Date: July 3, 2023, 2:00-4:00 PM via Zoom

Intake summary:
The intake session was conducted on July 3, 2023, via Zoom. CT is a 74-year-old Asian female, a retired commercial interior designer, who lives with her husband in CA, and has no children. CT is undergoing chemo tx for the third ocurrence of Ca in May 2023. She survived cervical Ca in 2015 and had a hysterectomy and colon Ca in 2019. Received the first infusion on 6/21/23; the next is scheduled for 7/12/23. Her primary objective for participating in the YTh sessions is receiving support during the chemo tx.

She developed lymphedema in the L forearm due to lymphoma under the L armpit. The latest measurements taken at the doc visit are Left - 6.75”/wrist 11.5”/forearm 12”/upper arm; Right - 6”/wrist 9.5” /forearm 12”/upper arm. A visit with the LE therapist is scheduled for 7/6/23. Additional side effects from chemo include nausea and fatigue that lasts ~4 days after infusion, tongue mucositis, and cognitive fog. She also saw PT for sciatica/piriformis syndrome, and the pain has been alleviated since.

She described herself as a strong, positive, and optimistic personality. She is grateful for a financially stable and comfortable home environment with a supportive husband and close friends. Although not too often, she feels resentment toward her body which allowed Ca to come back despite all the efforts to prevent it, including a healthy diet and regular workout. She is hopeful that with the advance of medicine, chemo tx this time will be effective and short so that she can get back to the normal life and start traveling again. Infusion is currently ordered for x3 every 3 weeks.

CT enjoyed gentle yoga at a gym pre-COVID and practiced for 2-3 years. She practices her version of visualization “of being a perfect body.” She is familiar with prana as she attended a Pranic Healing workshop in 2015 when she had a hysterectomy, but she no longer practices. She reported she had a near-death experience when she almost died due to an asthma attack when she was 13. She recalls “other body experience” as being peaceful and quiet, stating that death does not scare her, but pain and suffering are.

CT takes Xarelto, a blood thinner, indefinitely, due to a blood clot in the neck that developed in May 2023. She also takes Alpha Lipoic Acid for mild neuropathy in her feet, one of the side effects of chemo tx. It does not affect her balance.

Assessment Summary:
Swelling in the L arm is prominent in both the upper and forearm. Limited ROM is observed in L shoulder protraction, L wrist flex/ext, and L hand/finger flexion when making a fist. She complained of being “easily winded” when walking a long distance due to fluid accumulation around the lung from Ca, which should be alleviated by chemo. Presented no obstruction in 3-part Breathing during the session; however, we need to take caution for vigorous pranayama.

CT is talkative and maintains focus and eye contact, giving coherent responses. Stated that she has been staying optimistic with a commitment “to beat” this recurrence of Ca. States: the current level of stress is moderate; she tries to “snap out of it” by keeping herself busy or talking with her husband or girlfriends when anxiety about the uncertainty dominates her mind; she has a “capacity for being objective” from own emotions or thoughts, and tries to “correct” her mind/thoughts when it strays out to the negative side. She presented slight rajasic energy. As she is new to meditation, incorporating imagery or providing some sensory tools (mudras, chanting) may make the contemplative practice more accessible for her.

Being identified as a physically and socially active individual, she may be struggling with losing her persona due to her ailing body and trying to cling to her strong self-image. That could cause the rise of raga, the attachment property of Kleshas. She can work on Manomaya kosha towards acceptance and self-compassion to navigate her treatment process with less emotional struggle. The somatic experience of mindful and gentle movements of the body, calming pranayama, imagery meditation, introduction to ahimsa, and other forms of meditative practices can provide her the opportunities to connect with her true self beyond the ailing body while balancing each of the five koshas.

I explained to the CT that yoga has been introduced at medical facilities to support Ca patients, and scientific studies support its benefits. We will assess progress to determine future plans at the completion of four weekly sessions.

After the intake session, CT emailed me a copy of exercises prescribed by PT and a Lymphedema specialist, many of which can be found in yoga. Asanas.

Agreed-Upon Goals
Short-term: Learn how to utilize a wide array of yogic tools to support her during a Ca tx while addressing physical discomfort, lymphedema, and sciatica. Facilitate recovery process through reducing stress, self-compassion, and acceptance, support mental stability through grounding*, and improve energy flow and vitality.

[*“support mental stability through grounding” was added at Follow-Up Session 2]

Long-term: Develop the skills for self-regulation to maintain peace during the journey with cancer and beyond

How Yoga Therapy can help the client:

• Increase a sense of physical well-being through gentle joint movements and stretching while addressing lymphedema and sciatica pain (Annamaya)
• Improve energy flow and vitality depleted by cancer treatment. Activate PSNS to facilitate “rest & digest” functions during the recovery process (Pranamaya)
• Decrease harmful emotional interference to stay grounded* (i.e., anger/frustration towards the current state of the body, anxiety, worries about progression). Help release held emotions** (Manomaya)
• Develop witnessing faculty for self-regulation*** (Vijnanamaya)
• Promote a sense of well-being (i.e., acceptance, self-compassion, peacefulness) (Anandamaya)

*“Stay grounded” was added at Follow-Up Session 2 to reflect a change in the short-term goals
**Added after Follow-Up Session 2
***Revised after Follow-Up Session 1 [Updated from “Direct the consciousness to an inner voice and find clarity of self on the treatment path and beyond”]

Specifics of Care Plans:
Asana will be given to balance Annamaya, Pranamaya, and Manomaya by:
Improving arm mobility, lymph drainage, promoting a sense of being grounded and present, and countering stress and cognitive fog. Reducing sciatica pain by stretching hamstrings, gluteus, and piriformis.

• Repetitive gentle joint-freeing movements with breath - upper body/upper extremities, spine – Joint Freeing Mukunda Stiles
• Isometric contraction exercises (Namaste press, fist squeeze)
• Sukhasana, Malasana [Balasana was removed due to discomfort in the chest]
• Tadasana and gentle balance poses
• Hamstring stretches, resting pigeon, spinal twist, pelvic rock, and flowy bridge w/o arms in supine position.
• Restorative yoga

Note: Asana considerations include forward bend (fluid accumulation around the lungs). Allow asymmetry in arm movements (LE)

Pranayama will be given to balance Annamaya, Pranamaya, Manomaya Vijnanamaya by:
Activating PSNS for rest & digest, stimulating lymph & energy flow, countering stress, and inducing relaxation response.
• Breath Awareness Practice
• Deep Breathing/Dirgaswasm
• Ujjai
• [No kapalabhati due to hypertension]
• Alt. nostril breathing [FS2] (w/pratipaksa bhavana/Bhakti)

Guided imagery meditation and other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, Anandamaya by:
Reducing anxiety during chemo tx to support mental stability. Energetically promoting lymphatic flow back to the heart. Reducing stress, thereby downregulating inflammatory genes and upregulating the immune system through vagal tone stimulation.
• Guided imagery meditation adapted for chemo tx and lymphedema patients
• Yoga Nidra for Healing
• Witness Practice
• Yamas & Niyamas
- Ahimsa. Cultivate self-compassion/acceptance and feel good about herself without attachment to her own self-image
- Santosha. Notice parts of the body/mind that feel comfortable, content, and at ease [CT did not respond well, possibly due to mental blockage]
• Sutra 2.33 (Pratipaksa Bhavana)
o “Exhale illness, inhale health.”
• Loving Kindness Meditation during restorative yoga
o Cytokine reduction, self-compassion to love who you are (Bhakti)
• Daily journaling
o Self-regulation through reflection (Svadhyaya/Jnana)
• Mudra meditation
o Chemo infusion support through activating specific vayus to increase prana flow (Japa)
o Samana Mudra. Activate samana vayu for balance and make the body receptive to treatment.
o Prana Mudra for after the treatment. Help the body to recoup the energy of the body and to absorb the energy or the medicine into the body at the cellular level.
• Muladhara chakra meditation with “LAM” [Updated]
o Promote a sense of being grounded and present using chakra & vocalization & sankalpa/affirmation (Bhakti/Japa)

Resources:

Yoga AND cancer/chemotherapy side-effects:

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.

“Findings both during and after treatment demonstrated the efficacy of yoga to improve overall quality of life (QOL), with improvement in subdomains of QOL varying across studies. Fatigue was the most commonly measured outcome, and most RCTs conducted during or after cancer treatment reported improvements in fatigue. Results also suggested that yoga can improve stress/distress during treatment and post-treatment disturbances in sleep and cognition. Several RCTs provided evidence that yoga may improve biomarkers of stress, inflammation, and immune function.”

https://pubmed.ncbi.nlm.nih.gov/30933317/

2. Aybar DO, Kılıc SP, Çınkır HY. The effect of breathing exercise on nausea, vomiting and functional status in breast cancer patients undergoing chemotherapy. Complement Ther Clin Pract. 2020 Aug;40:101213. doi: 10.1016/j.ctcp.2020.101213. Epub 2020 Jun 14. PMID: 32891289.

“Consequently, it was determined that the [deep] breathing exercise reduced chemotherapy-induced nausea, vomiting and retching in breast cancer patients and affected positively functional status of patients.”
”
https://pubmed.ncbi.nlm.nih.gov/32891289/

3. Greenlee H, DuPont-Reyes MJ, Balneaves LG, Carlson LE, Cohen MR, Deng G, Johnson JA, Mumber M, Seely D, Zick SM, Boyce LM, Tripathy D. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017 May 6;67(3):194-232. doi: 10.3322/caac.21397. Epub 2017 Apr 24. PMID: 28436999; PMCID: PMC5892208.

“Meditation is recommended for improving quality of life in breast cancer patients (Grade A).”

“Yoga is recommended for improving the quality of life in breast cancer patients (Grade B). “ “… regarding yoga for anxiety/stress and for depression/mood disturbances, yoga can be adapted and modified for use in this population with low risk to the patient. Overall, yoga has shown preliminary efficacy in improving quality of life, and is recommended for use with breast cancer patients.”

“High levels of evidence support the routine use of mind-body practices, such as yoga, meditation, relaxation techniques and passive music therapy to address common mental health concerns among breast cancer patients, including anxiety, stress, depression, and mood disturbances. Additionally, meditation has been shown to improve quality of life and physical functioning, and yoga has been found to improve quality of life and fatigue.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892208/

4. Patel DI, Almeida GJ, Darby NT, Serra MC, Calderon T, Lapetoda A, Gutierrez B, Ramirez AG, Hughes DC. Therapeutic yoga reduces pro-tumorigenic cytokines in cancer survivors. Support Care Cancer. 2022 Dec 15;31(1):33. doi: 10.1007/s00520-022-07536-y. PMID: 36517621; PMCID: PMC9750838.

“TYP [therapeutic yoga program] led to a significant reduction in circulating cytokines associated with chronic inflammation in a heterogeneous sample of cancer survivors.”

https://pubmed.ncbi.nlm.nih.gov/36517621/

5. The role of yoga in inflammatory markers, Carolina Estevao Brain, Behavior, & Immunity - Health
Volume 20, March 2022, 100421

“A large randomised clinical trial that recruited 200 women, investigated the impact of yoga on inflammation, mood, and fatigue in cancer breast survivors. The control group was offered the yoga intervention later, as a wait-list control. The yoga group had higher vitality while having lower levels of IL-6, TNF-α, and IL-1 β. Lower levels of IL-6 and IL-1β were consistently found at follow-up, three months after the end of the treatment in the yoga group (Kiecolt-Glaser et al., 2014), indicating a long-term effect on the above-mentioned inflammatory markers.”

Lymphedema

1. Fisher MI, Donahoe-Fillmore B, Leach L, O'Malley C, Paeplow C, Prescott T, Merriman H. Effects of yoga on arm volume among women with breast cancer-related lymphedema: A pilot study. J Bodyw Mov Ther. 2014 Oct;18(4):559-65. doi: 10.1016/j.jbmt.2014.02.006. Epub 2014 Mar 1. PMID: 25440207.

“The results of this pilot study examining the effect of yoga on arm volume in women with BCRL [breast cancer-related lymphedema] are promising, showing a statistically significant decline in arm volume following 8 weeks of yoga participation, providing women with BCRL with another exercise to assist in managing lymphedema.”

2. Saraswathi V, Latha S, Niraimathi K, Vidhubala E. Managing Lymphedema, Increasing Range of Motion, and Quality of Life through Yoga Therapy among Breast Cancer Survivors: A Systematic Review. Int J Yoga. 2021 Jan-Apr;14(1):3-17. doi: 10.4103/ijoy.IJOY_73_19. Epub 2021 Feb 5. PMID: 33840972; PMCID: PMC8023442.

“Targeted yoga intervention programs have been proven to improve the overall sleep quality, reduced daytime functioning,[14] fatigue-related symptoms,[15] blood cortisol levels,[16] postchemotherapy-induced nausea and vomiting,[17] lowered musculoskeletal problems such as muscle soreness and overall physical discomfort,[18] and reduced psychological-related symptoms such as anxiety and depression.”

Asanas:
Benefits of Isometric Contraction for LE Patients:
Exercise for the Prevention & Management of Lymphedema by Cancer Exercise Training Institute
https://www.thecancerspecialist.com/2019/06/26/exercise-for-the-prevention-management-of-lymphedema/

Sciatica Pain
Piriformis Syndrome, Yoga Therapy by Mark Stephens (pp. 417-428)

Pranayama:
Pranayama and Cancer, YogaU
Breath observation, Ujjayi, Kapalabhati, Alt. Nadi Shodhana
https://yogauonline.com/yoga-and-healthy-aging/yoga-for-cancer/pranayama-and-cancer/#:~:text=The%20researchers%20concluded%20that%20pranayama,for%20cancer%20patients%20undergoing%20chemotherapy.

The 2015 article cites Dhruva A, Miaskowski C, Abrams D, Acree M, Cooper B, Goodman S, Hecht FM. Yoga breathing for cancer chemotherapy-associated symptoms and quality of life: results of a pilot randomized controlled trial. J Altern Complement Med. 2012 May;18(5):473-9. doi: 10.1089/acm.2011.0555. Epub 2012 Apr 23. PMID: 22525009; PMCID: PMC3353818.

Sutra/8 limbs of Yoga:
Yoga with Leona “Overcoming breast cancer through yoga” on Ahimsa
https://yogawithleona.com/2020/09/09/be-kinder-to-yourself/

Mudras:
Excerpts from An Interview by Marianne Woods Cirone, MS, MFA, CYT-500 with Indu Arora
https://integrativecancer.org/using-mudras-in-cancer-recovery/
Use of Mudras in Cancer Recovery

Imagery:
Guided Imagery Relaxation during Chemotherapy. Inspired by www.innerhealthstudio.com/chemotherapy.html

Additional resources for Yoga + Cancer:
A Yoga Therapy Model for Support in Cancer Patients: Weaving Pancha-Kosha and Vijnana Yoga Principles by C Or-Back

Yoga Boosts Cancer Survivors’ Well-Being, Yoga Journal October 2015 (YJ interview on Healing Yoga for Cancer Survivorship protocol study with Cheryl Fenner Brown)

Cancer-Related PTSD and Racial Equity: Bridging the Treatment Gap, 2023 SYTAR workshop by Cheryl Fenner Brown

• Yes

Session 1
Date: 7/10/23 Time: 2-3:30 PM Location: Virtual

Activities
1. Check-in
2. Discussed short-term and long-term goals. Shared summary of scientific studies and articles on yogic tools for cancer recovery (Pranayama, visualization/meditation, mudras)
3. Centering. Witness practice. CT feedback.
4. Asanas – All on mat
• Sukhasana. Created comfortable seated position using props.
• Repetitive gentle joint-freeing movements with breath in a seated position on mat. Joint Freeing Series p.1 - Upper body/upper extremities, spine (seated Cat & Cow)
• Hamstring stretches using a strap, resting pigeon, pelvic rock, and flowy bridge w/o arms, spinal twist (in spine position)
5. Relaxation
• Restorative poses (Supported Reclining Pose)
w/Cheryl Fenner Brown Yoga Nidra for Healing. pp.4-5 Guided Visualization
6. Pranayama
• Breath Observation
• Deep breathing/3-part breathing
• Ujjai
7. Mudras for pre-chemo and post-chemo. Samana Mudra and Prana Mudra
8. CT feedback. Discuss Home Practice and guidelines

1. Breath Observation Practice, Deep Breathing and Ujjai
2. Mudra practice (Pre/post-infusion)
3. Joint Freeing Series by Mukunda Stiles, Page 1 only (No or light practice only during recovery period)
4. Daily journaling to monitor your well-being – physical, emotional, mental, and spiritual. Note anything you noticed. Use Witness Practice for daily check-in. (body, breath, emotions, energy level, thoughts)
5. Keep track of your practice using the My Home Practice Chart

Handouts:
• Reading materials: Pranayama and Cancer
• Optional: Script for Guided Imagery Relaxation during Chemotherapy

*A list of Home Practice is posted and updated weekly on Google Doc

CT welcomes anything to help with the upcoming chemo tx. She is interested in the imagery technique she can practice during the infusion. She will be administered four types of drugs over 7 hours, including an immunotherapy drug. BP has elevated (160/101) since the first infusion, which will be medically managed. Manual lymphatic drainage by LE specialist on 7/6 appeared to be effective. Hair loss started a few days ago (2 weeks after the chemo); her hair stylist visited her home and cut hair close to the scalp. She now wears a cap. Reported swelling in upper arm reduced; she could see knuckles now; stress level is “ok.” Restorative yoga at the end of the session “helped ease tension.”

The second round of chemo is in two days, a large portion of the session was spent to prepare for the upcoming chemo. CT presented nervous energy, incessantly talking at the start. Seemed distracted and responded to queries less coherently. Her eyes welled up when talking about her girlfriend cooking a meal for her, but she maintained composure for the rest of the session.

CT followed the instructions for seated and floor asanas w/o problems or presenting discomfort. Presented tight hamstrings for both legs; bolster support under the sacrum aided knee extension. 3-part breathing didn't come naturally to her, so I provided instructions in the home practice package. CT understands the importance of deep breathing and expressed a willingness to try to practice regularly. She listened intently during mudra practice, asking me about the timing/frequency.

Short/long-term therapy goals are identified and agreed upon. CT stated that witness practice helped her notice the sensations in the body but nothing she noticed in the subtle layers, which may suggest a blockage in Manomaya or Vijnanamaya kosha. Also, her difficulty presented in pranayama practice may be due to physical or emotional tension. For the weekly home practice, I suggested practicing 3-part breathing whenever she noticed stress/anxiety and gave two mudras for pre/during/post chemo and a script for guided imagery relaxation. She will ask her husband to make a recording of the script.

It was a challenging session for me to stay grounded. A sudden change in her look affected me for the rest of the day. It reminded me that regular and strong personal practice is such a crucial part of being a yoga therapist, particularly if you wish to work with clients with life-threatening conditions.

We will meet on 7/18 at 2 pm, six days post-chemo #2. Will update the list of weekly home practice and additional materials on a shared Google Doc. CT will likely benefit from contemplative practice during the recovery period. Rooting/grounding practice will be given, focusing on the Muladhara chakra. Yoga Nidra will support her with deep & embodied rest. Kapalabhati will be removed from CP as hypertension is reported.

• Yes

Session 2
Date: 7/18/2023 Time: 2:30-4 PM Location: Virtual

Activities:
1. Check-in post-chemo
2. Discussion regarding updates to the goals. Added “Support mental stability.”
3. Reviewed HP sheet
4. Centering. Witness practice with santosha.

5. Asanas – All on the mat
• Sukhasana. Meditation with Muladhara Chakra with chanting LAM
• Repetitive gentle joint-freeing movements with breath in a seated position on the mat. Joint Freeing Series p.1 - Upper body/upper extremities, spine (seated Cat & Cow)
• Isometric contraction (Namaste press, fist squeeze)
• Malasana focusing on Muladhara chakra (w/props)
• Hamstring stretches using a strap, resting pigeon, spinal twist (in spine position)

6. Relaxation
• Savasana  Yoga Nidra
**Omitted the rest of the planned activities and ended the session as CT fell asleep during Yoga Nidra

1. Breath Observation Practice, Deep 3-Part Breathing and Ujjai
2. Meditation with Muladhara/Root Chakra
o Come to a cross-legged position with props. Sit high with towels/cushions under the knees. Practice Deep Breathing, then vocalize LAM 3x or more, OR
o Come to a squat position with a cushion/blocks under your buttocks. Bring the palms together. Elbows inside the thighs. Feel the connection with the Earth, grounding
3. Joint Freeing Series by Mukunda Stiles, Page 1 only (No or light practice only, during recovery period)

4. Daily journaling to monitor your well-being – physical, emotional, mental, and spiritual. Use Witness Practice.
5. Mental body scan. Focusing on where you feel good and at ease
6. Keep track of your progress using My Home Practice Chart

Handouts:
• The Root Chakra - Muladhara
• LAM chanting audio
• Yoga Nidra Audio File for relaxation

CT reported she received her second infusion six days ago; suffered fatigue and nausea during the 2nd-4th day. CT’s breathing and stamina are compromised due to the chemo. However, she stated she still wants to practice asana for lymphedema and sciatica pain as “she has a strong motivation to get better.” Stated 3-part breathing was helpful when she wanted to relax and before going to sleep as “it quiets the mind.” She hopes her “body will cooperate with” her and the last chemo on 8/2 will eradicate Ca. Stated: felt grounding vibration during LAM/Root Chakra chanting in Sukhasana, leaving her feeling calm afterward. She noticed long hours of standing aggravates neuropathy pain, a lasting side-effect from chemo received in 2019. Reported sciatica pain has returned due to inactivity but is minor. Reported swelling in L arm continues to subside; has been doing PT/LE exercise whenever possible but didn’t do much Joint Freeing or isometric contraction exercises at home.

Progress seen in L shoulder ROM in protraction; L wrist flexion. The upper arm looks looser than last week. She reported shortness of breath when moving quickly. Deep breathing does not seem to affect shortness of breath one way or another. PET/CAT scan is scheduled for 8/3, and she will know if she needs to undergo another round of chemo. She appears to convince herself that she will see favorable results.

CT didn’t seem to resonate with the modified witness practice with the spirit of santosha, whose main idea is paying attention to “what feels good, content and at ease” instead of “tension or discomfort”. She did not say anything about what she noticed. This could suggest the presence of held emotion or lack of self-awareness. She seemed to enjoy vocalization and the vibration she felt during the Muladhara Chakra meditation.

CT presented fatigue and moved slowly so that she didn’t get winded. We modified the activity plans to accommodate—shortened asana portion and omitted Supported Child Pose as it may compress her lungs. Didn’t practice Alt. N. Breathing or affirmation as CT fell asleep during Yoga Nidra, from which I left the session undisturbed. I checked back with her later via chat, and she stated it was relaxing and felt good afterward (although embarrassed). She said she is learning a lot of great techniques to relax, helping herself get well.

Due to the chemo, CT didn’t make much progress in home practice last week. While she repeatedly expresses her commitment “to beat cancer” to get well, her physical and mental energy is clearly depleted against her will. After discussing the unsteadiness observed at the last session, we updated the goal by adding “support mental stability.” She stated she liked the idea of feeling more grounded and recognized that she needs to have self-compassion for her body and emotions. We will find tools to access Manomaya, which will help her to release held emotions and be kind to them. “Stay grounded” has been added to the goals to support mental stability against uncertainty.

While clearly showing her depleted energy, CT is so determined that she pushes her through to “beat cancer.” I suggested focus be more on personal growth through her Ca journey. She was listening attentively. I intended to help her see “the bright side,” but I am unsure if it was the right thing to say. Such a suggestion could be insensitive to someone desperate to overcome a terminal illness.

• Further work on Manomaya and Anandamaya (LKM)
• Release held emotions through chanting
• Intro to Ahimsa (self-compassion)
• Balancing asanas (ease cognitive fog/regaining stability)
• Alt nostril breathing + Pratipaksha Bhavana
• Continue with Root Chakra meditation vocalizing affirmation - I am at peace right here, right now (grounding, Anandamaya)

• Yes

Session 4 *Last session*
Date: 8/1/23 Time: 12-1 PM Location: Virtual

Activities:
1. Witness practice. CT feedback.
2. Check-in
2. Assessment of the progress
Reviewed short-term and long-term goals. CT self-assessment, feedback, YTh feedback
3. Reviewed Mudras for pre-chemo and post-chemo. Samana Mudra (Absorption and assimilation) and Prana Mudra (Recovery)
4. Reflections
[Muladhara Chakra Meditation in Supported Child Pose is omitted as CT opted for self-reflection and Q&A]

CT will perform mudras and deep belly breathing before, during, and after chemo. Once she recovers, she will review the home practice up to date, design her regimen, and contact me if she needs support.

Shortness of breath worsened this past week, so she had to rest frequently while doing light activities. “Feeling anxious” as she will receive the 3rd chemo tomorrow. “My mind is racing,” and “putting too much unnecessary pressure on myself as I try to take care of everything before tomorrow.” Reflecting on the progress, she “recognizes and accepts anxiety as a natural emotion,” which she could not do a month ago. Stated: she didn’t receive mental support during the chemo for the last Ca tx (colon), and the YTh sessions have been helpful in various aspects, including opening herself up to accept help from others. She learned new breathing techniques to help her feel relaxed before and during infusion. She didn’t see much difference in arm swelling, but she “can accept it is a very slow process.”

CT moves too quickly during simple shoulder rolls, so I reminded her to go slowly with breaths, which seemed to settle her energy. Considering that she gets winded easily, we changed the activity plans and spent 75% of the session on reflection, discussion, and Q&A. CT requested a review of mudras for chemo, which we did. The latest arm measurement showed little progress in swelling.

At this 4th session, CT appeared to have found ease in talking about her held emotions, such as anxiety. CT chose to spend time on self-reflection and self-examination and talked about her personality and tendencies, which have supported her in challenging times in the past. Acceptance was a hard concept for her. She has been working on "letting go."

Reviewing mudra and breathing techniques supported her as she prepared for tomorrow's chemo. Reviewing the session goals and progress evaluation went well. CT stated that the four weekly sessions helped her with mental and emotional stability and provided comfort. She began to spend more time observing thoughts and emotions calmly. I highlighted achievements and self-efficacy she started to develop through witness practice, breathing, and mudra.

As I continued to meet with my CT, I gained insight that much of her emotional struggle comes from her inability to come to terms with disagreement between her self-image (strong/independent) and reality (ailing/dependent). I was able to recognize, although her strong self-image aided her in pushing her through the aggressive treatment she had chosen, it also contributed to her suffering, adversely affecting Manomaya kosha. Without explicitly sharing my observation, I emphasized the benefits of witness practice to help her become aware of emotions and thoughts without judgment or categorizing them as good or bad. CT continued the witness practice independently. At our 4th session, she said she was able to observe them “as they are,” making tangible progress in balancing Vijnanamaya. As she felt grounded through root chakra chanting, performing mudras, or practicing alternate nostril breathing with pratipaksha bhavana, she started to experience relief by choosing to let go of her held emotions and beliefs/attachment. These contemplative practices were easily accessible to my CT as they work directly with the senses. Due to her depleted energy during the recovery from infusion, we could not make noticeable improvements in the physical body nor alleviate her lymphedema; however, relaxation practice provided nourishment to balance Annamaya.

This case study was challenging and had me explore the boundaries of being a yoga therapist. It was easily observable that the treatment had taken a toll on her. She had hair when we first met, then lost all her hair by the 4th session. The change in her appearance and the harshness of chemo’s side effects she shared with me was shocking, and I felt sorry for her. Occasionally, I had to pull myself back from giving personal advice or showing my emotions to maintain a proper distance. It was also HAH’s strength and independent nature that kept me away from crossing the fine line.

On a separate note, this case study gave me another challenge: adapting my activity plan on the fly to respond to CT’s stamina, focus, and state, which fluctuated considerably, session by session. It helped me to be well-prepared but flexible. I am improving at asking open-ended questions, and applying other client-centered counseling techniques to elicit my CT to engage in deep conversation, and providing a safe space to unload whatever is in their mind.

CT will contact me when she wants follow-up sessions. The future sessions will be billed at $30/hr during my practicum.