. (2021) demonstrate reasonably strong integration of existing literature on institutional betrayal, medical trauma, and trauma-informed care principles. Their recognition of the particular vulnerability of patients with stigmatized conditions reflects sophisticated understanding of healthcare disparities, systemic bias, and structural inequities that align with nursing’s commitment to social justice and advocacy for vulnerable populations. The authors effectively connect their framework to established concepts in trauma theory, healthcare quality research, and patient-centered care literature.

However, the literature integration suffers from several important limitations. The authors fail to provide comprehensive comparison with existing trauma-informed care frameworks, missing opportunities to position BITTEN within the broader landscape of trauma-informed interventions. They do not adequately discuss alternative approaches to healthcare trauma assessment, limiting readers’ understanding of how BITTEN compares to other available tools and frameworks. Additionally, the authors provide insufficient discussion of implementation science literature that could inform successful adoption and sustainability of the framework in clinical practice.

Assessment of Theoretical Contribution and Innovation

The BITTEN framework addresses a genuine and important gap in clinical practice by providing structured, systematic guidance for assessing and responding to healthcare-related trauma. From a nursing perspective, this systematic approach to evaluating betrayal history, trauma indicators, and trust levels provides much-needed structure for what might otherwise be intuitive but inconsistent clinical responses to patient vulnerability. The framework’s emphasis on preventing retraumatization rather than simply treating existing trauma represents an important paradigm shift toward preventive approaches in healthcare delivery that aligns well with nursing’s health promotion philosophy.

The systematic organization of assessment domains offers practitioners concrete, actionable tools for implementation, moving beyond general trauma-informed care principles to specific assessment strategies and intervention approaches. This practical orientation represents a valuable contribution to the trauma-informed care literature, which often lacks concrete implementation guidance for busy clinical environments.

However, the theoretical presentation suffers from several significant limitations that restrict its contribution to nursing knowledge. Lewis et al. (2021) provide insufficient discussion of potential implementation barriers, resource requirements, training needs, or organizational changes required for successful adoption. The framework’s complexity and comprehensive assessment requirements may pose significant challenges for busy clinical environments with time constraints, high patient volumes, and competing priorities, yet the authors offer limited guidance for addressing these practical implementation concerns.

Evaluation of Clinical Significance and Practice Implications

The framework’s potential clinical significance lies in its systematic approach to addressing healthcare trauma, which represents a growing concern in healthcare quality and patient safety literature. The structured assessment domains could potentially improve patient-provider relationships, enhance care quality for vulnerable populations, and reduce healthcare-related retraumatization. These potential benefits align closely with nursing’s core values and commitment to holistic, patient-centered care.

However, the clinical significance remains theoretical due to the absence of empirical validation. Without systematic evaluation of patient outcomes, provider satisfaction, implementation feasibility, or cost-effectiveness, the framework’s actual clinical value remains unknown. This limitation is particularly problematic given healthcare’s increasing emphasis on evidence-based practice and value-based care models that require demonstrated effectiveness and measurable outcomes.

Comprehensive Strengths and Weaknesses Analysis

Significant Framework Strengths

Systematic Approach to Complex Assessment: The BITTEN framework provides a comprehensive, organized approach to assessing multiple dimensions of healthcare trauma that have traditionally been addressed in an ad hoc manner. The six-domain structure ensures systematic evaluation of critical factors affecting patient care while providing clear guidance for provider assessment and intervention (Lewis et al., 2021).

Alignment with Nursing Philosophy: The framework’s holistic, patient-centered approach aligns exceptionally well with nursing’s fundamental philosophy and scope of practice. The emphasis on therapeutic relationships, patient advocacy, and comprehensive assessment reflects core nursing values and competencies that distinguish nursing care from other healthcare disciplines.

Practical Clinical Applicability: Unlike many theoretical frameworks that remain abstract, BITTEN provides concrete, actionable assessment strategies that can be readily integrated into clinical practice. The clear assessment domains and specific indicators offer practical guidance for busy healthcare providers seeking to implement trauma-informed care principles.

Focus on Prevention: The framework’s emphasis on preventing retraumatization rather than simply responding to existing trauma represents an important paradigm shift that aligns with healthcare’s growing focus on prevention and harm reduction. This proactive approach could potentially improve patient experiences and outcomes while reducing healthcare-related trauma.

Recognition of Vulnerable Populations: The framework specifically addresses the needs of stigmatized patient populations who face increased risk of healthcare discrimination and inadequate care. This focus on health equity and social justice reflects nursing’s commitment to serving vulnerable and marginalized communities.

Interprofessional Applicability: While developed for nurse practitioners, the framework’s principles and assessment domains could potentially be adapted for use by various healthcare professionals, enhancing interprofessional collaboration and consistency in trauma-informed care approaches.

Critical Framework Weaknesses

Complete Absence of Empirical Validation: The most significant weakness is the total lack of empirical evidence supporting the framework’s effectiveness, safety, or validity. Without systematic evaluation, healthcare providers cannot determine whether BITTEN actually improves patient outcomes or might inadvertently cause harm through systematic trauma inquiry.

Inadequate Implementation Guidance: The framework lacks comprehensive guidance for implementation, including resource requirements, training needs, organizational support, time allocation, and integration with existing clinical workflows. These omissions limit practical applicability in real-world healthcare settings.

Potential for Retraumatization: Systematic inquiry into trauma history carries inherent risks of triggering emotional distress or retraumatization, yet the authors provide minimal guidance for recognizing, preventing, or managing such situations. This represents a significant patient safety concern.

Limited Scope of Validation: The framework has been illustrated only through a single composite case involving fibromyalgia, providing no evidence for effectiveness across diverse patient populations, clinical settings, or healthcare conditions.

Absence of Outcome Measures: The authors provide no guidance for measuring framework effectiveness, patient outcomes, or implementation success, limiting ability to evaluate or improve the intervention over time.

Insufficient Comparison with Alternatives: The framework is presented without adequate comparison to existing trauma-informed care approaches, making it difficult to assess its relative advantages or determine when it might be preferred over alternative interventions.

Evidence-Based Analysis and Alternative Frameworks

Comparison with Existing Trauma-Informed Care Approaches

The nursing literature includes several established trauma-informed care frameworks that provide important context for evaluating BITTEN’s contribution. The Substance Abuse and Mental Health Services Administration (SAMHSA) trauma-informed care principles include safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and cultural, historical, and gender issues (SAMHSA, 2014). While BITTEN incorporates some of these principles, particularly trust and safety, it lacks explicit attention to peer support, empowerment, and cultural considerations.

Harris and Fallot’s (2001) trauma-informed care model emphasizes organizational assessment and change, staff training, consumer involvement, and trauma screening and assessment. BITTEN focuses primarily on individual patient assessment without addressing organizational factors, staff preparation, or systematic implementation strategies that research suggests are critical for successful trauma-informed care adoption.

The ARC (Attachment, Regulation, and Competency) framework provides a comprehensive approach to trauma-informed care that addresses attachment relationships, emotional regulation, and developmental competencies (Blaustein & Kinniburgh, 2010). While developed primarily for children, ARC’s systematic attention to relationship building and emotional regulation offers insights that could enhance BITTEN’s approach to trust assessment and therapeutic relationship development.

Assessment of Innovation and Contribution

BITTEN’s primary innovation lies in its specific focus on healthcare-related trauma and institutional betrayal, which distinguishes it from more general trauma-informed care approaches. The framework’s systematic attention to healthcare-specific trauma indicators and the emphasis on preventing retraumatization during medical encounters represent a valuable contribution to trauma-informed care literature.

However, the innovation is limited by the lack of empirical validation and comparison with existing approaches. Without systematic evaluation, it remains unclear whether BITTEN offers significant advantages over established trauma-informed care frameworks or represents merely a repackaging of existing principles without added value.

Implementation Feasibility and Resource Requirements

Organizational and System-Level Considerations

Successful implementation of the BITTEN framework would require significant organizational commitment and resources that Lewis et al. (2021) fail to adequately address. Healthcare organizations would need to invest in staff training, workflow modifications, documentation system changes, and ongoing supervision and support for providers implementing the framework. The authors provide no guidance for organizational assessment, change management, or sustainability planning that implementation science research suggests are critical for the successful adoption of new clinical interventions.

The framework’s comprehensive assessment requirements may conflict with productivity expectations, time constraints, and billing requirements in many healthcare settings. Without addressing these practical barriers, the framework’s real-world applicability remains questionable, regardless of its theoretical merit.

Training and Competency Development Needs

Implementation of BITTEN would require healthcare providers to develop competencies in trauma recognition, therapeutic communication, crisis intervention, and safety planning that many providers may not currently possess. The authors provide no discussion of training requirements, competency assessment, or ongoing professional development needs that would be essential for safe and effective implementation.

Additionally, providers would need education about institutional betrayal, healthcare trauma, and the specific needs of stigmatized patient populations. This educational component represents a significant resource investment that healthcare organizations would need to plan and budget appropriately.

Patient Safety and Risk Management Considerations

Potential for Unintended Harm

While trauma-informed care is generally considered beneficial, systematic inquiry into trauma history carries inherent risks that Lewis et al. (2021) inadequately address. Patients may experience emotional distress, retraumatization, or psychological decompensation when asked detailed questions about past healthcare trauma, particularly if providers lack appropriate training in trauma-sensitive communication and crisis intervention.

The framework’s emphasis on systematic assessment could potentially create situations where providers feel obligated to pursue trauma inquiry even when patients are not ready or willing to discuss such experiences. Without clear guidelines for recognizing patient readiness, respecting boundaries, and managing distress, the framework could inadvertently cause harm to the vulnerable populations it aims to help.

Legal and Ethical Implications

Systematic trauma assessment raises important legal and ethical questions about informed consent, documentation requirements, confidentiality protections, and mandatory reporting obligations that the authors do not address. Healthcare providers implementing BITTEN would need clear guidance about how to handle disclosures of abuse, neglect, or other traumatic experiences that might trigger legal reporting requirements.

Additionally, documentation of trauma history raises questions about patient privacy, access to sensitive information by other providers, and potential for discrimination or stigmatization based on documented trauma experiences. These considerations require careful attention to policy development and staff training that Lewis et al. (2021) do not discuss.

Conclusion

Lewis et al.’s (2021) presentation of the BITTEN framework represents an ambitious and well-intentioned attempt to operationalize trauma-informed care principles within routine clinical practice. The framework addresses a genuine and important gap in healthcare delivery by providing systematic guidance for recognizing and responding to healthcare-related trauma, particularly for vulnerable patients with stigmatized conditions who face increased risk of institutional betrayal and inadequate care.

From a theoretical perspective, the BITTEN framework offers several valuable contributions to nursing knowledge and practice. The comprehensive assessment domains provide structure for addressing complex psychosocial factors that significantly impact patient health and healthcare experiences. The framework’s emphasis on preventing retraumatization rather than simply responding to existing trauma represents an important paradigm shift toward preventive approaches that align well with nursing’s health promotion philosophy. Additionally, the framework’s systematic approach to building trust and therapeutic relationships reflects nursing’s fundamental commitment to patient-centered, holistic care.

However, the article’s profound methodological limitations significantly constrain its scientific impact and clinical applicability. The complete absence of empirical validation, lack of systematic evaluation, and reliance on a single hypothetical case study represent fundamental flaws that prevent confident recommendations for clinical implementation. As nursing students committed to evidence-based practice, we must recognize that innovative frameworks, regardless of their theoretical appeal or intuitive logic, require rigorous evaluation to ensure patient safety and demonstrate effectiveness before widespread adoption.

The authors’ failure to address critical implementation considerations, including resource requirements, training needs, organizational support, patient safety protocols, and ethical guidelines, further limits the framework’s practical applicability. Healthcare organizations considering BITTEN adoption would face significant challenges in developing appropriate implementation strategies without adequate guidance from the framework’s developers.

For the nursing profession, this article highlights both the potential for nurses to lead trauma-informed care initiatives and the critical importance of maintaining rigorous scientific standards when developing and evaluating clinical interventions. While the BITTEN model shows promise as a tool for improving care for vulnerable patients, its adoption should be contingent upon systematic evaluation and continuous refinement based on empirical evidence and clinical experience.

Future research priorities should include rigorous pilot studies examining the framework’s implementation feasibility, safety, and preliminary effectiveness across diverse patient populations and healthcare settings. Validation studies comparing BITTEN to existing trauma-informed care approaches would help establish its relative effectiveness and identify optimal applications. Additionally, development and evaluation of comprehensive training protocols, implementation guidelines, and outcome measurement tools would be essential for supporting safe and effective adoption in clinical practice.

As nursing students preparing to enter professional practice, this analysis reinforces several critical lessons about evidence-based practice and clinical innovation. First, we must maintain healthy skepticism about new interventions, regardless of their theoretical appeal, until adequate empirical evidence supports their safety and effectiveness. Second, we must recognize that successful clinical innovation requires not only good ideas but also rigorous evaluation, systematic implementation planning, and ongoing refinement based on evidence and experience. Finally, we must appreciate that our professional responsibility to patients requires that we support promising innovations while demanding the highest standards of scientific rigor to ensure patient safety and optimal outcomes.

The BITTEN framework, despite its limitations, represents an important contribution to ongoing discussions about trauma-informed care and healthcare quality improvement. As future nurses, we have opportunities to contribute to the framework’s development and evaluation while maintaining our commitment to evidence-based practice and patient safety. Through careful research, thoughtful implementation, and systematic evaluation, frameworks like BITTEN may eventually contribute to improved care for vulnerable patients who have experienced healthcare trauma and institutional betrayal.

References

Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. Guilford Press.

Harris, M., & Fallot, R. D. (2001). Using trauma theory to design service systems. New Directions for Mental Health Services, 89, 3-14. https://doi.org/10.1002/yd.23320018903

Lewis, C. L., Lathan, E. C., Selwyn, C. N., Agnew, G. A., McCabe, S. D., Gigler, M. E., & Langhinrichsen-Rohling, J. (2021). BITTEN at the bedside: An application guide for nurse practitioners. The Journal for Nurse Practitioners, 17(6), 675-679. https://doi.org/10.1016/j.nurpra.2020.12.006

Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer.

Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services: Treatment improvement protocol (TIP) series no. 57 (HHS Publication No. SMA 14-4816). U.S. Department of Health and Human Services.