How Close is Too Close?: This Is Not About Social Distancing

No matter where or how folks are existing during COVID-19, there is no question that potentially triggering challenges may arise. The collective is thinking about having enough, getting needs met, the future, and the indefinite uncertainties around these things. With so much unknown and out of individuals’ control, what is certain is that today many people are spending time quarantined either alone or with others and have to cope with their environments somehow.

 Now, more than ever, is a time for considering relationships. This could look like reaching out to old friends and building community through electronic communication or perhaps taking measures to navigate being “stuck” in one place with the same people or person day after day. Perhaps some people are taking the time to go off the grid and focus on the relationship with themselves. Maybe some folks are encountering a mixture of these and other relational nuances. Regardless of what the exact circumstances are, it is true that navigating relationships at this time may take some extra care and creativity. 

Although we won’t be covering best practices for physical distance during COVID-19, we will be breaching the topic of boundaries in relationships. Not far off, right? The Cambridge English Dictionary  has several definitions for the term “boundary” that can create frameworks for how we look at relational boundaries. The first is, “a real or imagined line that marks the edge or limit of something.” The edge could be a personal edge or limit. In this thinking for example, a boundary might mark where my personal experience ends and someone else’s experience begins. The second definition is, “the limit of what someone considers to be acceptable behavior.” Here, a boundary could dictate my orientation around another person’s actions; ie: what can I tolerate? It is true that everyone has different experiences and levels of awareness concerning the content and function of relational boundaries and that we as humans are constantly navigating these nuances as they arise in our relationships. 

One view of boundary negotiation is demonstrated in the challenge of enmeshment within relationships. During the systems theory renaissance of the 1960s and 1970s in the U.S., Salvador Minuchin, pioneer of structural family therapy, coined the term “enmeshment” to describe family systems in which personal boundaries are diffuse, absent, or ill-defined (Dorfman, 1998; 2015). When a family is enmeshed, expectations to adhere to spoken or unspoken rules concerning beliefs, values, emotions, and life experiences hinder the family members from developing functional autonomous selves. Members learn to self-regulate based upon the needs of other family members or the family as a whole rather than on personal needs (Paul, 2019)

A consequence of enmeshment-informed regulation is the sense that, “I am only ok when this/these relationship(s) are ok.” While this form of regulation appears to keep the family system “intact,” it does not support the evolution of individuals as separate from their families. While the term “enmeshment” was developed in the context of understanding families, it can actually occur in any relationship (Paul, 2019). Although the qualities of enmeshment can describe a breadth of relational contexts, it is also important to remember that the concept originated in a Westernized lens supporting the philosophy of individualism. As a result, this area of study sees limitation around cultures that operate under collectivistic, rather than individualistic, value systems (Barrera, Blumer, & Soenksen, 2011).

While everyone will consider boundaries differently according to their own unique life experiences and cultural contexts, it could be helpful to think of relational boundaries as systems that allow individuals to feel the most resourced in the contexts of their relationships. For instance, the term boundary can connote a meaning that puts the focus on the outside, ie: keeping something or some behavior out of my space. While this is not an unhelpful connotation, another way to look at a boundary is exploring what the imaginary line is keeping inside. This internal view of boundaries lends opportunities for an individual to create boundaries based upon self-knowledge and exploration rather than reactions to outside circumstances. Given that a person’s internal experience can shift from moment to moment, boundaries that serve the function of inward resourcing can be fluid and change to best serve the dynamic needs that result from changing internal states. 

Grappling with boundaries in personal and work relationships circa COVID-19? Here at TPN.Health we are here to support our clinical community and remind you that you are not alone here. You can gain access to all of our online resources–digital CEUs, clinical discussion panels, AND a trusted referral network–when you create a TPN.Health clinical profile. Click here to get started.


Barrera, A. M., Blumer, M. L. C., & Soenksen, S. H. (2011). Revisiting adolescent separation-individuation in the contexts of enmeshment and allocentrism. PsycEXTRA Dataset. doi: 10.1037/e741452011-008

BOUNDARY: definition in the Cambridge English Dictionary. (n.d.). Retrieved from

Dorfman, R. A. H. (1998). Paradigms of clinical social work. New York: Brunner Mazel.

Enmeshment. (2015, August 19). Retrieved from, J. (2019, November 26). Signs that You May Be in an Enmeshed Relationship. Retrieved from

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STDs: Physical, Psychological, and Social

Sexually transmitted diseases (STDs), while physical in nature, incorporate a breadth of social and psychological contributing factors and consequences. In recent years, sexually transmitted diseases in the United States are more common than ever with reported cases reaching a record high at 2,457,188 cases in 2018 (2019). No one who is sexually active is exempt from STD susceptibility, but some groups, such as women, young adults, youth, people of color (POC), men who have sex with men (MSM), and incarcerated people, have a particularly high-risk for contracting STDs (2010). 

With a growing number of reported cases of STDs, developing prevention measures is paramount. However prevention and treatment of STDs undergo a variety of barriers. Some of these barriers involve policy, such as recent budget restrictions on state and local STD programs. However, many of the obstacles to both treatment and prevention are more complex, such as pervasive shame and stigma, comorbidity with other mental health issues, and population-specific challenges such as equity and access. 

Shame is defined as the negative opinion of oneself that results when failing to live up to a perceived standard, while stigma refers to a discriminatory label resulting from a link between a group of people and a set of unpleasant characteristics (Fortenberry, et al., 2002). One report on the relationship between shame, stigma, and STDs notes that shame is often referred to as an internalization of stigma (Fortenberry, et al., 2002). Studies show that MSM are especially vulnerable to homophobic stigma, and youth/young adults are vulnerable to shame and embarrassment as barriers to STD prevention (2010). With marginalized groups, it is also suggested that a ‘layered stigma’ effect can occur (Morris, et al., 2014).

A 2014 study examining the effects of STDs on quality of life in women revealed that women in the sample experienced feeling “dirty,” decreased self esteem, fear, anger, shame, and sexual undesirability (Passanisi, Leanza, & Leanza, 2014). Likewise, STD studies show high comorbidity rates with mental health and substance use issues among specific populations, namely incarcerated populations, as these specific comorbidities can facilitate STD transmission (2019).

Research on STDs demonstrates not only the physical but the poignant social and psychological implications for individuals and communities. Although some barriers to treatment and prevention can seem easy to pinpoint and resolve, it is largely the complex social and psychological implications that contribute to the challenges of societal attitudes and action around addressing STDs.

Looking to refer out for a specialization in sexuality or other focus issue? TPN.Health has got you covered. Click here to create your clinical profile and start connecting to a trusted referral network. 


Fortenberry, J. D., Mcfarlane, M., Bleakley, A., Bull, S., Fishbein, M., Grimley, D. M., … Stoner, B. P. (2002). Relationships of Stigma and Shame to Gonorrhea and HIV Screening. American Journal of Public Health, 92(3), 378–381. doi: 10.2105/ajph.92.3.378

The Impact of STDs in Different Populations. (2010, August 4). Retrieved from

Morris, J. L., Lippman, S. A., Philip, S., Bernstein, K., Neilands, T. B., & Lightfoot, M. (2014, September). Sexually transmitted infection related stigma and shame among African American male youth: implications for testing practices, partner notification, and treatment. Retrieved from

Passanisi, A., Leanza, V., & Leanza, G. (2014, March 19). The impact of sexually transmitted diseases on quality of life: application of three validated measures. Retrieved from

STDs Continue to Rise in the U.S. Press Release. (2019, October 8). Retrieved from

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What We Know and Room to Grow: Sexual Violence in the U.S.

In honor of Sexual Assault Awareness Month, TPN.Health is sharing the some of the realities around sexual violence in the United States.

According to the National Sexual Violence Resource Center (NSVRC), sexual violence includes rape, sexual assault, incest, sexual harassment, unwanted sexual touch or contact, masturbating in public spaces, exposing sexual body parts and sharing sexual images without consent, sexual exploitation, sex trafficking, and non-consensual voyeurism.

Sexual violence affects all communities and excludes no demographics. 

In 2015, the CDC’s National Intimate Partner and Sexual Violence Survey (NISVS) reported that, in their lifetimes, 43.6 percent of women and 28.4 percent of men experienced sexual violence involving contact. Twenty percent of women and approximately 2.6 percent of men experienced attempted or completed rape. 

The Rape, Abuse, and Incest National Network (RAINN) reports that people ages 18-34, ranking the highest in sexual assault rate, occupy fifty-four percent of sexual assault victims. Twenty-eight percent of victims are ages 35-64, fifteen percent are ages 12-17, and three percent are over age 65.

RAINN reports that transgender, genderqueer, and gender non-conforming (TGQN) college students have greater risk of being sexually assaulted than non-TGQN college students. Compared to four percent of non-TGQN male students and eighteen percent of non-TGQN female students, twenty-one percent of TGQN college students have been sexually assaulted.

Compared to all races included in sexual violence data, Native Americans are twice as likely to experience rape or sexual assault in their lifetime, according to RAINN reports. 

Sexual violence can occur in any relational context.

In 2015, NISVS reported that, in their lifetimes 18.3 percent of women and 8.2 percent of men experienced sexual violence involving contact in the context of an intimate partnership.

According to the National Coalition of Anti-Violence Projects (NCAVP), it is estimated that almost ten percent of intimate partner violence (IPV) survivors identifying as LGBTQ have has experienced sexual assault in those partnerships (Human Rights Campaign).

RAINN reports that approximately thirty-four percent of childhood sexual abuse cases involve incest.

RAINN reports that in prisons, a majority (sixty percent) of inmate sexual violence cases occur with prison staff members as perpetrators .

“Sexual assault is likely the most underreported crime in the United States.” —Jessica Henderson Daniel, PhD, President of the American Psychological Association (2018)

According to RAINN criminal justice reports, only 25% of sexual assault cases are actually reported. The data collected on sexual violence from 2005-2010 illustrates a variety of reasons why the victim did not report to the police. The top three reasons were that the victim feared retaliation (20%), believed that officials would not take any action to help (13%), and believed it was a personal matter (13%). Likewise, it is important to remember data-collection on sexual violence is subject to limitations of individual collection methods, such as the measure of self-report.

In honoring Sexual Assault Awareness Month, it is paramount to keep in mind the voices and stories that historically have been excluded from conversations and/or data collection on sexual violence because of limited narratives that have historically guided attitudes on sexual violence. For instance, it was not until the 1980s that state laws begin to recognize that males cold be victims of rape. Likewise, for most of the of the nation’s history, sodomy laws, the last of which was abolished in 2003, were the only context to examine sexual violence in same-sex interactions (Richards & Marcum, 2015). Sodomy laws, criminalizing a breadth of sexual acts including oral sex and anal sex even in heterosexual interactions, were discriminatory of the LGBTQ community by nature (Richards & Marcum, 2015). 

Given the the pattern of exclusion regarding the LGBTQ community’s participation in public sexual violence dialogue, data on this community’s trends in sexual violence is limited and subject to the unique inconsistency of having no standardized data-collection measure (Richards & Marcum, 2015). Although in recent years the CDC’s NISVS has included data outlining sexual violence trends among those identifying as lesbian, gay, and bisexual, the body of research on sexual violence in the LGBTQ community has a long way to go. 

The historic ostracism of the LGBTQ community in the United States is just one example of a variety of population subsets that have been alienated from the sexual health dialogue-at-large, specifically that of sexual violence. The gendered, ableist, classist, and racist constructs that have placed limitations on sexual violence studies are deeply rooted in our history and, by degrees, are being addressed in the public sphere. Still, we have room only for progress.

Need to refer out for a specialization in sexual trauma, LGBTQ, or other specific focus area? Get started here to create your TPN.Health clinical profile and find the best clinical fit for your next referral.


About Sexual Assault. (n.d.). Retrieved from

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Female Victims of Sexual Violence, 1994-2010 (2013).

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2010-2016 (2017)

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Sex Offenses and Offenders (1997); ii. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Crimes Against the Elderly, 2003-2013 (2014).

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Sexual Assault of Young Children as Reported to Law Enforcement (2000).

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Sexual Victimization in Prisons and Jails Reported by Inmates, 2011-2012 (2013).

Human Rights Campaign. (n.d.). Sexual Assault and the LGBTQ Community. Retrieved from

Incest. (n.d.). Retrieved from

Richards, T. N., & Marcum, C. D. (2015). Sexual victimization: then and now. Thousand Oaks, CA: Sage.

Smith, S.G., Zhang, X., Basile, K.C., Merrick, M.T., Wang, J., Kresnow, M., Chen, J. (2018). The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief – Updated Release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention

Statement of APA President Regarding the Science Behind Why Women May Not Report Sexual Assault (2018, September 24). Retrieved from

Victims of Sexual Violence: Statistics. (n.d.). Retrieved from

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From Saying “No” to Asking “How?”: Changing Priorities in COVID-19

TPN.Health member Angela James, LPC, like many behavioral health professionals, wears several hats. In addition to consulting and practicing privately, she serves as Assistant Director of the Accessibility Center at Tulane University in New Orleans, LA. Years of experience working in disability services in higher education and a social justice lens inform Angela’s passion for creating solutions for people with a range of abilities and access needs.

“I have always been the ‘possibilities girl’.” -Angela James, LPC

Having worked for Tulane in the past, Angela entered the position this go-round with an open mind, which has served to help her orient to the changes as well as the similarities from when she worked there in prior years. She feels fortunate to be part of such a well-oiled work environment where the transition to fully remote online operations, given the COVID-19 climate, has been relatively seamless.  

“We are seeing opportunities to approach accessibility proactively versus reactively.” -Angela James, LPC

In Angela’s perspective, the world of accessibility services, in higher education and as a whole, is seeing a great shift in this climate. Now, because of the conditions with which we are all faced, access-challenges affect everyone, not just a subset of the population. Prior to COVID-19, Angela reflects that the biggest challenge in the accessibility realm was finding ways to eliminate institutional barriers. Now, the organizations and institutions where people work and learn, by necessity, are shattering some of these barriers preventing accessibility just to keep basic operations running.

“If we don’t address these barriers, none of the students can learn. None of the staff can work. So the barriers I have been advocating to diminish are now crumbling in some ways because the broader public has to reckon with them.” -Angela James, LPC

So, what does this mean for the future  of accessibility services in higher education? In the behavioral health field? In other professions or institutions of learning? It is Angela’s view that the collective’s approach to accessibility is fundamentally changing, now that people know the potential for solutions with available technology and are actively making those solutions a reality. No longer are these solutions centered around retrofits for a small group. Rather, the whole population is in consideration. She notes, “I think those shifts will be very meaningful for individuals who were always told, ‘This isn’t possible.’ Now we know what’s possible, so get ready.”

With the hope of a collective shift toward solutions in accessibility, now is also a time for deliberate and thoughtful considerations at the individual level. For Angela, who has never done online counseling prior to COVID-19, this means continued education and growth in the use of technology such as Telehealth. Likewise, it is an opportunity to attend to the small details, such as lighting, payment options, and delay time which contribute a great deal to a client’s experience on digital platforms.

At TPN.Health, we take seriously the needs of our behavioral health community, especially during this time. Want to have unlimited access to quality online CEUs and the opportunity to build your digital referral network? Click here to create your TPN.Health profile to get started!

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Celebrating National Autism Awareness Month

Here at TPN.Health, we are celebrating National Autism Awareness Month throughout the whole month of April, 2020. We celebrate those whom autism spectrum disorder (ASD) affects as well as the committed behavioral health practitioners, researchers, and teachers who specialize in the realm of ASD.

ASD is classified as a set of developmental disorders ranging in severity and symptoms and resulting from a variety of genetic and environmental factors. These include Kanner’ syndrome, Aspbergers’ syndrome, and pervasive developmental disorder not otherwise specified (PDD-NOS). It was only in 2013 that the definition of autism broadened to include those neighboring developmental disabilities in a spectrum format. 

Symptoms of ASD can include but are not limited to repetitive patterns of behaviors and interests, delayed development in childhood, difficulty adapting to change, and challenges in relating to other people verbally and nonverbally. ASD can also include tendencies toward truth-telling (even when it is not in one’s best interest), a preference for structure, and the ability to focus on one area of interest for a long period of time. Once again, these symptoms are by no means an exhaustive list, and each individual on the autism spectrum is unique with their own set of challenges and strengths.

Did you know…

Males are four times more likely to be diagnosed with autism than females.

Some studies suggest that females, who are considered “high-functioning” on the autism spectrum, are likely to conceal their symptoms and potentially go undiagnosed as a result. Also known as ‘camouflaging,’ the effort to conceal symptoms can surface as persistent mimicry of neurotypical behaviors, such as forcing oneself to make eye contact or rehearsing lines to say in conversation. Camouflaging can also surface as efforts to suppress Stereotypy, the repetitious behaviors associated with ASD symptoms. However, studies on camouflaging are limited, and more research in the field is needed to draw any conclusions.

From 1911 to 1943, Autism was associated with symptoms of schizophrenia. 

Eugen Bleuler, an influential Swiss psychiatrist, used “autos,” the Greek word for “self,” to create the term “autism.” He used the term to classify symptoms of self-absorption that he saw in schizophrenic patients. It wasn’t until 1943 that Austian-American psychiatrist Leo Kanner distinguished Autism from schizophrenia and defined it as a separate socio-emotional disorder.

Before the behavioral health community knew about the genetic component of autism, it was theorized that parental apathy brought on autism.

This belief took hold after Bruno Bettelheim, Austrian-American psychiatrist and early writer on autism, coined the term “Refrigerator Mother” in the 1950s to describe research on the relationship between delayed  childhood development and parental emotional neglect. With the popularization of this term, it became a common belief that parents with a cold, uncaring attitude toward their children were responsible for “causing” autism. It wasn’t until the late 1970s that researchers discovered the genetic component to autism. 

Need to refer out for a client who has symptoms of ASD? Click here to create a TPN.Health profile, and use the filter-search to find the best clinical fit!


Asperger Profiles: The Big Picture – Strengths. (2016, September 21). Retrieved from

Correcting the record: Leo Kanner and the broad autism phenotype. (2018, April 5). Retrieved from

Osborn, C. O. K. (2019, March 8). Understanding Autism in Women. Retrieved from

Strengths and abilities in autism. (2018, September 17). Retrieved from

The costs of camouflaging autism. (2020, February 7). Retrieved from

The Editors of Encyclopaedia Britannica. (2020, February 6). Autism spectrum disorder. Retrieved from

What is Autism Spectrum Disorder? (2019, September 23). Retrieved from

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Historical Figures in Behavioral Health: Springtime Edition

Happy Spring! A season of new growth, planting, and preparing for abundance awaits us. It is a good time to remember the work of those who planted seeds and tilled the soil in the field of behavioral health. So, to kick off the month, TPN.Health is recognizing a few April-born historical figures who have cultivated the field of behavioral health through their significant contributions in research, teaching, and activism. 

Abraham Maslow, PhD: April 1st, 1908 – June 8th, 1970

Arguably Maslow’s most well-known contribution to the field of behavioral health was his “Hierarchy of Needs,” which sprang from observations in his early work with monkeys. Rooted in human motivational studies, Maslow’s Hierarchy of Needs is arranged in five levels with basic needs at the bottom, psychological needs in the middle, and self fulfillment needs at the top. 

Having originally pursued philosophy and behaviorism (a prominent force in psychology at the time), he did not begin his work studying human motivation until the humbling experience raising a family during the collective upheaval of World War II prompted him to do so. Deviating greatly from the thought leaders of his time, who framed the human being in machine-like terms of reductionism, Maslow’s work in humanism, encompassing self-actualization and human motivation, served to integrate “personhood” into the field. His research laid the groundwork for developments in the field of personality psychology, which ultimately grew to shape the orientation of the behavioral health field as we know it today. 

Dorthea Dix, Mental Health Reformer: April 4th, 1802 – July 17, 1887

A teacher by trade, Dix’s journey in social reform began while teaching Sunday school at a women’s prison in Massachusetts. Immediately, she noticed the horrific conditions and particularly cruel treatment of those with mental health issues. Subsequently devoting her life to the reform of prisons, poorhouses, and mental institutions for better treatment of their inhabitants, Dix went on to lobby at the national and international levels. In the U.S. her efforts resulted in a federal grant for public land to be used in service of those with mental illness, a grant which President Franklin Pierce unfortunately vetoed several years after issuance. In Europe, Dix’s report to Pope Pius IX on the incongruity of public and private health facilities brought on the construction of a hospital, which was to benefit those with mental health issues.

Mamie Phipps Clark, PhD: April 18, 1917 – August 11, 1983

Clark was an active researcher, practitioner, and force in social activism in her time. Even up against the walls of sexism and racism in mid-twentieth-century America, Clark pioneered studies of the effects of internalized racism in black children in her master’s thesis and was the first African American woman to obtain her PhD in psychology from Columbia University. Her thesis contributed to structures underlying the field of developmental psychology and was instrumental in the creation of the first mass-produced doll with African-American representation.

In her time working at a private home for the refuge of young black females in New York, she noticed a serious deficit in mental health services for black children as well as rampant mis-diagnoses of the individuals in the facility. Upon the refusal of governing bodies to provide adequate services after Clark and her husband, Kenneth Clark, presented this issue, the Clarks elected to open what is now called the Northside Center for Child Development, which was the first institution to offer full-time psychological and social services to families in Harlem. Likewise, serving on a number of committees and advisory boards throughout her life, Clark maintained active involvement in her community and testified as an expert witness in the 1954 Brown vs. Board of Education case as well as other school desegregation cases.  

Three claps for these trailblazers in behavioral health history! Today, you can create a TPN.Health clinical profile to begin reaping the benefits of a trackable referral network and a trusted clinical community–all at your fingertips.

Click here to get started.


Boeree, C. G. (n.d.). Retrieved from

Clark, Mamie Katherine Phipps. (n.d.). Retrieved from

Dorothea Dix. (2019, April 12). Retrieved from

Mamie Phipps Clark, PhD, and Kenneth Clark, PhD. (n.d.). Retrieved from

Wood, A. G. (2000, February). Dix, Dorothea Lynde (1802-1887), social reformer. Retrieved from

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