March 26, 2025

Yoga and practice with Dr. Vanika Chawla

Running time: 19:30

Edited for grammar and clarity by CAMH

[Musical intro]

David Gratzer: Mindfulness. Acupuncture. Yoga. These are all ones considered alternative treatments. You know, the sort of thing that our patients might be enthusiastic about but generally lacked evidence. Well, times have changed. Mindfulness as a therapy is included, of course, in the CANMAT depression guidelines. In terms of acupuncture, there's a very compelling and exciting paper recently in JAMA Psychiatry talking about applicability for those with PTSD. And of course, there are other papers that have been published. But what about yoga? Does depression care include the downward dog?

My name is Doctor David Gratzer. I'm a psychiatrist here at CAMH and welcome to Quick Takes, a podcast series by physicians for physicians. Today we're joined by Doctor Vanika Chawla, who is an assistant professor at Stanford University. She's part of their lifestyle medicine team. She's also a registered yoga teacher. Doctor Chawla is a former U of T resident, and she spent much time here at CAMH. Full disclosure she did her PGY-2 inpatient rotation with me back in the day when I had a full head of hair. Welcome Doctor Chawla.

Vanika Chawla: Thank you so much for having me, Doctor Gratzer, it's a pleasure to be here.

David Gratzer: So, you have a personal interest in yoga? How did you get interested in yoga?

Vanika Chawla: Yeah, I was 18 and undergrad and I went on a trip, a volunteer trip to India and was exposed to some more kind of traditional yoga practices there. And the next summer, I had a little bit of time off and decided to do my 200-hour registered yoga teacher training. And since then, it has been a true passion of mine. So that's how it all started.

David Gratzer: So, you are a physician, but as I mentioned already, you are registered as a yoga teacher. You mentioned 200 hours. That's a big commitment. What else is involved in training?

Vanika Chawla: Yeah. So that's usually the minimum starting point is a 200-hour teacher training. And then there are other, you know, options to further training in the field as well. So, I did a 300-hour training. And then I'm currently working towards my yoga therapy training which is more focused on using yoga as a therapeutic intervention. And I'm doing that right now through Stanford. They actually have a program focused on integrating yoga into health care and offer a yoga therapy program.

David Gratzer: Now, when we speak of yoga, and pardon my ignorance, we often speak about different types of yoga, but to a layperson such as myself, I don't quite know the differences between them.

Vanika Chawla: That is a great question because yoga is quite a diverse practice. Even between different schools of yoga teacher training there would be differences on kind of emphasis philosophy. Oftentimes in the modern Western world we think of yoga primarily as an exercise or the postures. And that's usually the focus, say, at your gym class or in the community yoga studio. But yoga is a very kind of holistic practice that includes not just the postures, but there is a philosophy, there is an ethical lifestyle component. And then there are also different practices like breathwork and different meditative practices, including concentration and mindfulness-based practices. So, it's more of a holistic system in which the postures are one part of it.

David Gratzer: So, you've done training in yoga teaching per se. Now it's more clinically relevant. What have you discovered as being different between the two?

Vanika Chawla: Ya. So generally, when we look at the literature often yoga-based interventions involve, I would say, generally three components. But there might be different variations, different emphasis, different ratios. But the three components are generally: the postures, the breathwork and the meditative based practices. So, integrating it clinically, I've done it in a few different ways, and it really depends on the context. You know, depending on if it's individual or group-based work and depending on the patient's needs. So that's the cool thing about yoga. It can be applied, I think, in a lot of different ways and based on what the patient is needing. But again, that also makes it challenging when we're trying to standardize and study it.

David Gratzer: You’ve brought up clinical work and of course we're clinicians. So, what are some types of problems you've incorporated yoga into your practice?

Vanika Chawla: So right now, I am running a yoga psychotherapy group. It's a 12-week group. Transdiagnostic. Typically, patients present with issues related to mood, anxiety, trauma and it's focused on stress reduction. It integrates yoga-based intervention, philosophy with a goal to help people with nervous system regulation, stress reduction, improving things like mindfulness, self-compassion. And I think there's a lot of parallels between some of those interventions and, you know, existing third wave psychotherapies like MBSR [mindfulness-based stress reduction] and ACT [acceptance and commitment therapy] and so forth. So, that's how I integrated it into group work and individually, it really depends. Often, it's an adjunct to existing kind of evidence-based treatments like meds and therapy but sometimes, you know, the majority of the session is focused on a yoga-based intervention. And sometimes it's kind of a mini-intervention, like teaching someone diaphragmatic breathing in addition to the CBT skills that they might be learning or the medication that they might be taking or a mini mindfulness exercise. So, there's different ways to bring it into work.

David Gratzer: So, let's flesh this out. You work with students, I'm assuming Stanford students?

Vanika Chawla: Yes. I work in a few different clinics. I work in a clinic, a cultural psychiatry clinic. So, I work with South Asian folks and then students. And then in the lifestyle clinic it's a general kind of patient population where patients might be interested in more, you know, alternative interventions in addition to their standard care.

David Gratzer: Stanford is pretty open minded, eh?

Vanika Chawla: Very!

David Gratzer: Okay. So I, you know, I too see students largely through the emergency department, not exclusively. They tend to be very open minded, in my opinion, as to, again, these quote unquote alternative treatments. Um, I'd assume that you're thinking about patients who are more on that anxiety/depression problem set. So how would that look? What might you do in terms of the yoga and the breathing? Is that's something brought up early in your work together, late in your work together. How do you discuss it with them?

Vanika Chawla: Yeah, it's a great question. My answer is probably more of an "it depends", but I can kind of give you a general approach. I think in the general intake I'll talk about different treatment options as you would with any patient visit, right? We have meds, we have therapies. And then within that discussion, I include kind of the yoga-based interventions as an option. So, it's more like expanding the toolbox, right? It's the therapies, the treatments that you would already offer. And then add that in as an option, both individual- or group-based. And then depending on their level of interest sometimes we might do a therapy focused on an eight-week course where we go over yoga-based skills including movement, some breathwork practices and meditation with a portion of the visit, also for checking in for talking about some of the kind of philosophical or psychoeducational principles that they could take off the mat and so forth. So that might be one example.

The interventions could include learning different breathing practices like diaphragmatic breathing, or other breathing practices to regulate the nervous system. Mindful movement and a variety of different meditation practices, often similar to the ones we might see in MBSR or ACT. And then we might talk about how we could apply some of the experiential learnings within that session off the mat and into one's daily life.

David Gratzer: And of course, it's an option for patients and they may not opt for it. What are some of the reasons patients have provided in terms of some hesitancy around this? As I assume some have.

Vanika Chawla: Well, I think there are a lot of misconceptions around yoga, and especially when we're thinking of applying it in a more therapeutic way. So, people might say, well, “I'm not flexible” or “I'm not strong enough.” There's a lot of misconceptions that yoga is a practice where one has to be in a certain physical state or has to perform or embody certain shapes in a specific way. So that is usually one misconception or hesitation around it. Sometimes I'll get questions around, “is this a spiritual or religious practice?” And people might have thoughts around that. And I talk about how I integrate this not in a way that imposes a sort of kind of spiritual or religious philosophy on folks, and it's more about the skills and how they can utilize those skills in a way that works for them. So those might be some examples. And then again, trying to balance engaging in these types of treatments versus doing a standard course of CBT or med management and how that might work in conjunction or combination.

David Gratzer: So, it's complementing what they're already doing. Do you find that that's a potent combination that if they're doing better with the yoga, they're engaging with you perhaps a little bit more with the CBT and vice versa?

Vanika Chawla: I think this is one of the reasons why I love yoga, and I love that we're starting to look into some of these more traditionally alternative therapies, is I think that they really expand our toolbox, and they give people more tools and more options. So, a lot of psychotherapies, for example, really focus on top-down like they're cognitively focused. Whereas yoga I think really brings in this nice aspect of bottom-up where we're making our breath to shift our respiratory system, cardiovascular system, engaging in different practices that shift the MSK [musculoskeletal] system, and then the signals that our body then sends to the brain. Right. So, it gives people more options and tools to self-regulate, to manage symptoms, to find a sense of resilience. And then that can really complement some of the more top-down work that is being done.

David Gratzer: You've done this for some time. You're in an environment where it's supportive. Do you see this as being part and parcel of your clinical work from here on in?

Vanika Chawla: I would hope so. I would like it to be. Yeah. It's been really neat to kind of integrate some of these practices in as an adjunct to what we might offer, and it's been great to hear some of the feedback from patients about how they're finding these skills helpful.

David Gratzer: Can you tell us about a patient who you're working with, or have worked with, and you incorporated some of these yoga principles and how it worked out?

Vanika Chawla: So, one individual that I'm working with is a mid-30s female with a diagnosis of PTSD, generalized anxiety disorder and significant pain. And she finds that her pain tends to really increase when she's really anxious or there are trauma related triggers. She actually is a mental health therapist herself so therapy is a little bit challenging because she's like, “I already know the CBT and ACT techniques” and is very intellectual, can really intellectualize a lot of these skills from multiple modalities as a provider herself. And she is on medication for anxiety and the pain as well but is still struggling with significant jaw and neck pain and was seeking alternate kind of treatments and modalities. So, I saw her for a course of yoga therapy. And throughout our work together we integrated some breathwork, some mindful movement and some meditation. The movement was very much focused on helping her kind of tune into some of her body signals, her sensations and shift her relationship with them. So, noticing the pain from more of a stance of curiosity, and then also making more kind of empowered decisions on the mat around what shape she wanted to take around what cultivated more of a sense of agency within her body. Thankfully, because it's a newer intervention, she wasn't able to read up too much about it or kind of intellectualize it too much and it was really about experiencing these practices within her body. And she found her pain and her anxiety levels decreased but she also found it to be a really nice kind of experiential exercise where she could experiment with shifting her relationship with her body on the mat, which was related to some of the trauma that she has experienced. So that's one example of a case where I've used yoga therapy.

David Gratzer: It sounds like some patients really find a connectedness. It helps with rapport. I mean, over time do you really think it might help with some of those core mood and anxiety symptoms or PTSD symptoms in the case of this patient?

Vanika Chawla: So, with PTSD we've been finding in our groups – we have a lot of folks with a trauma history and PTSD symptoms – and it really helps with some of the autonomic nervous system dysregulation and the challenges with self-regulation and self-soothing. So, definitely it's been a helpful modality from that regard. I think it's a nice form of behavioural activation. It's a way to be in a group setting, be around people and to move the body in a form of physical exercise as well. And then for anxiety addressing some of the somatic symptoms of anxiety in addition to the cognitive ones, I think that can be a nice role for yoga-based interventions.

David Gratzer: And you found it personally useful in terms of your role as a physician. I know you do present at national and international conferences in terms of evidence and so on. What's your read of the literature?

Vanika Chawla: Yeah. So, the literature. Definitely there's been a lot of interest in yoga research over the past several years and the literature has challenges, though I would say it's been improving even in the last couple of years. The TLDR [too long; didn't read] of most of the systematic reviews and meta-analyses is that generally there's a positive result and again, most of the literature has been, I would say mood, anxiety, trauma, and then some studies actually out of India in the area of schizophrenia. Generally, a positive result, though the results need to be interpreted with caution given the kind of methodological limitations of the literature. For example, there was one recent paper published in JAMA in 2023 comparing yoga to cognitive processing therapy for veterans with trauma, and they found yoga to have equivalent effectiveness to CPT. There was also a nice study comparing Kundalini yoga to CBT and stress education for people with GAD. It was an RCT, and they found that yoga was more effective than stress education, but not as effective as first line treatment with CBT. So, I think some of the more recent studies, like these two examples, have incorporated comparisons to first line kind of evidence-based treatments and have improved methodological quality as well.

David Gratzer: What sort of research questions are unanswered in your opinion at this point?

Vanika Chawla: I think there are many. As I mentioned, yoga is a really heterogeneous kind of intervention. There's a lot of different components. I don't think there's any clear answers around what components or what diagnoses, how long, how often. I think those are all unanswered questions. And the therapeutic applications of yoga are: this is more of a recent phenomenon so what is an ideal yoga protocol for someone with GAD versus PTSD versus depression? And what are the different components that need to be emphasized? What are the different kind of additional components that might need to be added to make it more therapeutic? And there's no kind of clear guidance around that. Much of the research is also into yoga as an adjunctive treatment. So, I think there's questions. Could it be a mono therapy? Should it be offered as part of our kind of toolbox of first line treatments? And so, I think there's a lot of unanswered questions there for sure.

David Gratzer: Doctor Chawla. It's a Quick Takes tradition that we close out with a rapid-fire minute. A series of quick questions and quick answers. Are you up for this?

Vanika Chawla: Sounds good! Yeah.

David Gratzer: Let's put a minute on the clock. Uh, here we go.

What's one thing you think all clinicians should know about yoga?

Vanika Chawla: That it is a really diverse practice. And yoga can mean different things to different people. And that studio yoga is not the same as therapeutic yoga.

David Gratzer: What's the biggest surprise in terms of your clinical work with patients and yoga?

Vanika Chawla: That it is possible to do it virtually. Given the kind of limitations of the virtual world, it still works to do virtual yoga-based interventions.

David Gratzer: Do you recommend patients do more yoga and explore yoga more?

Vanika Chawla: Yes. I think it's a wonderful way to expand people's toolbox in addition to existing treatments.

David Gratzer: And after all this study, after all this training, and after all this interest, do you still do yoga on a regular basis?

Vanika Chawla: I try to! I sometimes don't practice what I preach, but even if my kind of frequency ebbs and flows, I always come back to the mat. So yeah.

David Gratzer: And one last question at the buzzer. It's important and popular now to talk more about physicians and physician burnout. Do you think yoga is not something only applicable to our patients, but hey, maybe people like me should also be hitting the mat, so to speak?

Vanika Chawla: Yes, there was actually a really nice study published recently on using breathing based yoga for burnout. So yes, I think that's a great area to continue to explore and can have great applications as well.

David Gratzer: Doctor Chawla, we really appreciate your time. And of course, we recognise your expertise and passion. And on a personal note, it's nice to see how your career has been developing.

Vanika Chawla: Thank you so much for having me! Appreciate it.

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