AJ is a 39 year old scientist & mother of a 1 year old. She was diagnosed with breast cancer in March 2023. She had two lumpectomy procedures, 3 lymph nodes removed in May, and will start AC-T in late June. She has regular appointments with her oncologist and psychologist (who she has worked with for many years). She currently takes zoloft for anxiety and depression and starts an AC-T chemo followed by a radiation program soon.

She has a history of running, hikes weekly, walks in nature 5 times a week (even after surgery), gentle yoga, vinyasa, and hatha, Pilates, and has a good knowledge of mindfulness practices too. She has been practicing elongated exhalations daily and yoga nidra (insight timer) recordings every evening since her diagnosis to manage stress and help with sleep.

She has a history of DIP joint pain in her right hallux, left hip pain, and a history of hormonal migraines that nearly subsided with her last pregnancy. She has a very positive outlook and even has experience researching one of the drugs on her treatment plan. She is relieved to have a plan in place for both her medical needs and also with yoga therapy she hopes to manage some of the anxiety and inactivity that come with the treatments as well. AJ reported that she feels she not only does not want to have cancer or go through the treatment but the "anticipation about treatment" is what causes the most distress. The cancer is not what causes the pain for her, it is the site of the incisions and temporary reduction in movement. She gives herself extra time after medical visits now to process, cry, and allow herself to feel anything that comes up for her. She also goes into these visits knowing that they will likely cause some emotion.

Her main goal: Improve general well being and decrease stress during cancer treatments.

Practices to continue: elongated exhalations & evening guided relaxation/ yoga nidra
Practices to add: feeling feet, gentle neck stretches, alternate nostril breathing, counting breaths with finger tap meditation for 1-3 mins a day.

Added to the care plan: pratipaksha bhavana

1) Danhauer SC, Addington EL, Cohen L, Sohl SJ, Van Puymbroeck M, Albinati NK, Culos-Reed SN. Yoga for symptom management in oncology: A review of the evidence base and future directions for research. Cancer. 2019 Jun 15;125(12):1979-1989. doi: 10.1002/cncr.31979. Epub 2019 Apr 1. PMID: 30933317; PMCID: PMC6541520.

"There is sufficient evidence to support the benefits of yoga for patients while they are undergoing cancer treatment and when they move out of the medical setting and into survivorship. Yoga improves multiple aspects of QOL, cancer-specific symptoms, psychological outcomes, and important biomarkers such as stress hormone regulation, immune function, and inflammatory markers. As a low-cost and safe intervention, yoga should be provided alongside the standard of care to help improve multiple aspects of cancer patients’ adjustment to cancer and its treatment."

2) Eyigor S, Uslu R, Apaydın S, Caramat I, Yesil H. Can yoga have any effect on shoulder and arm pain and quality of life in patients with breast cancer? A randomized, controlled, single-blind trial. Complement Ther Clin Pract. 2018 Aug;32:40-45. doi: 10.1016/j.ctcp.2018.04.010. Epub 2018 Apr 30. PMID: 30057055.

"The group receiving yoga showed a significant improvement in their pain severity from baseline to post-treatment, and these benefits were maintained at 2.5 months post-treatment... Yoga was an effective and safe exercise for alleviating shoulder and arm pain, which is a complication with a high prevalence in patients with breast cancer."

• Yes

This session started with discussion about the past week. We moved on to practice pranayama: cleansing breaths, breath awareness, elongated exhalation, and six rounds of bhramari. Then ended with tensing and releasing, guided relaxation of healing light, & finger tap meditation.

New Homework: grounding and sensing the feet at doctor appointments.
Practices to continue: elongated exhalations & evening guided relaxation/ yoga nidra.

AJ was a bit more anxious this week. She is waiting to see when she can start her AC-T program based on how she heals from the lumpectomies. Her breathing did slow and she did seem calmer by the end of the session but still more anxious than our intake meeting. The waiting seems especially challenging and she reflected that her provider said it is a common experience for people with cancer that the waiting for results and treatment causes a lot of stress. She said she has been trying to remind herself it is normal to be stressed while waiting and that these tools will help keep her present.

I feel that my cues and offering of options for groups that trauma sensitive yoga is sometimes too wordy for private sessions. I think that this is something I will need to continue to work on. I want to provide options and give space for self autonomy and exploration when appropriate but not "over optioning" each practice and pose. I think this is a balance I am still working on with each group and private client. How can I create an environment of self discovery without over talking or over educating.

I plan to add on some gentle neck stretches and alternate nostril breathing next week.

• Yes

Checked in and AJ shared some of the challenges she was having. Her port and AC-T treatment was delayed due to a cold and infection with the incision site of her lumpectomy. We spent time talking about ways to identify thought patterns that create stress and redirect them. The session moved on to bhramari, palming and self massage of upper neck and subclavius muscles. We followed that with neck JAPA, active assisted neck stretch with yoga strap, alternate nostril breathing, finger tap meditation, and Cheri Clampett’s Guided Relaxation for Cancer & Lymph Flow.

Practice 1 min of alternate nostril breathing and 1 minute of finger tap meditation focusing on the breath (inhale, exhale, switch finger tap) around AJ's lunch break each day.

AJ expressed feeling powerless and anxious while she waits for the incision to heal from her lumpectomy. She reported having a tendency to want to research and actively look up ways to work on or even fix the situation she is in. This was causing her to stay up at times and lose valuable sleep. She reflected on knowing this behavior is not productive but feeling cognitive dissonance that she cannot just rest and do nothing either. She noticed that the times when her thoughts snowball and feel out of control, she is less able to pause and use the tools she has learned to calm them. When she needs them most she finds it hard to remember to use them. Recognizing these tendencies is challenging at the moment.

As AJ expressed her challenges, we addressed them one by one. First I encouraged AJ to remember that rest IS doing something, it is resting. The rest she gets is helping her incision heal, her body recover and grow stronger. Everyone needs rest but especially a working mother who is recovering from surgery. I was also reminded of ishwara pranidhana and shared a reframed version of surrendering with her. When we cannot know or change the outcome and we have a good plan and team supporting us, the act of surrendering to this plan and allowing for rest could be helpful. The body will fight cancer, her mind can rest easy knowing her body and the medications she will receive will do the work she doesn't need to do more work on top of that. I indirectly reminded AJ that if these actions cause her to lose sleep or create stress, it is working against her goal of recovery.

We also discussed unproductive thoughts and worries about things that have not happened yet causing actual pain or stress. Reframing pratipaksha bhavana seemed most appropriate to address this concern and build some awareness around unconstructive thought patterns. I shared these concepts as a perspective from yoga to keep them open to interpretation for her to connect with whatever works best at this time.

I added gentle music to the deep relaxation to help focus her thoughts on the sounds as she was having an especially challenging week.

I plan to add a few restorative yoga poses with props if AJ's incision is healed and she is cleared for it by next week. She has been itching to move and stretch but due to the infection at her incision site, we have not pursued this as much.

• Yes

After checking in we started with standing rocking -sensing the feet, seated breath awareness, elongated exhalation, and bhramari pranayama. After that we moved on to palming the jaw and neck and gentle neck stretches. Then practices of mountain brook, side lying resting pose, dragonfly, resting butterfly, half moon with arm circles, and the guided relaxation from last week all with gentle music.

Continue lunchtime alternate nostril breathing and finger tap meditation for up to 3 minutes each. Anytime AJ notices herself feeling stressed she can take a pause and practice cultivating the opposite with a thought that is neutral or positive to redirect.

AJ has been practicing all of her tools daily and diligently.This is an extremely stressful time but she continues to find some relief with yoga therapy, CBT, and walks in nature with her family. Our session was right before she went to the hairdresser to have her hair cut off and the day before her port would be put in. She has been waiting for this but it also brings with it a new list of concerns, fears, and anticipation of results. She was quite understandably stressed and shed some tears at the start of our session together.

In this session I felt AJ was able to participate actively in her rest by practicing the restorative/ therapeutic yoga poses. I was able to see if this type of yoga worked well for her as well. Having gentle music playing and a clear focus to help redirect thoughts in each practice seemed useful. I do need to be sure to fully practice the zoom set up prior to the start of the session. My spotify had some upgrade pop ups that caused some delay and interruption in our session flow at the start.

I have been grateful to work with AJ during this transitional and challenging time. Due to her history of anxiety and depression and her rajas tendencies in both the body and mind, I felt a less is more approach was appropriate. She is so busy between family, work, therapy and oncology appointments. I wanted our sessions together to be simple, slow, and build slowly on eachother only as needed. I designed the care plan with this in mind trying to provide enough but nothing complicated or too involved. Her practices needed to be portable for waiting room time and also simple enough as to not create stress and be recalled when needed.

While I cannot relate to her personal experience with her diagnosis and treatment, I can offer the tools that have helped me through stressful times and have been proven to help others. AJ is a do-er and homework follower even when I set meditation for one minute she went well beyond that most days. These tools are a vehicle for her deeper practices of introspection. Just as we build interoceptive awareness in the body, sensing tension or pain and listening and learning from its messages, we can build the introspective awareness of thought patterns and tendencies too. One tool that AJ particularly liked and reflected on was Swami Ramananda’s example of allowing the mind to rest in meditation. Our body needs sleep and our mind needs rest that isn’t dreaming. That has given her permission to prioritize small pockets of time to step out of her thoughts and let them be. It has also given her time to pause and observe her thought patterns, sometimes choosing to redirect and cultivate opposite thoughts instead. These self discoveries and connections she is making could be helpful as she manages her expectations during cancer treatments as a working parent.

On reflection, working with this client has reinforced just how important yoga therapy is to provide safe accessible spiritual support. It does not replace her chemotherapy or cognitive behavioral therapy either but it does provide practices that help her to access a deeper connection with the Self. Beyond treatments and therapies there is this place within that is all her own to tap into. While she is not religious she has proven to be deeply spiritual and profound. As this cancer is not AJ neither are her tensions or anxieties. It has been beautiful to start to see her connect with this true self.

I plan to continue with the same practices adding or modifying the new restorative yoga poses as needed in a way that does not put pressure on AJ's port. She may respond well to left nostril pranayama instead of alternate nostril breathing on days that are particularly challenging and causing anxiety. Continuing to discuss lessons from the yoga sutras would also most likely be helpful as needed.