What yogis realized thousands of years ago—and what the western medical community and researchers are now catching on to—is that practicing Yoga can make a critical difference in one’s health and wellbeing. In this interview, Timothy McCall, MD, a leader in the Yoga therapy field and author of  the groundbreaking book, Yoga as Medicine, discusses how Yoga principles can be applied holistically to evaluate, treat and research various medical conditions.

Integral Yoga Magazine (IYM): It’s been some years since the publication of your groundbreaking book, Yoga as Medicine. Have your views on Yoga therapy changed since then.

Timothy McCall (TM): I’ve always believed that as Yoga therapists, we need to evaluate people holistically but I believe that more passionately now than ever. This idea is still foreign to most health practitioners in the West. In fact, holism is a word that’s often used as a synonym for alternative medicine or natural medicine, but that’s not really the meaning. I define holism as: evaluating and treating the individual in their entire context. We live in a world dominated by western medicine and a medical model that is primarily based on a diagnosis. If someone has diabetes or arthritis or hypertension, we then shape our treatments based on that diagnosis. That’s the Western medicine model, which is reductionistic—we reduce the complexity of the person and base treatment on the diagnosis. In Yoga therapy, Ayurveda, and Traditional Chinese Medicine (TCM), that’s not how we work. We work in a holistic way. Yes, we look at the medical diagnosis, which can be useful, but primarily we should look at the whole person.

IYM: Can you give us an example of what that looks like?

TM: I was working with a woman a few years ago who had low back pain and she began exploring Yoga therapy. In researching her condition, she found out was that those who have low back pain may have a disc problem, so rather than doing forward bends—which she read were contraindicated because they can exacerbate sciatica—she began doing gentle cobra and other poses that were commonly recommended for those with back pain. When she came to see me, I examined her and then asked her to show me how she did her asana practice. I observed that she was overarching her spine—hyper-extending her upper lumbar spine whenever she did back bends. I asked her to point to her pain and she pointed to the vertebrae where she was overextending her back. The prescription I gave her was to stop doing the back bends as she had been doing and to start doing forward bends. In other words, the medicine I prescribed was exactly what the books said was contraindicated. I then retrained her to do her back bends differently.

Someone else I saw during one of my “Yoga as Medicine” workshops was a woman who had debilitating back pain. She was a chiropractor and she had a dedicated Hatha Yoga practice. She knew alignment and anatomy well and she had done everything to get into good alignment, but she still had this debilitating pain that was interfering with her life. Through some psychological exercises I led as part of the workshop, she came across some resentment in her life and she began to work with the resentment, to write about it, and she had a major emotional release. Guess what? Her back pain went away!

IYM: Can you give us an example of how you work holistically with patients using a holistic Yoga therapy model?

TM: I like to say that with holism we treat any individual condition by improving the overall condition of the individual. I embrace tools of standard western reductionistic medicine when they make sense. There are those who need pharmaceutical drugs or surgery and they can be a godsend. While right now, those tools are grossly over-used; true holism embraces the selective use of reductionist tools. In my workshops, I teach Yoga therapists how to assess people individually using five categories. I use an acronym I devised called SNAPS: Structural, Nervous System, Ayurveda, Psychology, and Spirituality. In the structural evaluation, I’m teaching people to look at the postural habits, bony alignment, to look for patterns of muscular overwork and underwork. Where does the person hold tension? Does the person have a slumped posture? Do they hold the head forward of the spine? We are looking for patterns, structural samskaras.

The next area of evaluation is the nervous system, which affects blood pressure, heart rate, breathing, the function of every internal organ, and the immune system. Many people suffer from a lot of stress and stress-related diseases. But there’s something we sometimes miss in our understanding of Yoga and Yoga therapy: Yoga isn’t just about relaxation. Much of what happens in a Yoga class is stressful: Full back bends, sun salutations, kapalabati, and other practices actually activate the sympathetic nervous system (the flight or fight system). What we are trying to teach people through Yoga is how to turn on their stress response system when they need it and to turn it off when they don’t. Here’s the part I think we miss as Yoga teachers: Some students don’t have enough stress activation. They have too much activation of the parasympathetic nervous system. These people may suffer from chronic fatigue syndrome, fibromyalgia, some types of depression, and so on. They have abnormally low levels of stress hormones so they don’t have the energy they need to really thrive. They require an approach different from those who are frazzled and stressed. The abnormally low stress response can be a consequence of being highly stressed for a long time: Eventually the body gives out and the person goes into a state of vital exhaustion.

Of all the autonomic functions, the one that can be brought under voluntary control is the breath. Breath work is a key tool in Yoga for many reasons. It is intimately tied to the autonomic nervous system and is its doorway. Change the breath, and you change how the autonomic nervous system functions. Breath holding, upper chest breathing, and rough, erratic breathing can adversely affect the autonomic nervous system. Breath and blood pressure, breath and the immune system, breath and the heart—we potentially affect the entire body with the breath.

IYM: Why did you start to incorporate Ayurveda into your approach?

TM: When I was initially researching Yoga as Medicine in the late 1990s, I knew many Yoga practitioners and teachers took an interest in Ayurveda. My impression at that time, though, was that some of the Ayurvedic concepts seemed a bit “out there.” I was coming from my Western medical training and trying to write a book to lend legitimacy to Yoga therapy. But, as they say: the universe had other plans.

In 2004, I spent a year at Kripalu as a scholar-in- residence. My housemate was Swami Shivananda Saraswati, an Ayurvedic practitioner. Kripalu had just started their Ayurveda program and some of the best in the field like Vasant Lad, Robert Svoboda, and others gave programs there. After attending their programs and following some of the very simple Ayurvedic lifestyle advice that Swami Shivananda gave me, I felt the benefits and gained a new respect for Ayurveda. Around the same time, Josh Summers, a friend of mine, starting a Traditional Chinese Medicine practice in Boston. He asked me to write an endorsement. I told him that I liked Chinese medicine but had never had a treatment from him so I wasn’t comfortable writing anything. He offered to give me a treatment so I could experience it. He focused in on improving my kidney function. Swami Shivananda measured my pulse before and after. He found that my vata had decreased. Low kidney energy in Chinese medicine and increased vata in Ayurveda are two ways of describing basically the same thing. It really made an impression the way these two seemingly different traditional medicine systems using completely different methods, reached the same conclusions. When I finished writing Yoga as Medicine, I decided to go to India again, this time to explore Ayurveda. I wound up meeting and studying with a very traditionally trained Ayurvedic physician in Kerala who came from a long line of practitioners. He is perhaps the most amazing clinician I’ve ever seen.

IYM: What did you discover about the relationship between Yoga therapy and Ayurveda?

TM: They both share a philosophical foundation in Samkhya, so at the core they share a fundamental parallel in their orientation. But I’ve discovered that many Yoga practitioners and teachers in the West don’t know that much about Ayurveda and many Ayurvedic practitioners, particularly those in India, don’t know much about Yoga. I find they work amazingly well together, each enhancing the effectiveness of the other. You can also blend Yoga and TCM. They don’t have all the same language, but it works. I think Tai Chi and Qi Gong—viewed from a broader perspective—are almost like a form of Yoga and can be combined to get many of the same benefits. In other words, I don’t think Ayurveda is the only system you can combine with Yoga, it’s just a very natural pairing. And, the growth of Ayurveda in America mostly comes from those who have an interest in Yoga, so they are being integrated more.

For example, I’ve seen that when Yoga therapy fails to incorporate Ayurvedic principles people didn’t benefit as much as they might have. We may prescribe asana practices that are biomechanically sound but may be energetically problematic. Say someone has a vata derangement—whether caused by too much activity of mind or just in general—and they also have a tendency to slump their shoulders. Backbends might be helpful for correcting the slouching, but too many backbends can send vata in the wrong direction. So the idea is that, while someone may come in with a structural problem, they may also have such a doshic imbalance that’s a more threatening piece, so I’ll focus on that. Then again, someone else may have a mild Ayurvedic imbalance, but that may not be the main place we go. Even better is when you choose practices that work well both biomechanically and energetically. When we utilize Yogic and Ayurvedic principles in concert—geared to the specific individual—we can get better results.

IYM: Would a Yoga therapist then prescribe vitamins, dietary supplements, or Ayurvedic herbs?

TM: Unless they have training in medicine, herbology or Ayurveda, TCM, etc., I don’t think Yoga therapists have any business making such recommendations. Yoga teachers are often highly trusted by their students, even in areas where they lack expertise. While that teacher may have had a good experience with an herb or supplement, I believe they shouldn’t recommend them to students.

Rather than teach them to practice Ayurveda, I’m trying to get Yoga teachers and therapists to use basic Ayurvedic methods to assess the student’s inborn constitution (their prakriti) and their current level of imbalances (their vikruti), their level of digestive fire (agni), etc. Then they can utilize Yoga to help them get into better balance. If you can choose yogic practices and make recommendations for lifestyle and diet that address more than one problem the student has, so much the better. For example, you might recommend a program to address a structural problem you detect, which simultaneously addresses Ayurvedic imbalances.

IYM: Let’s look at the “P” in SNAPS: How does psychology fit in?

TM: The study of psychology is all about seeing ourselves more clearly. Many people have dysfunctional psychological samskaras: self-sabotage, self-loathing, and other habits that they persist in though we know they are harmful. In this part of the evaluation, we’re asking people to become conscious of and bring awareness to those issues and begin to figure out where they come from and what they can do about them. In Buddhist meditation circles, practitioners are encouraged to feel their emotions as they arise. In Yoga, our tendency is to say, “I’m not supposed to be angry or sad, because I’m a yogi.” But what happens? We think, “Oh, I’m not supposed to be sad so let me distract myself.” So, we go to the movies, watch TV, get high, have sex—whatever we can find as a distraction so as to not feel sad or lonely or whatever. There’s a tapas to being able to stay with things that are uncomfortable in the short term for the benefit in the long term.

What we learn from the Buddhist psychologists is that what we want to do is to feel our emotions: Where do they live in our bodies, what do they feel like? You feel the emotion rather then getting hijacked by the story, which is the samskara. By repeating the story endlessly we actually deepen the samskara. Instead, stay in the physical sensation and allow the emotions to arise as you mindfully watch them, observing how they change and eventually can be released. When we can disengage from the reaction, from the story, we can ask ourselves: “Is there a message in my sadness, in my anxiety? Is there something in my world or my reaction to it that isn’t as it should be?” We can begin to use the psychological disquiet to study ourselves and to reformulate healthier samskaras.

This is essentially what Patanjali was teaching in the Yoga Sutras. Pratipaksha bhavana, cultivating the opposite feeling, is an example of re-patterning a psychological samskara with a new one. As Swami Vivekananda said, commenting on the Yoga Sutras, “The only remedy for bad habits is counter-habits; all the bad habits that have left their impressions are to be controlled by good habits.”

What we’re essentially doing in Yoga therapy is providing people with the tools to develop a really efficient practice—if only 20-30 minutes a day—that addresses as many imbalances in any of the five SNAPS areas. A good Yoga therapist can look at someone’s SNAPS aspects and craft a practice to move those factors in a good direction. They will try to address as many factors as possible to move the person to better balance through realistic, bite-sized steps. Often today people don’t have a lot of time to dedicate to their Yoga practice. To re-pattern samskaras, to build new positive habits, it’s most effective if you can practice daily, even if it’s only 15 minutes a day. That’s better than taking a longer class once or twice a week. The most crucial thing we’re doing in Yoga therapy is giving people a technology to build new samskaras, to build better habits of thought, word, and deed.

IYM: The “S” in SNAPS is for spirituality. In what way does this play a role in your evaluations?

TM: Modern medicine has paid a lot of attention to pain but not to suffering. Yoga pays attention to how to release suffering and to cultivate santosha (contentment), ananda (joy), and so on. This is spirituality. We want to see if the individual has a sense of what he or she is on the planet to do. Are you living your life in accordance with your gifts, your talents, what it is you are here to give to the world—your svadharma? Now of course, not everyone who comes for Yoga therapy is interested in psychological or spiritual help. They may have some knee pain and they just want that relieved. We don’t want to shove things down people’s throats. But if someone has knee pain, and if during their SNAPS evaluation I see that they are a bit depressed or lost, I might, in some indirect way, recommend things that will be a positive influence on these issues for which they didn’t overtly come in. If they continue on their yogic path, at some point they may be open to addressing these issues.

There are really two important agendas in Yoga therapy: (1) What to do right now to put the person in a better direction, and (2) to help the student over the longer-term to develop the tools to steer themselves in a better direction, which is what Yoga therapy is really about.

IYM: Where do you see Yoga research heading?

TM: Right now we do studies that are dictated or dominated by western medical research standards. For example, we use standardized protocols based on the western medical diagnosis. All clinical Yoga research is conducted in a way in which we take people with medical conditions and give them a Yoga therapy intervention and then measure to see if that’s effective. These standardized protocols have almost always been designed by people who haven’t laid eyes on the people going through the protocols. Now, that research is helping us make the case for Yoga, so that’s a gift. The good news is that even these plastic, dumbed down versions of Yoga being studied still works pretty well for most things. The bad news is that what is being studied is nowhere near the quality of what good Yoga therapists can offer.

The problem is that the current research model doesn’t recognize the holistic evaluation model. For example, with a holistic evaluation model, at Week 2, I might change or adjust my treatment plan to meet the individual’s changing needs. Based on how the person responds to the Yoga therapy or something that has happened in their life, perhaps they’ve lost their job. Yoga therapy isn’t about doing a standardized twelve-week protocol, which is what the western medical research model is geared to evaluate.

A Yoga teacher or therapist might design a protocol for people with low back pain. But those people may have low back pain for different reasons—a structural reason, psychological issues, emptiness, lack of fulfillment, sometimes the nervous system is spent, some are Ayurvedically out of balance—all those things could lead to pain. What we see in back pain research is a structural approach, based on factors people with that diagnosis commonly share. But, a skilled Yoga therapist will adjust the treatment plan and working holistically based on the individual in their entirety. The current research model can’t evaluate that.

IYM: Can we gradually shift the research to a more holistic approach?

TM: I think we can. Dr. Sat Bir Khalsa (a Yoga researcher at Harvard Medical School) and I are talking about this. Medical institutions and government don’t fund that kind of research, so it’s not currently supported financially. What we need to consider is utilizing outcome studies, like Dr. Dean Ornish’s. He used standardized treatment protocols but you don’t have to. You simply give one group the intervention and another group doesn’t get the intervention and then you compare results. Most medical scientists hate that type of research. Why? They want to know: In Dr. Ornish’s study, was heart disease reversed because of the Yoga, the exercise, the diet, or the support groups? They still bring this reductionist mentality to the research. They want to know: Was it the trikonasana or the alternate nostril breathing that lowered blood pressure? It’s more  likely that the different Yogic practices are working together synergistically. They are imposing a western reductionist model on a holistic system and it’s not a very good fit, so we do need a shift in research.

IYM: You seem to have a lot of exciting programs and projects coming up.

TM: Yes, because students have been asking for opportunities to go deeper, I offer Level 2 “Yoga As Medicine Seminars.” These are: 5-day workshops on “The Ayurveda of Yoga Therapy” and “Yoga Therapy for the Nervous System.” I also offer Level 2 courses on “Structural Issues” and “Psychological/Spiritual Healing.” In 2016, we published the first medical textbook on Yoga therapy. It’s titled, Principles and Practice of Yoga in Health Care. It’s a collaboration between myself, Sat Bir Khalsa, Shirley Telles (who is the most prolific Yoga researcher in the world), and Lorenzo Cohen (director of the Integrative Medicine Program at The University of Texas MD Anderson Cancer Center). This was a very exciting project and a very positive step forward for Yoga therapy.

About Dr. Timothy McCall:
Timothy McCall, MD, is a board-certified specialist in internal medicine and a dedicated Yoga practitioner who has traveled extensively in India and the West, studying with, observing, and interviewing many of the world’s leading Yoga teachers and therapists. He is the medical editor for Yoga Journal, and author of Yoga as Medicine: The Yogic Prescription for Health and Healing. For further information about him and his programs, please visit: www.drmccall.com.