Psychiatrist Explores Possible Benefits Of Treating PTSD With Ecstasy Or Cannabis

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. We've talked before on FRESH AIR about how psychedelic drugs - including LSD, psilocybin, MDMA and marijuana - are being used experimentally in clinic settings to treat mental health issues. My guest, Dr. Julie Holland, is one of the psychiatrists involved with that research. She is a medical monitor on studies testing the use of cannabis and MDMA on post-traumatic stress disorder. These are studies being sponsored by the Multidisciplinary Association for Psychedelic Studies - known by the acronym MAPS - which is also involved with developing psychedelics into prescription medication.

Holland is a psychiatrist specializing in psychopharmacology. She has a private practice in Manhattan. From 1996 to 2005, she was in charge of Bellevue Hospital's psychiatric emergency room on weekends. Her new book is called "Good Chemistry: The Science Of Connection, From Soul To Psychedelics." Part of her book is about dealing with anxiety, a timely subject, for sure, which we'll get to a little later.

Dr. Julie Holland, welcome back to FRESH AIR. Why are you interested in using psychedelics for therapy?

JULIE HOLLAND: Well, quite a few things here. There are certain plant medicines in particular - things like psilocybin or ayahuasca - that really help people not only explore their personal trauma and maybe do a little bit of debriefing and coming to terms with their traumas, but also there's often this feeling of unity and connection, connectedness and oneness, that can be very powerful and, potentially, transformative. People really come away from these experiences having a new perspective that everything is connected and interconnected, and that they are part of that interconnectedness. And that can be not only good for your psychology but also your physiology, your body. So that's the main issue.

But for MDMA-assisted psychotherapy in particular, it's just a perfectly designed drug to be a catalyst to allow psychotherapy to go deeper and be more efficient and more effective, basically. So you know, good psychotherapy takes years. And there's a lot of fits and starts. And people run away when things get too heavy. So to have something akin to anesthesia during surgery that allows people to be more open and vulnerable and also feeling strong enough and calm enough that they can really explore their traumas, that's incredibly helpful for the field of psychiatry. And we've never had anything like this before.

GROSS: Your specialty is psychopharmacology, which means using medications to treat mental health issues. Have you been disappointed in the current crop of drugs to treat things like PTSD and depression, anxiety?

HOLLAND: Absolutely, no question. And, you know, I have to say that the crop is pretty old, first of all. The antidepressants, you know, we haven't had a lot of innovation in antidepressants in a long time. And, you know, people got on these medicines, and then they never got off. And a lot of people are taking antidepressants for decades. And they really weren't designed to be used that way. So that's sort of a No. 1 issue.

But things are absolutely changing, where people are having a better understanding that it's not as simple as just, you know, altered chemistry or altered genetics, that your childhood experiences and trauma and things like income inequality - there's all sorts of things that have an impact on what your mental health is going to be. And a big part of it is processing trauma.

So a lot of these - the daily doses of antidepressants, anti-anxiety medicines, sleeping pills, antipsychotics, they're really - they're not there to help the primary problem. They're there to sort of, you know, seal up the cracks and act as Band-Aids. And whereas psychedelic-assisted psychotherapy is really trying to get to the root cause of the symptoms instead of just sort of papering over the symptoms.

GROSS: I know you have concerns about the widespread use of antidepressants, about their side effects, about the difficulty of going off them, about how a lot of doctors who prescribe them aren't actually psychiatrists. But do you see benefits with antidepressants in a lot of your patients?

HOLLAND: Yes, absolutely. And you're - I should make that more clear. I mean, this is something that - my main job is that I prescribe antidepressants and anti-anxiety medicines and sleeping pills and, sometimes, mood stabilizers, antipsychotics. There are medicines that work very well. My patients are doing very well. And they're taking these medicines. So I don't want to completely disparage it. It's just, for some people, it's not really what they need. It's not appropriate. But for other people, they need to stay on their meds. And it's very dangerous to go off their medicines.

So I don't mean to imply that everybody should throw their pills away at all. But I do think, for people who have been on just antidepressants for decades that it is worth exploring whether there aren't other ways that, maybe, you can treat some of the symptoms and maybe get at some of the underlying causes of the symptoms. You know, I don't want to throw the baby out with the bathwater. But there really - there are some people who absolutely need medicines. And, yes, these medicines do give them benefit. But they really weren't designed to be taken for decades on end.

GROSS: Both of the studies that you're monitoring now are working with patients who have post-traumatic stress disorder. Why was PTSD chosen as the subject for these experiments with cannabis and with MDMA?

HOLLAND: Well, there are a few reasons. I mean, the anecdotal data was very strong for both of these medicines that they help people with PTSD, and also that the current treatments that are available are grossly inadequate for treating PTSD. They're all about just covering up symptoms and not really getting to the root cause of any of the symptoms. So this is sort of a new paradigm, a revolutionary way to treat trauma, where you're not just sort - you know, the symptoms - when people are traumatized, they get very anxious. They get sort of hyper-aroused. They can't sleep well. They can't eat well.

And, you know, you can give medicines to decrease anxiety or medications to help with sleep. But you're not really getting to the root cause, which is that they've been traumatized. And they need to further process the trauma and work through the trauma. Sometimes, it gets sort of trapped in your body. And you're very sort of physically agitated.

But if you can have very deep psychotherapy to address the trauma and to arrive at some sort of a place of equanimity or peace and acceptance that this trauma did happen and that you have to fully integrate it - you know, people tend to sort of splinter off the parts of themselves that got hurt. And they end up less and less integrated. So part of oneness and connection is just being one with yourself and connected with yourself.

GROSS: So how controversial is the use of cannabis or MDMA or micro-doses of LSD or psilocybin? How controversial is that in the larger psychiatric field?

HOLLAND: In a word, very, I would say, still. You know, I mean, maybe it's not quite the third rail it used to be. But it's still absolutely not very mainstream or widespread in its acceptance. But it's changing more and more. You know, the medical journals - like Nature, Lancet or Scientific American, American Journal of Psychiatry - like, major, foundational medical journals are printing this research, though, because it is so well-done.

And the data is so compelling that, in my opinion, people in my profession have no excuse for not knowing what's going on, but they don't. They don't know what's going on. Or they consider that it's still very fringy. But it is becoming more mainstream and accepted every day, more and more.

GROSS: So let's talk about cannabis and PTSD and this is one of the studies that you're monitoring. How is cannabis used in PTSD therapy? It's not like you're giving them weed to smoke, right?

HOLLAND: Well, actually, this particular study which is done - it's actually closed now. But what we were doing is we were looking at different strains of smoked cannabis, whether it was high THC or high CBD or a third choice, which was a balance, a one-to-one of these two cannabinoids. We were just looking at how that had an impact on various symptoms of PTSD.

GROSS: And why don't you explain the difference between the CBD and the THC?

HOLLAND: So, you know, the main psychoactive component of cannabis is THC, and this is the one that most people have heard of, and that is the one that sort of gets you high or makes you feel intoxicated. For many people, that might be relaxing. But for some people, it's not relaxing; it's sort of agitating. But the second-most-popular chemical in the cannabis plant is CBD, which is cannabidiol. So it's not intoxicating, but it is psychoactive in that it can help quite a bit with anxiety. It can help with insomnia. And it can help people sort of achieve, like, a calm focus. So I don't say that it's not psychoactive, which is what some people say. But I will say that it's nonintoxicating.

GROSS: And it doesn't get you high.

HOLLAND: It doesn't get you high. But for post-traumatic stress disorder - you know, the way to think about it is that it's like somebody's sort of stuck in fight or flight. And because they're stuck in fight or flight and they're very anxious and they can't sleep and it's sort of kill or be killed, there's a certain level of paranoia. You're either sort of antagonizing people or you have a very short fuse. You're fighting with people. Or you're running away and you're avoiding things. So that's all fight or flight.

And what CBD does and cannabis does and some psychedelics do and MDMA does is it puts you over into the other side of the nervous system, which is the parasympathetic nervous system, which is not about fight or flight; it is about staying and being open, and it's about resting and digesting, and it's also the only time where the body can repair itself. So being in parasympathetic is really important for our sort of healthy physiology. And being stressed, as most of us are now with COVID-19, a lot of us are sort of much more in the sympathetic fight-or-flight state than we typically would be.

So - and, also, we're being traumatized. So, you know, as a nation, as a globe, you know, many of us are afraid, and there's a higher level of trauma for many of us than there's ever been. So more of us are in fight or flight. And cannabis helps to get you over into the parasympathetic state, rest and digest. It's also - Brene Brown has called it tend and befriend because it's a place where you can make social connections better. You know, if you're trying to put out a fire in your kitchen, you don't pick up the phone and call your neighbor (laughter), you know. You're like, there's no time for chitchat.

So when you're in fight or flight, we - because this kill-or-be-killed, we're not there to make friends, we're not very trusting, we're more paranoid. So some of these medicines help to get you out of fight or flight and over to the other side, parasympathetic side.

GROSS: Your study is using three different versions - all CBD, all THC and a combination of the two. Why are you doing it that way?

HOLLAND: Well, because we wanted to figure out which component really made a difference with PTSD. Like, some people are using CBD to treat their PTSD, and some people are using cannabis or high-THC cannabis. And so we wanted to get a sense of what really worked for what symptoms. And what I have to tell you, the sort of sad news here, is that the study was completed; unfortunately, we didn't have very robust findings, and the main reason why we didn't is because the quality of the available study drug was very poor.

GROSS: I'm sure some of the patients in the cannabis study smoke weed at home. So what's the difference for them between smoking weed at home and participating in the study where they're getting different doses of different aspects of marijuana?

HOLLAND: So first of all, if they were cannabis users, they had to taper off and have a washout period where they weren't using any at all before they could be in the study. And then in the study, they're assigned to all these different arms, right? There's a high-THC, low-CBD cannabis. There's a high-CBD, low-THC cannabis. There's a 1-to-1 ratio cannabis. And then there's also a sort of - I don't want to misspeak, but I believe we had a placebo cannabis as well. And so they're randomized. They don't know what they're getting because it's a blinded study.

And, also, it's very measured amounts. Like, they're given these machines that measure out exactly when they smoke and how much. And when they come back in a week, they have to - we have to measure what they haven't smoked and, you know, do the math and figure out what they have. So it's very different than if they were just self-treating. But what some of the research subjects said after they'd been through the whole study was that they were happier with the quality of the product they were using on their own prior to the study, which isn't - which I can totally understand. I mean, there's all sorts of varieties of cannabis that are available to people that are superior to what we were using as a study drug.

GROSS: So what's the next step for that study?

HOLLAND: When it comes to cannabis, there are so many states now that are medical states, and there's so many states that are legal, and more and more states every year are going to just go to full legalization. So I think that it doesn't necessarily make sense to reinvent the wheel. I don't think we're going to repeat that study. I think as long as our only source of study drug is that one source, the sort of government monopoly, then I don't think it makes sense for us to do the study again.

So I feel like, you know, medical cannabis is going to be fine without us, you know? I mean, there's no question. It's very effective. And what we're seeing in states that have medical programs or especially in states that have legalization programs is that we're - you're having lower numbers of opioid overdoses and fewer opiate prescriptions even being filled. So it has a momentum all its own now.

GROSS: If you're just joining us, my guest is Julie Holland. She's a psychiatrist who's involved with clinical research on the use of psychedelics in therapeutic settings to treat PTSD. Her new book is called "Good Chemistry." We'll talk more after a short break. This is FRESH AIR.

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GROSS: This is FRESH AIR. Let's get back to my interview with Julie Holland. She's a psychiatrist specializing in psychopharmacology. She writes about the use of psychedelic drugs in treating mental health issues. Her new book is called "Good Chemistry."

Let's talk about the use of MDMA, aka molly or ecstasy, in a clinical use in treating mental health issues. You are a medical monitor in a study examining this. And like with the cannabis study, this is with people who have post-traumatic stress disorder. Why choose MDMA as a drug for post-traumatic stress disorder?

HOLLAND: Well, MDMA is just a exquisitely perfect chemical for augmenting the process of psychotherapy, so that's really why it has been chosen. MDMA helps people to feel more relaxed and more open and trusting and more trusting of the therapist, which is important. But because it's got sort of a methamphetamine base, it helps people be awake, alert, verbal, want to talk, want to explore. But, also, because it increases serotonin, there is a feeling of very little anxiety and also a feeling of satiety, like you don't really need anything, like you have everything you need.

So this high-dopamine, high-serotonin and also high-oxytocin state makes it really great for being open, being trusting, being able to explore traumas comfortably and trusting your therapist, that they're going to help you to explore these traumas safely. And you - and this feeling of safety is actually very important. MDMA, because it increases oxytocin, there is a quieting of the amygdala, the fear response, because exploring trauma is scary, and often, if people become afraid, they close down, and they don't want to talk, and they don't want to explore.

GROSS: So you mentioned oxytocin. What is oxytocin?

HOLLAND: So oxytocin is a hormone and a neurotransmitter that enables the kind of openness and trusting and bonding that underlies human connection, cooperation, communication. So high-oxytocin states are states that have this very intense bonding, either - for instance, like, a nursing mother and her infant, there's a lot of oxytocin happening there in both the baby and the mother that help to solidify the bond. And orgasm is another high-oxytocin state, which helps to solidify a bond between partners.

And the other time that you see high-oxytocin states, though, is in social cohesion, feeling part of a group, feeling like you belong. This - any time there's a sense of unity or oneness or connection, almost always you will see oxytocin involved.

GROSS: Is there an example of someone you could talk about who emerged from MDMA-assisted therapy feeling more integrated, feeling less traumatized, feeling more comfortable in the world?

HOLLAND: Pretty much everybody that I've spoken to who has had an MDMA-assisted psychotherapy session has come away from it feeling like they have processed a good deal of their trauma - maybe not all of their trauma, but they certainly have a better sort of lay of the land of what it looks like.

You know, I don't want to sort of divulge my patients' stories. I mean, I have a patient who's - who had a - her spouse committed suicide, and she had a very hard time sort of forgiving him or processing that. And, you know, she was able to do that in one session and to just, you know, leave some of that weight and heaviness there in the therapy room. So I've had patients who have stopped self-harming or, you know, picking at themselves. I've had patients who are no longer feeling compulsively suicidal, lots of patients who have changed their behaviors around alcohol or eating compulsively or drug abuse.

It's - I mean, somebody - Sasha Shulgin, actually, described it as penicillin for the soul in that it is sort of a broad-spectrum antibiotic. It does have a lot of different uses. It's not specific to one illness or one set of complaints because it really gets at fundamental causes for a lot of discomfort, psychic discomfort.

GROSS: My guest is psychiatrist Julie Holland. Her new book is called "Good Chemistry." We'll talk more about the use of psychedelic drugs in therapeutic settings and we'll talk about dealing with anxiety after we take a short break. I'm Terry Gross, and this is FRESH AIR.

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GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Julie Holland. She's a psychiatrist involved with clinical research who also writes about clinical research on the use of psychedelic drugs in therapeutic settings to treat mental health issues. Her new book is called "Good Chemistry." From 1996 to 2005, she was in charge of Bellevue Hospital's psychiatric emergency room on weekends. She also has a private practice.

In your private practice, you're not allowed to prescribe MDMA. So how are you able to have patients who are using it? Or are you just referring to the study that you're monitoring?

HOLLAND: So I do - you know, I've had a private practice in New York City for, like, 25 years. And there are plenty of opportunities for underground therapists who are working with MDMA or psilocybin, or there are ayahuasca circles. You know, it's not hard to find practitioners in a densely populated area who are doing this kind of work. So I have had patients come to me who have already done this work or who are interested in this work. And they know where to go.

And it's not - I'm not doing this work. And I'm not sending them to do this work, but they're out there. The underground therapists are all over the United States and all over the world. And they are already doing this work. There are people who appreciate how potentially potent and efficient and effective these medicines are. And they're already doing this kind of work. And so I think, you know, my job - because I'm very interested in harm reduction and trying to make sure that if people are going to do risky things, they do it more safely. So I will - people sort of seek me out for advice about harm reduction. How can I do this more safely?

And one of the things that comes up a lot is that people are on medication. They're on antidepressants. They've been on antidepressants for years but you really can't be on these antidepressants if you want to do this kind of work. So things like psilocybin, ayahuasca, MDMA - none of them really play well with others and especially not with antidepressants. So, sometimes, I am in the process of trying to very slowly and gently and carefully change a person's medicines around so that they will be able to experience these other medicines. And that's sort of tricky work.

GROSS: Why don't they go together?

HOLLAND: Well, for instance, in the case of antidepressants and MDMA, the SSRI is the most commonly prescribed antidepressants. And by the way, 80% of these antidepressants are prescribed by people who aren't psychiatrists. And they just get renewed over and over. So antidepressants that work on serotonin, what are called the SSRIs, where they sit is exactly where MDMA needs to go to do the work. So they absolutely block the site, the reuptake site. So if you're taking an SSRI, you basically won't feel MDMA if you take it.

So - and then you have something like ayahuasca, which is very popular, which is a psychedelic tea. And there are a bunch of medicines that you cannot take if you're going to have an ayahuasca experience. And so, you know, there needs to be some sort of medical monitoring, sometimes, in these situations because, you know, I don't want people to do things that are potentially deadly when they could have a positive growth experience if they just weren't taking certain medicines.

And speaking of growth, there is one thing I just want to mention because it's so important - is that a lot of these medicines we're talking about, like ayahuasca and psilocybin, MDMA, cannabis - they all facilitate what's called neuroplasticity, which is the brain sort of growing and changing and rewiring. And there's - there are things called synaptogenesis, which is, like, new synapses forming. And then there's neurogenesis, which is new brain cells forming. And so, you know, we all have this idea that, like, drugs kill brain cells, that, like, these drugs kill brain cells.

But it's actually the exact opposite - that a lot of these plant medicines and psychedelic medicines - they engender brain cell growth and what's called neuroplasticity, which is sort of new connections being formed and, potentially, the brain being somewhat rewired, which really helps - that's what's fostering the growth and the change in behavior.

And you don't necessarily see a lot of growth and change in behavior when people are taking antidepressants or even maybe going to therapy for years. I mean, in the - you know, with really good therapy - and you go for years - you do have behavioral changes. But to see them after one session is really remarkable. And it's hard to just go back to, you know, the daily dose after you see this kind of tremendous behavioral change.

GROSS: So the kind of rewiring you're talking about would enable you perhaps to see a traumatic experience in a different way, to comprehend it or to distance yourself from it in a way that you were unable to before?

HOLLAND: Well, you know, the distancing is what sort of happens naturally that we do anyway, you know - that we sort of shut off that part of ourselves. And that didn't happen to me. You know, so what I would say is that it allows more of an integration and an acceptance. And, you know, MDMA, actually - it helps - there's something about memory consolidation right. Every time you remember something, you change it a little bit. You know, every time you pull out the file, it's like you write in a little bit. And then you put the file away, but it's got new writing in it. So when you're reprocessing a trauma, and you're adding a little bit of a new narrative, it changes the memory.

So you can add things to the memory, like, I was unable to move in that situation. And there's nothing I could've done in this situation. And I have fully accepted that I was blameless, for instance, whereas maybe for years, you were blaming yourself. But you add that into the memory. And so the next time you have the memory, you're like, yeah, that trauma happened. I was blameless. But I am owning it. I'm integrating it. You know, I'm accepting that it happened. And it was me, but it wasn't my fault, you know? But maybe every time before that, you were like, this terrible thing happened, and it was because of me.

GROSS: It kind of sounds like you're describing somebody who was raped. Do you have a lot of patients who've been rape victims?

HOLLAND: Well, a lot of the early research with MDMA was done in people who are victims of sexual assault. And both in Spain and in the United States, the earliest studies were looking at those people. And for sure, this is a particularly good therapy for dealing with sexual assault, yes.

GROSS: The group that is sponsoring the studies that you are monitoring - you're a medical monitor on two studies, one using cannabis and one using MDMA in therapeutic settings for PTSD. The group is called MAPS, the Multidisciplinary Association for Psychedelic Studies. What is this group?

HOLLAND: So MAPS is, like, a consortium of MDs and Ph.D.s and scientists and researchers who are interested in exploring the use of these psychedelic drugs to be used for therapeutic purposes. So it's an organization that's been around for decades. And it has been responsible for funding the MDMA-assisted psychotherapy studies that are going on. And MAPS is in the process, really, of developing MDMA into a prescription medicine going through the FDA approval process, which is lengthy and expensive.

GROSS: So do you feel like the research you're involved with is being used to further, not only the development, but the sales of a drug? Do you feel like there's a profit motive that is coloring the research in any way or a conflict of interest, or a conflict of interest?

HOLLAND: MAPS is not profit-driven is one thing that I will tell you, that they have a design where any profits that come from the sale of the medicine would feed the nonprofit arm of MAPS. So they're considered, like, a public benefit corporation. And that's how they're set up. But there are profit motives, for sure, in the psychedelic community. And, you know, I'm trying to sort of be on the right side of things as much as I can.

I'm not really a big fan of capitalism. You know, in medicine, unchecked growth is called cancer. And, to me, it is pretty much the same thing in business. If it's all about growth and profit, you're sort of missing public benefit. So I prefer to put my energies with organizations where, you know, it's not about the stock price, for instance.

GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Julie Holland. She's a psychiatrist who's involved with clinical research on the use of psychedelics in therapeutic settings to treat PTSD. She also writes about the use of psychedelics in therapeutic settings. Her new book is called "Good Chemistry." We'll talk more after a break. This is FRESH AIR.

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GROSS: This is FRESH AIR. Let's get back to my interview with Julie Holland, a psychiatrist who writes about the use of psychedelic drugs in treating mental health issues. Her new book is called "Good Chemistry."

Let's talk a little bit about anxiety because this is certainly a time of great anxiety. What kind of symptoms are you seeing in your patients related to anxiety now?

HOLLAND: Well, here's what I would say is that even before the pandemic and the sort of political unrest, I had patients who were extremely anxious just by the current political situation. Or, you know, some people are upset about the environment and what's happening. So our anxiety levels were already pretty high before all of this happened in the spring. And, you know, basically, since the '90s, the numbers have just been going up and up on prescription anti-anxiety medicines being used. And we saw a big spike around 9/11. And we're going to see a big spike now as well.

So it's pervasive. It's an ongoing problem. Anxiety has sort of overtaken depression as the No. 1 complaint, really, not only with psychiatrist but just sort of general medical practitioners. You know, you have to keep in mind, about 80% of psychiatric medicines in our country are written by GPs and people who aren't psychiatrists. So it's, somebody comes in. And they're stressed. And they're anxious. And they're not sleeping well. And you give them prescription. You send them on their way. But then they end up taking those pills on a regular basis. And they're hard to get off.

So yes, now we're definitely seeing more anxiety. And one thing that I think is really important to talk about is that at the beginning of the pandemic, there was anxiety about contracting the virus. But what's happened over the last several months is there is - besides the sort of pervading sense of anxiety and doom, is that the people who've been isolated, the people who are living alone - my patients haven't had any human touch for three months. And being that isolated and that disconnected will make you more anxious. It will make it harder to sleep. It puts you in sympathetic mode. It puts you in fight or flight.

So being isolated takes you out of the parasympathetic. It makes it harder to be social, which is sort of paradoxical, right? You're already not social. And then you've got this sort of side effect of having worse social skills because you're isolated. So it feeds on itself. So that's the thing I'm really worried about now is that the isolation and the disconnection affects the physiology, makes people more anxious. And then they don't sleep well. They don't eat well. They're trying to soothe themselves with all these unhealthy behaviors. And it's just - it all cycles on itself.

GROSS: Does that mean you're prescribing a lot more anti-anxiety medication and sleeping pills?

HOLLAND: Well, you know, it's funny because one of the things that I do quite a bit in my practice is I try to taper people off their medicine slowly. And what - I have really hit a wall this spring, where anybody who we were going to do tapering has said, I don't feel - I don't want to taper right now. So I'm at least trying to hold the line and not, you know, over-medicate people or give them more medicines. But, for sure, I've got - you know, I'm getting emails all the time asking for refills (laughter) on anti-anxiety medicines. Or I'm hearing from patients I haven't heard from in years who are saying, you know, I need to go back on my medicines. Can we make an appointment?

So I'm definitely seeing an uptick in anxiety for sure. And, you know, we're seeing, you know, that, like, stockpiles of Zoloft are going down. And, you know, there's some drug shortages and things like that. So I don't know how much of it is supply-side problems and how much of it is that there is more demand because I haven't really seen these numbers. But my intuition is that the prescribing for all of these medicines is going up, that, you know, the pharmaceutical industry is going to have a banner few years.

GROSS: So you said, usually, you try to help patients titrate off medications. And now you're just trying to keep them at a - where they are because people are really afraid to go off their anxiety medications now because everybody's so anxious. What are some of the alternatives to medication or some of the additions to medication that you're suggesting to your patients and that you'd like to suggest to our listeners now? - for example, breathing techniques that might be helpful in lowering anxiety.

HOLLAND: Right. So I definitely - I give a lot of good sort of tips in "Good Chemistry." But I would also say that, you know, women get sort of over-diagnosed and overmedicated. And so I gave a lot of examples of things to do besides meds. But, yes, breathing is absolutely one thing that you can do, breathing only through your nose - in and out through your nose. Making sure your exhale is longer than your inhale, that's very helpful. And then, if you're really acutely anxious, you can actually plug your nostril and breathe in and out only through your left nostril, and that can calm you.

There's also something called a havening, when you - you basically hug yourself. And you stroke your arms downward from the shoulder to the elbow over and over again, this downward stroke from the shoulder to the elbow, while you hug yourself. That's called havening. And while you're havening, you can say things like I am safe, I am cared for, I am looked after, I am loved. That can be very soothing.

But I also - you know, the things I've always recommended to my patients are exercise, nature, sunshine, anti-inflammatory diet - all those things can really help anxiety. You know, regular sleep cycle - sleeping at night, being up during the day - I mean, that's more important now than ever is just sort of keeping a regular schedule. But I personally find nature to be extremely soothing and the perfect antidote to trauma.

And so if you have access to nature - I mean, the problem is, unfortunately - and it's not a coincidence - that where there's a lot of trauma, there's not a lot of nature. But that is something that can help to put you over in that parasympathetic state and make you feel connected. And depending on the natural environment, it can fill you with awe, or it could just, you know, make you feel safe. Or at least it's a time when you're not on your phone or your laptop and you're not hooked into, you know, the traumas of the world.

And you know, I appreciate that that is a privileged position to be able to disconnect from that. But I do feel like no matter how much activism we're doing, you know, you do need to disconnect from the social media and from the glowing devices. That is a way to be less anxious is to just walk away from your screens.

GROSS: We've talked before on our show about breathing techniques and why that can be helpful in lowering anxiety levels. Why is it that a longer exhale compared to the inhale is helpful in lowering anxiety?

HOLLAND: So anytime you have a longer exhale than inhale, you're more likely to flip over into that parasympathetic state and away from fight-or-flight. Right? So when you're in the sympathetic state, fight-or-flight usually are panting or you're not breathing very much or you're breathing through your mouth. So breathing through your nose - and that longer exhale helps to keep you in the parasympathetic state, which is why things like singing, chanting, monologuing - you know, you take a little breath, but then you're letting it out slowly. That can help to keep you in parasympathetic - so even just talking. But singing and chanting are particularly good for getting into parasympathetic. And also, you know, music for a lot of people can be incredibly soothing.

GROSS: I want you to talk about havening a little bit more, where you're basically hugging yourself. Your hands are on your shoulders with your arms crossed, and your hands are moving down your arms, kind of like petting yourself. Is there any kind of physiological explanation for why that can help lower anxiety?

HOLLAND: Well, this - you know, if you look at, like, rats (laughter) - basically, rats lick their babies. They stroke their babies with their tongues. And it's not only a way to clean the baby, but it's a way for the baby to know that it is being attended to and cared for. And so to me, it's sort of like this - it's basically just like a mama rat licking her baby except you're licking yourself by stroking your arms. So it's just this act of, like, stroking or petting. You know?

And first - there's two things. Being stroked or being pet means that somebody is attending to you and taking care of you. But also, when you do the stroking and petting and you're caring for somebody, both of those activities have the potential to increase oxytocin. Being cared for or caring will get more oxytocin through your system. And oxytocin is the hormone that underlies the parasympathetic nervous system.

GROSS: So does your body understand that kind of petting gesture as being soothing even though you're doing it to yourself as opposed to having somebody do it to you?

HOLLAND: Yes. And it works if somebody does it to you, also, or if you do it to somebody else. You can haven yourself, or you can haven your partner or your child. And it is all - it's soothing all the way around.

GROSS: Julie Holland, thank you so much for talking with us.

HOLLAND: It was absolutely my pleasure. Thanks for having me.

GROSS: Julie Holland is a psychiatrist and author of the new book "Good Chemistry." After a break, John Powers will review the series he says might be the best TV show in the world right now. This is FRESH AIR.

(SOUNDBITE OF THE JAMES HUNTER SIX'S "I'LL WALK AWAY") Transcript provided by NPR, Copyright NPR.