Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive Behavioral Therapy for Insomnia (CBT-I)

Exploring Your Life Goals

Exploring Your Life Goals


Meaningful goals can give direction to your life, highlight your most important values, and give a sense of purpose. This activity is designed to get you thinking about your short term and long-term goals in different areas of your life.
Sometimes, holding ourselves accountable and setting expectations generates fear and anxiety because it means there is potential for failure and disappointment.
But remember, failure is an event, not a person.
And it’s okay to have failed. Actually, it’s necessary…it provides us the opportunity to grow.
So, let’s formulate some goals!

General Tips for writing goals

When thinking about 5-year goals, ask yourself how you would like your life to look in 5 years.
Then, think of your 1-year, 1-month, and 1-week goals as steppingstones to that 5-year goal.
You’ll start more general with the 5-year goals. But as you write more short-term goals, they will become more specific and structured (the next tip explains what this means).
When writing weekly or monthly goals, be sure to write goals that are measurable. For example, instead of “eat healthier” make a goal of “eat a vegetable with every meal.” Instead of “get fit” make a goal of “exercising 3 days per week.”
Choose goals that are within your control. For example, “get a promotion at work” requires others to act. However, “take an additional online course to improve my professional skills” is in your control.
When planning each of your goals, it is important to also consider any foreseeable obstacles and potential strategies for overcoming them
Complete the exercise below. When complete, you will be able to download your responses. Do not refresh the page or exit the browser or your responses will be lost.


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Dialectical Behavioral Therapy (DBT)

Dialectical Behavioral Therapy (DBT) is a cognitive-behavioral treatment developed by Marsha Linehan, Ph.D., in the 1980s to help people who experience extremely intense emotions, catastrophic thinking, anxiety, stress, and “all or none” thinking (to name a few). These experiences are commonly, but not always, due to a history of trauma.

The “D” means “dialectical.” A dialectic is a synthesis or integration of opposites. A DBT-oriented therapist consistently works with an individual to find ways to hold two seemingly opposite perspectives at once, promoting balance and avoiding black and white (all-or-nothing) styles of thinking. In service of this balance, DBT promotes a “both-and” rather than an “either-or” outlook. The dialectic at the heart of DBT is acceptance and change.

Dialectical strategies help us get unstuck from extreme positions. They help us stay “in-balance” so we can reach our ultimate goals as quickly as possible. The Wise Mind illustrates this point (see below).

Dialectical behavior therapy (DBT) provides new skills to manage painful emotions and decrease conflict in relationships. DBT specifically focuses on providing skills in four key areas.

(1) Mindfulness: Mindfulness focuses on improving one’s ability to accept the present moment without judgment. 

(2) Distress Tolerance: Distress tolerance is geared toward increasing one’s tolerance of negative emotions, rather than avoiding them.

(3) Emotion regulation: Emotion regulation covers strategies to manage and change intense emotions that are causing problems in one’s life.

(4) Interpersonal effectiveness: Interpersonal effectiveness consists of techniques that allow one to communicate with others in a way that is assertive, maintains self-respect, and strengthens relationships.

Using a DBT approach, a therapist guides a client or patient through the process of acceptance and change by validating and accepting the individual as he or she is.  A DBT therapist appreciates that too much focus on change results in the individual feeling misunderstood and invalidated. Working with people with extreme emotional sensitivity requires careful attention to the balance between acceptance and change. It also requires an assessment of personal boundaries

DBT was originally developed to relieve the emotional sensitivity experienced by individuals with borderline personality disorder. However, research shows that DBT has also been used successfully to help people suffering from depression, bulimia, binge-eating, bipolar disorder, post-traumatic-stress disorder, abandonment/attachment problems, and substance abuse. 


How to maintain a healthy work-life balance to prevent burnout

What is Work Burnout?

Work burnout is considered a type of work-related stress characterized by feelings of reduced accomplishment and loss of personal identity. Work burnout is not a medical diagnosis, but the stress associated with work burnout can be detrimental to your mental and physical health.

Research suggests that individual factors, such as personality traits and family life, influence who experiences work burnout. Let’s consider how to know if you are suffering from work burnout and what you can do to relieve the suffering. 

What are common signs and symptoms of work burnout?

  • Becoming cynical or critical at work

  • Dragging yourself to work and having trouble getting started

  • Irritability or impatience with co-workers, customers or clients

  • Fatigue

  • Difficulty concentrating 

  • Lacking satisfaction from your achievements

  • Using food, drugs or alcohol to feel better or to void negative feelings

  • Sleep problems

  • Unexplained headaches, stomach or bowel problems, or other physical complaints

If any of the above symptoms resonate with you then consider whether you’re suffering from work burnout. It is always recommended to talk with your healthcare provider because these symptoms can also be related to health problems such as depression.

Who is at risk of developing work burnout?

Although anyone can develop work burnout, those who have a heavy workload, work long hours, have little control over their work, or work in a helping profession (e.g., health care workers, emergency medical personnel, firefighters, law enforcement officers, lawyers) are at increased risk of developing burnout. 

What are some consequences of work burnout?

Work burnout can have significant consequences, including:

  • Excessive stress
  • Fatigue
  • Insomnia
  • Sadness, anger or irritability
  • Alcohol or substance use disorders
  • Heart disease
  • High blood pressure
  • Type II diabetes
  • Vulnerability to medical problems, including infections

What are some strategies for managing work burnout?

Admit and accept that you’re struggling with work burnout. Recognizing the signs and symptoms of burnout and whether they are negatively impacting your life is first (and most important) step!

Discuss specific concerns with a supervisor (if possible). Perhaps you can reassess expectations and develop solutions together. 

Prioritize daily tasks (more on this later).

Seek support. Whether you reach out to co-workers, friends or loved ones, support and collaboration might help you cope. If you have access to an employee assistance program, take advantage of relevant services.

Engage in one or more stress-reducing activities for at least 20 minutes each day. This may include yoga, meditation, tai chi, martial arts, mindfulness exercises, boxing, weight training, cross-fit, running, swimming, other aerobic exercise, sports, creative writing, painting, drawing, listening to music, playing an instrument, or reading for pleasure. 

Get quality sleep. We spend about a third of our lives sleeping. Sleep allows our body to reset. Interestingly, sleep is important for our memory, our immune system, and our ability to regulate our emotions.

Healthy diet. Junk food is comforting, but it doesn’t help your cause. Having the occasional “cheat meal” is important, but limit those sweets and saturated fats as much as possible. A high protein, high fiber, moderate fat, and low carbohydrate diet can improve your energy levels, concentration, memory, and mood!

Set healthy work-life boundaries. Setting healthy work-life boundaries will not only improve your mental health but prevent burnout and promote more effective and efficient work!

Let’s discuss healthy boundaries in a bit more detail…


Boundaries are the rules we set for ourselves in our relationships, our work, and our personal lives. 

Healthy boundaries mean preventing others from projecting beliefs, judgements, or expectations onto you. Many people will use “I don’t have time” as the reason for not taking care of their own needs. If you can’t make time for yourself, then what you are really saying is “my needs don’t matter.” If you don’t respect your own needs, then you certainly can’t expect others to. Putting others’ needs before your own will eventually stir up feelings of resentment, anger, and overwhelming fatigue.

A person with healthy boundaries can say “no” when needed without allowing the fear of disappointment to overpower their personal needs.

Remember, if someone feels disappointed or let down because you said “no” and took care of yourself, then you probably needed firmer boundaries anyway. 

Tips for setting healthy boundaries at work.

Take an honest look at your self-care habits. The first step in setting healthier boundaries is to honestly assess your self-care practices. Use this tool to assess your self-care habits.

Prioritize your values. Boundaries should be based on your beliefs and values–the things that are important to you. These may or may not align with others–and that is okay! Take time to make a list of what’s important to you in life. Each day, make time in your schedule for the things you value most. Use this tool to explore your values.

Create a flexible schedule that includes activities that align with your values. This does not mean scheduling every minute or hour of your day. You don’t want to become a prisoner of your schedule, so a basic flexible outline works best. In making this schedule, set times for checking your email and phone. One of the biggest mistakes people make is obsessively checking their email and phone. Obsessive checking is anxiety-provoking and inefficient–it disrupts your focus and is unnecessary. Use the auto-respond function to inform those who email you of when you check your email. You can also instruct people to call you directly if it is urgent.

Let Smartphones Be Smartphones. When you need to focus on completing a task, silence your phone and place it facedown next to you. If answering phone calls is important for your work, place your phone on vibrate and keep it in your pocket. When not working, set a time to put your phone on silent in a drawer or somewhere out of view for at least 30 minutes. By doing this, you’ll learn that you DO NOT need to have your phone on you at all times. 

Take a break from your computer. Your computer should only be used for work during work hours. When the workday is over, shut down your computer and put it away. If you need to use the computer for personal use, then use it for personal use ONLY. Some people find it helpful to have two devices – one for work and one for play. But this may not be possible.

Consistency is key. Try your best to remain consistent with your schedule!  Try not to get down on yourself if you struggle at first to be consistent. Simply recognize when you’re deviating from the plan and make adjustments to get back on track.

Use technology to help, rather than hurt, your boundaries. Many smartphones have reminder functions. Try setting reminders for when to take breaks, check emails, spend time with family, or exercise. There are many apps out there that can help with prioritizing your daily tasks as well!

Share your boundaries with others. It is important to share your boundaries with family, friends, co-workers, and supervisor(s). Ask your friends and family to keep an eye on your behaviors so they can point out when you might need to make some adjustments. Inform your co-workers and supervisor(s) so they can provide input and suggestions. While it is important to maintain healthy boundaries, it is also important to know how to compromise. That being said, compromising does not mean tossing your boundaries like a hot potato.

Take a moment to check in with yourself prior to doing work-related activities during non-work hours. Whenever you have the urge to work during non-work hours, make a habit of asking yourself whether the activity is in line with your values and priorities. How important, on a scale from 1-10, is it that you complete this RIGHT NOW? Anything 6 or below can wait.

Begin and end each day with anything but work. It is essential to begin and end your day with something positive. Something you enjoy. If the first thing you do each morning is check your email and the last thing you do is check your email, then you are setting yourself up for burnout. Do not let the first and last activity of each day be something work-related. 

Exercise for Couples

Relationships require work. They require patience, humility, sacrifice, empathy, and compromise. But here’s the thing…healthy relationships are only possible when we have a healthy relationship with ourselves.
Afterall, how can we expect to maintain healthy relationships with others if we don’t maintain a healthy relationship with ourselves?
So, before blaming the problems in our relationships on others, we need to stop and ask ourselves this question:
Do I genuinely love myself?
If not (or you aren’t sure) then you have some individual work to do.
Relationships are like tending to a garden. We have to make time for them, sacrifice for them, and nurture them if we want them to thrive. 
This exercise was designed to help couples connect with each other–to remind each other of the reasons they fell in love in the first place. But remember, it takes two to tango.
So, allow yourself to be vulnerable, to be open to suggestions, and to be an empathic listener. And remember, you can’t expect to cultivate a healthy relationship with someone else if your authentic, vulnerable self doesn’t show up to the table.

Medication Algorithms for Mental Disorders

Medication Algorithms For Mental Disorders

These algorithms are from the Psychopharmacology Algorithms Project at the Harvard South Shore Psychiatry Residency Training Program

Project Leader: David Osser, MD

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Medication List

Pregnancy & Postpartum

Alternative Treatments

Neuromodulation & Ketamine

How do medications interact to cause side effects?

Medications can “interact” in a variety of ways

Here are the most common types of drug-drug interactions (this is not a comprehensive list)

Displacement from transport proteins

Many medications travel in the bloodstream attached to proteins called “transport proteins.” Some medications/drugs might remove or “kick off” a medication from its transport protein.

Altering the activity of metabolic enzymes

Recall that enzymes are like “Pac-Man” that break down (or metabolize) drugs and medications. Some medications alter the activity of the enzymes that metabolize other medications and drugs. If an enzyme’s activity is increased, then the medication metabolized by that enzyme may be metabolized or broken down too quickly. This results in decreased blood levels of the medication which may decrease the medication’s effectiveness. If an enzyme’s activity is decreased, then the medication metabolized by that enzyme may be metabolized or broken down too slowly. This results in increased blood levels of the medication which might cause side effects and toxicity.

Competing for receptors

Some medications might compete with other medications at the same receptor. 

Altering the function of organs like the kidneys, intestines, and liver

Some medications can alter the body’s ability to eliminate drugs and medications. This can occur when one medication alters the functioning of the kidneys, intestines, and/or liver.

Below are the most common drug-drug interactions to be aware of when taking psychotropic medications (i.e., medications used to treat mental disorders)

Valproic acid (VPA, Depakote) + Lamotrigine (Lamictal)

  • Valproic acid (VPA) increases lamotrigine levels by decreasing lamotrigine metabolism
  • Increased lamotrigine levels increase the risk of developing a severe rash
  • Increased lamotrigine levels increase the risk of Steven-Johnson’s Syndrome (SJS/TEN)
  • When taking both valproic acid (Depakote) and lamotrigine (Lamictal), the general recommendation is to decrease the dose of lamotrigine by 50%

Carbamazepine (CBZ) is an inducer of CYP3A4

  • CBZ induces its own metabolism by increasing the activity of the CYP3A4 enzyme
  • CBZ also induces the metabolism of other medications that are metabolized by CYP3A4 such as oral contraceptives, clozapine, alprazolam, buspirone, and clonazepam

Lithium levels are INCREASED when combined with the following

  • Non-Steroid Anti-inflammatory Drugs (NSAIDs), except aspirin
  • Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)
  • Thiazide diuretics such as hydrochlorothiazide
  • Low sodium diets

Lithium levels are DECREASED when combined with the following

  • Caffeine
  • Theophylline
  • High sodium diets

Grapefruit Juice

  • Grapefruit juice is a potent inhibitor of CYP3A4 and P-glycoprotein (another protein that helps eliminate drugs)
  • Therefore, grapefruit juice increases blood levels of many medications metabolized by CYP3A4

Smoking Tobacco cigarettes

  • The hydrocarbons in the smoke of tobacco cigarettes, but not nicotine, increase the activity of CYP1A2 enzymes
  • Smoking cigarettes decreases blood levels of medications metabolized by CYP1A2 such as Olanzapine, Clozapine, and Caffeine

Tyramine + Monoamine Oxidase Inhibitors (MAOIs)

  • Tyramine (TIE-ruh-meen) is an amino acid that occurs naturally in the body and aids in regulating blood pressure. Elevated tyramine levels can lead to dangerously elevated blood pressures.
  • Tyramine is also found in certain foods such as banana peel, beer, fava beans, aged cheese, sauerkraut, sausage, soy sauce, and concentrated yeast extract.
  • An enzyme called monoamine oxidase (MAO) breaks down excess tyramine in the body. Monoamine oxidase inhibitors (MAOIs) are used to treat depression.
  • If taking a monoamine oxidase inhibitor, it is important to avoid certain foods high in tyramine.

Monoamine Oxidase Inhibitors (MAOIs)

  • Monoamine oxidase (MAO) is an enzyme that breaks down monoamines such as serotonin, dopamine and norepinephrine. Therefore, monoamine oxidase inhibitors (MAOIs), such as selegiline and phenelzine, are used to treat depression.
  • Combining MAOIs with Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic Antidepressants (TCAs), Pseudoephedrine, and Stimulants increases the risk of serotonin toxicity and dangerously high blood pressures

Fluoxetine, Paroxetine, and Bupropion are potent inhibitors of CYP2D6 

  • Drugs like fluoxetine, paroxetine, and bupropion inhibit CYP2D6 enzymes and increase blood levels of other medications metabolized by CYP2D6.
  • Fluoxetine, paroxetine, and bupropion decrease the effectiveness of Tamoxifen and Codeine because Tamoxifen and Codeine require CYP2D6 activity to be effective. 

Antimicrobial-Psychotropic Drug Interactions

  • Antimalarials increase levels of phenothiazines such as chlorpromazine (Thorazine)
  • Azoles increase levels of alprazolam, midazolam, and buspirone
  • Clarithromycin and Erythromycin increase levels of alprazolam, midazolam, carbamazepine, clozapine, and buspirone
  • Quinolones increase levels of clozapine and benzodiazepines (but decreases the effects of benzodiazepines)
  • Isoniazid increases levels of haloperidol and carbamazepine. Isoniazid + disulfiram can cause problems with motor coordination (called ataxia)
  • Isoniazid and Linezolid are weak inhibitors of monoamine oxidase (MAO) and therefore increases the risk of serotonin syndrome and hypertensive emergencies if used with serotonergic drugs (like SSRIs, SNRIs, and TCAs)

Erythromycin, Clarithromycin, and Ketoconazole + Tricyclic Antidepressants or antipsychotics

  • Combining Erythromycin, Clarithromycin, or Ketoconazole with Tricyclic Antidepressants or antipsychotics increases the risk of QT prolongation and cardiac (ventricular) arrythmias

Drug-Drug Interaction Tables


A 2-minute exercise to relieve anxiety and stress


Try this mindfulness exercise whenever you’re feeling anxious or stressed

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