Intake summary:
The intake session was conducted via Zoom on 7/13/23, 8:30-10:30 AM. CT is a 34-year-old Asian female who works full-time remotely as a client service manager at a multinational corporation. She lives in Silicon Valley with a boyfriend and the puppies they foster for adoption.

She suffers from lower back pain (muscular), stress, and anxiety; she also occasionally experiences headaches and sleep disturbance. She was diagnosed with Hashimoto’s Disease two months ago and experienced weight gain, lethargy, and brain fog, all of which are now medically controlled.

She works in a high-stress and deadline-driven environment. Her typical workday starts at 8 AM and ends around 7-8 PM with a 1-2 hr. break, which she seldom takes. She also works on some weekends and can be sitting at a desk for back-to-back video conferences for as long as 9 hours without eating lunch. She is aware that her constant thinking about work has been the primary cause of anxiety and stress; she habitually worries about making mistakes, not getting things done on time, etc. She contemplates the possibility that a speech impairment she had in childhood might be the underlying cause of her low self-confidence.

CT’s objectives for participating in yoga therapy are addressing physical and psychological health to bring more balance to life and incorporating yoga into the long term. Her first yoga experience was not enjoyable, as she was too self-conscious while practicing right next to her advanced yogi friend.

Assessment:
Long hours of working at a desk, lack of physical movements, and sustained intense mental activities appear to be the primary causes of tension in her body, affecting Annamayakosha, which manifested in her lower back pain, headache, and other imbalances. Her deskbound lifestyle also blocks the flow of energy, impacting the health of Pranamayakosha, which is observable in her shallow breathing and stiffness in her postures, movements, speech, and expression, as well as low sleep quality. CT’s lack of interoceptive awareness corroborates her not noticing her body’s needs, such as moving the body to release muscular tension, adequate rest for the brain, and a regular supply of nourishment.

Imbalance in Manomayakosha is presented as anxiety rooted in low self-confidence, creating negative thought patterns and unhealthy habits, including sensory overload from extended screen time (Raga Klesha/attachment).

Vijanamaya is also affected by the misconception of “I am not enough” and misidentification, which seems to be the source of her inability to relax (Avidya Klesha/ignorance & negative habits). Working from home daily, she cannot draw clear boundaries between work and personal time. She continues the negative cycle without experiencing a sense of well-being.

The physical assessment suggests weakness in core muscles, psoas, rectus femoris, quad, erector spinae, and L hip extensor and tightness in scalene muscles, hamstrings, glutes, lats, and erector spinae. Nervous and restless energy was observed, especially at the beginning of the intake, indicating Rajasic dominance in Gunas.

Agreed-Upon Goals:
Short-term: Learn how to apply yoga techniques to release tension and regulate ANS to increase resilience against stress/anxiety. + Cultivate compassion for self and others
Long-term: Bring more balance into the physical, mental, and energetic body with appropriate personal time/space, exercise, and a positive attitude toward self
Note: “+” denotes updates to the initial goals

How Yoga Therapy can help the client, kosha by kosha:
• Learn a whole-body activation sequence (e.g., Surya Namaskar/Sun Salutation) to release muscular tension and nervous energy and improve interoceptive awareness. Address LBP, and stiffness in shoulders and prevent headaches through stretching and alignment. (Annamaya)
• Learn the breathing techniques to balance SNS and PSNS (alert and calm) and to reduce anxiety/stress through relaxation techniques. (Pranamaya)
• Regulate sensory input to tone down the busy mind when rest is needed (Manomaya)
• Cultivate a sense of trust in the body & mind, wisdom, and intuition. Work on the will to say no. (Vijnanamaya)
• Learn to trust yourself and let go of the rest to Higher Power. + Cultivate compassion for self and others (Anandamaya)

Note: CT will practice Ishwara Pranidhana via Surya Namaskar, as it can be a moving prayer. She can also practice Pratyahara through the sequence by withdrawing the energy from the thoughts about the pose and focusing instead on the pose itself, sensations, and energy flow. She can then rest in Savasana by focusing only on her inner self.

Note: “+” and “-“ denotes updates to the initial plans

I. Asana will be given to balance Annamaya, Pranamaya, and Manomaya by:
Releasing tension and pent-up energy through flowy repetitive movements, improving muscle tones through a whole-body warm-up focusing on activation and stretching the back of the lower body (erector spinae, lats, hamstrings, glutes, etc.) focusing on restoration.

• Cat & Cow (lower back)
• Sun Salutation
• Hamstring stretches, resting pigeon, spinal twist (supine position)
• Hamstring stretches, forward bend, spinal twist* (seated position)
• Viparita Karani
*Practice seated twist to learn “breathing in a tight spot” and learn to apply it to anxious feelings in other situations

II. Pranayama and other energy work will be given to balance Annamaya, Pranamaya, and Manomaya by:
Reducing rajasic energy by inducing relaxation responses to counter stress and anxiety, promoting quality sleep.

• Deep Belly Breathing
• Dirgaswasm
• Alt. nostril breathing w/ext. exhalation
• Ajna Chakra meditation for pineal gland activation [This has been moved to the Follow-up Session 4 as insomnia appeared to have improved]

III. Meditation and other mindfulness techniques will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by:
Cultivating awareness and discriminative faculty, including interoceptive awareness, trusting inner voice, and evoking calm and joy; producing a relaxation response while managing sensory overload.

• Witness Practice (also Jnana yoga)
• Practice Pratyahara via a body scan, Sun Salutation, and Savasana

IV. Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by developing self-esteem and faith in Self while releasing negative thought patterns and feeling uplifted, cultivating compassion and happiness through positive interactions.

• Metta/Loving Kindness meditation
• Alt. nostril breathing w/Pratipaksha Bhavana (Sutra/Bhakti yoga)
• Santosha (Sutra/Niyama)
• 4 locks & keys (Sutra)

Lower Back Pain:
a. Yoga for Back Pain by Loren Fishman, MD, and Carol Ardman
• Muscular Pain pp. 45
• Pain with Specific Activities pp. 48-50
• “[Ernest Holmes, Dr. Harold Koenig and Larry Dossey] assert that prayer can actually modulate pain and illness, possibly by reducing stress.” P. 52

b. IAYT Research summary; Yoga Therapy for Lower-Back Pain

Stress and LBP:
Davis KG, Marras WS, Heaney CA, Waters TR, Gupta P. The impact of mental processing and pacing on spine loading: 2002 Volvo Award in biomechanics. Spine (Phila Pa 1976). 2002;27(23):2645-2653. doi:10.1097/00007632-200212010-00003
“Mental processing stress acted as a catalyst for the biomechanical responses, leading to intensified spine loading. Mental stress appeared to occur as a function of time pressures on task performance and resulted in less controlled movements and increases in trunk muscle coactivation. These adjustments significantly increased spine loading. These results suggest a potential mechanism for the increase in low back pain risk resulting from psychosocial stress caused by modern work demands.”

Anxiety:
Yoga As Medicine, Timothy McCall “Anxiety and Panic Attacks” – Viparita Karani, Cross-Legged Twist

Insomnia:
a. Pineal gland and Aija chakra
Third eye chakra or Ajna chakra, Ekhard Yoga article https://www.ekhartyoga.com/articles/practice/third-eye-chakra-ajna-chakra#:~:text=Physical%20Body%3A%20The%20third%20eye,circadian%20rhythms%20and%20reproductive%20hormones.
“The third eye is located in the centre of the head, level with the middle of the eyebrows. It is associated with the pineal gland, a small gland situated deep in the brain which secretes melatonin that regulates the body’s internal clock influencing circadian rhythms and reproductive hormones.”

b. Yoga As Medicine, Timothy McCall “Insomnia” – Viparita Karani, Supported Child

Self-confidence:
How to Trust Yourself and Build True Self-Confidence by Rhonda Britten (Life coach)
https://fearlessliving.org/how-to-trust-yourself-and-build-true-self-confidence/

Asanas:
Integral Yoga Hatha Class on YouTube. https://www.youtube.com/watch?v=T7WnfFDnmmk

Neck and Shoulder stretch, Ann Swanson https://www.dropbox.com/scl/fi/3xc0s87rvqp923y6i8f8g/Neck-shoulder-spine-release.docx?rlkey=x578i95ifs307gfpujdvys6mx&dl=0

Sutras:
a. Four Locks, Four Keys: A Simple Approach to Relationships, Integral Yoga Magazine. Sutra I.33
https://integralyogamagazine.org/four-locks-four-keys-a-simple-approach-to-relationships/

b. Pratipaksha Bhavana
Yoga Sutra of Patanjali II.33 “When disturbed by negative thoughts, opposite ones should be thought of. This is Pratipaksha Bhavana.”, Inside the Yoga Sutras by Rev. Jaganath Carrera

c. Pratyahara
Yoga Sutra of Patanjali II.54
“… control of senses is attained not by pulling the mind away from the sense object but by redirecting attention towards something elevating. One of the benefits of redirection is that it cultivates non-attachment by replacing transitory sense satisfactions with the deeper, more satisfying contentment of the sattwic mind.”, Inside the Yoga Sutras by Rev. Jaganath Carrera p.157

d. Yamas & Niyamas
Ahimsa, Satya, Santosha, Svadhyaya, Ishwara Pranidhana

Other:
Loving Kindness Meditation:
Uchino, B. N., Bowen, K., Kent de Grey, R. G., Smith, T. W., Baucom, B. R., Light, K. C., & Ray, S. (2016). Loving-Kindness Meditation Improves Relationship Negativity and Psychological Well-Being: A Pilot Study. Psychology, 7, 6-11. http://dx.doi.org/10.4236/psych.2016.71002 Loving-Kindness Meditation Improves Relationship Negativity and Psychological Well-Being: A Pilot Study

“This pilot study suggests that LKM may be a novel intervention approach to improve well-being by fostering relationship processes. A major benefit is that it appears to be a more comprehensive approach to altering relationship perceptions as it both increased social support and decreased social negativity.”

• Yes

Session 1
Session Date: 7/19/23 Time: 8:30-10 AM Location: Virtual on Zoom
Activities:
1. Check-in. Follow-up Qs from assessment and discussion to co-create specific therapy goals. Discussion topics/prompts include:
a. Is it possible to identify the causes of 1) Anxiety, 2) Phys & mental stress?
b. Are they pointing to some emotional pain that needs healing?

2. Pranayama: Reviewed 3-part breathing and introduced alt. n breathing with extended exhalation (1:2)

3. Asanas: Short warm-up in all 4s. Introduced Sun Salutation sequence. Supported legs-up-the-wall pose (Viparita Karani) w/back support for releasing tension in LB, addressing insomnia, and inducing relaxation

4. Q&A and feedback, going over Home Practice assignments

Weekly assignment is shared with CT in a GoogleDoc
CT will:
1. Stop working at 6 or 6:30 pm, 2 days/work week. Will get out of the office space and go outside for a physical activity (power walking with a dog and/or practicing Sun Salutation x3*). Will reach out to her sister to be an accountability partner.
2. Pranayama (Breathing practice) every day. 3-part breath and alternate nostril breathing. Will try 3-part breathing during a stressful meeting and alt. nostril breathing to help me go to sleep.
3. Nourish body & mind. CT will eat lunch every day and drink more water. Prep lunch and set a reminder to eat it. Will take a lunch break whenever possible. Will keep water by the desk and remind myself to drink.

*Integral Yoga Hatha Class on YouTube, Sun Salutation section ONLY*. SS starts at around 8:00. Duration: 5 mins. It’s a great warm-up and activation in the entire system, so practicing before bed is not recommended. Written Instructions for the Sun Salutation is here. Note: Bend your knees slightly in Uttanasana (Hip flexion).

4. Use My Home Practice Chart to keep track of progress.

Reading materials:
1. Research summary; Yoga Therapy for Lower-Back Pain
2. Viparita Karani (Legs up the wall pose for relaxation, 5-20 mins), Supta Padangusthasana (Reclining Hand-to-Big-Toe Pose) using a strap (3-5 mins, hold it longer for the leg that feels tighter)

CT identified the source of LBP: “sitting too much, w/poor posture,” and “not drinking enough water and missing lunch.” This week, in particular, additional stress came from “interactions with colleagues whom I do not respect” and the fact that she “has to maintain a professional front in order to keep the team together”— “that drains me.” CT also contemplates that her insecurity and lack of trust in herself may be the root causes of her anxiety. “I couldn’t let go”. She described she must physically move out of the house to separate herself from working till the evening. She is interested in practicing Sun Salutation with her boyfriend, who “similarly couldn’t set the boundary between work and personal life.”

Through the self-reflective exercise, we narrowed down the objectives of the 5-week yoga therapy sessions: 1) Improve flexibility/mobility and reduce lower back pain, 2) incorporate yoga into life, and 3) achieve mental and physical well-being. The exercise prompts include: What is physical pain telling you? What are the lifestyle errors that contribute to that pain? Working from home can make it hard to defend personal time—are there any helpful ways to establish a boundary? Where is the anxiety coming from?

Considering her schedule, which is driven by a workload and changes weekly, we devised a realistic home practice regimen using the SMART method (Specific, measurable, attainable, timebound, and time-bound) as follows.

1. Disconnect from work at 6 or 6:30. Leave your office. Leave your workspace for physical activities (walking a dog, Sun Salutation x3, 2 days/week
2. 3-part breath and practice alt. nostril breathing. Try 3-part breathing during a stressful meeting.
3. Prep lunch and set a reminder to eat it. Take a lunch break whenever possible. Keep water by the desk and remind yourself to drink.

CT was more relaxed and open to discussing emotional struggles than at the intake session. She was actively engaged in the goal setting and discussion about the root cause of physical pain, and it is observable that she is motivated to make some changes. She responds well to Sun Salutation practice. I suggested that she strive to make incremental changes and celebrate small successes. Will update the care plans with 4 locks & keys, which might benefit her challenge with her coworkers.

I used motivational interview techniques, normalizing, showing compassion, and building rapport by stating my support for her path. It’ll be a change in lifestyle for her and may take time, so I set a realistic goal to “make a baby step.” This differs from many of my previous case studies, in which I focused more on providing therapeutic support for CT’s recovery period or illness. She is also at the age of building a career and starting a family, much younger than my previous CTs; I want her to gain a perspective of seeing life as a long journey.

I will email her next Thursday to check the progress, as we won’t meet for almost two weeks. The next session will be focused on anxiety, sleep hygiene, and resting the mind. We will discuss sensory stimulation overload, leading to meditation, and the “4 locks & keys” home practice handout

• Yes

Session 2
Session Date: 8/10/23 Time: 8-9AM Location: Virtual on Zoom
Activities:
1. Check-in
2. Witness Practice
3. Discussion about sensory overload
4. Asana
a. Sun Salutation
b. Janusirsasana w/strap
c. Ardha Matsyendrasana
5. Meditation w/Jnana Mudra. Discussion of benefits of meditation for stress reduction and anxiety
+ affirmation “I am enough, exactly as I am”

Weekly assignment is shared with CT in a GoogleDoc
CT will:
1. Defend personal time. Step out of the office space and go outside for a physical activity (powerwalking with a dog and/or practicing Sun Salutation x3)
2. Pranayama (Breathing practice) every day. 3-part breath and alternate nostril breathing
3. Nourish body & mind
4. Add one-minute meditation to my pranayama with Jnana mudra at the end of the day.
5. Asana practice. Sun Salutation (w/o video, focusing on experience instead of forms), Janusirsasana, Ardha Matsyendrasana
6. Witness Practice as daily check-in

Reading materials:
1. How to Trust Yourself and Build True Self-Confidence (Rhonda Britten, life coach)
https://fearlessliving.org/how-to-trust-yourself-and-build-true-self-confidence/
2. Four Locks, Four Keys: A Simple Approach to Relationships, Integral Yoga Magazine
https://integralyogamagazine.org/four-locks-four-keys-a-simple-approach-to-relationships/

From 7/24 to last Sunday, she was immersed in a special project and worked 10-12 hours, including weekends. She had no time for asana practice but used 3-part breathing when stressed. CT described, “It works as a reset button.” During that intense week, her “mind was completely taken over by work,” and she missed lunch regularly (she had snacks) and missed dinner because she “didn’t want to break focus.”

This week, the work returned to its regular schedule. She has resumed daily Sun Salutation practice and is getting more comfortable with the sequence. She “uses the slow, long breath to relax the tight muscle in the lower back.” Mudra during the meditation “was helpful as it brings the focus back to the physical sensation of the fingers.” She stated she wants to get back on track with the home practice regimen.

CT demonstrated good progress. Home practices done prior to the busy week supported her during the stressful week. She self-rated, “My stress is currently low, anxiety low. No issue with sleep.” Based on the information, “sleep hygiene” was removed from the planned intervention for today's session and replaced with affirmation for self-confidence (as well as Ishwara Pranidhana) as it appeared to appeal to her. She took notes on her observations during Witness Practice. We discussed trusting our own feelings and approaching true feelings with compassion.

She seemed to have gained an appreciation for the holistic experience of asanas. I suggested that once she becomes comfortable with the Sun Salutation sequence, she can stop watching the video and try to focus on the sensations, breath, and energy flow, referencing the paper instructions if necessary.

It is observable she started taking ownership of her practice. She started practicing affirmation and journaling independently using a workbook she bought. She writes down the positive things to focus on at the beginning of the day and “the negative stuff” she wants to release at the end of the day. I suggested she incorporate the daily affirmation into her meditation or breathing practice.

We effectively discussed sensory overload as a segue into meditative asana and meditation with mudra. It smoothly transitioned from “theory/teaching” to “practice.”

During the seated twist, I suggested she remind herself of the “breathing in a tight spot” technique she can apply when anxiety or stress arises.

As she returns to working with her challenging coworkers, which appears to be one of the significant sources of stress, the next session will address her relationship with herself and others. She will practice Pratyahara during Sun Salutation and Savasana.

• Yes

Session 3
Today’s Session Date: 8/16/23 Time:8:30-10 AM Location: Virtual on Zoom
1. Check in. Progress assessment
2. Discussion: Four Locks, Four Keys: A Simple Approach to Relationships, Integral Yoga Magazine
3. Neck and shoulder release
4. Body scan. Practice attunement to sensation.
5. Practice pratyahara via Sun Salutation (withdrawing the energy from the thoughts about the pose and focusing instead on the pose itself) and Savasana (focusing only on your inner self)
6. Supta padangusthasana/resting pigeon using a wall
Loving Kindness meditation (full version – myself, loved ones, neutral, negative, everyone/everything)
7. Alt. nostril breathing (w/Pratipaksha Bhavana). INH “I’m enough,” EXH “Let go”

Weekly assignment is shared with CT in a GoogleDoc
CT will:
1. Defend personal time. Step out of the office space and go outside for a physical activity (powerwalking with a dog and/or practicing Sun Salutation x3)
2. Pranayama (Breathing practice) every day. 3-part breath and alternate nostril breathing. Apply Pratipaksha Bhavana: Exhale unhelpful quality; inhale uplifting quality, leading to meditation
3. Nourish body & mind.
4. Add one-minute meditation to my pranayama with Jnana mudra at the end of the day.
5. Asana practice. Sun Salutation (w/o video, focusing on experience instead of forms), Janusirsasana, Ardha Matsyendrasana. Neck and Shoulder stretch at a desk to prevent headaches.
6. Journaling homework - Pratipaksha Bhavana with suggested prompts

CT suffered acute LBP last week along the lower lumbar right above the coccyx. Sharp pain persisted for a few days since Saturday but appears to be subsiding. Icing and Bengay cream helped. She doesn’t know what triggered it. Slow and gentle stretching seemed to ease the pain, so she did not stop asana practice. She no longer needs to watch the video for Sun Salutation. During the session, the low lunge was replaced with Cat & Cow to alleviate discomfort in the lower back, to which she responded positively. Also, Supta Padangusthasana, using a wall, was added on the spot for LBP release.

Another project is about to start, which makes her anxious. She is doing all the prep she can do “to have a sense of control.” Breathing practice helps when the “nervousness and anxiety bubble up.” She reported that she approached one of the two “difficult” coworkers to reduce the unsustainable workload, presented her work log, and negotiated to delegate tasks. Unlike last time, he took it seriously, and they were able to hash it out. She felt “a ton of relief.” Her action demonstrated improved self-confidence and skilled interaction with people she perceives negatively.

We assessed progress against the baseline taken at the intake session. Quality of sleep was significantly improved (5 days/wk from none), difficulty falling asleep and waking up at night was down from 5 days to none, and she had no headache; she had LBP for 3 days during the busy period (Baseline was 1 day/week). The stress level was 4 (high) during the busy period but then reduced to 1 once her workload returned to normal. She stated that setting a boundary between work and personal time has become easier. She stopped working at 6 PM, two days a week for regular workdays.

Today, we worked on Pratipaksha Bhavana and Pratyahara, the main topics I intended to cover during this session. She appeared to enjoy discovering the meditative aspect of the asanas.

From the beginning, it was easily observable that my CT is rational, extremely focused, and goal-oriented. Therefore, my plan for Session 1 was to elicit her motivation to shift her lifestyle and mental state by taking a systematic approach to work on her goals and care plans. I allowed ample time for discussion to clarify: 1. Where she is now, 2. Where she wants to get to, 3. How she can get there. Through this simple but effective self-inquiry, she was able to articulate and resolve her ambivalence. We applied the SMART concept to co-develop a home practice regimen that works well for her.

Based on the progress assessment conducted, we both agreed that the primary objectives were met. Her improvement in the health of Pranamayakosha was particularly notable. She learned to apply yoga techniques to release tension and regulate ANS to build resilience against stress/anxiety. With improved interoceptive awareness, she has become aware of the effects of breathwork on her anxiety and emotional disturbance and appreciates it. This also demonstrates her excellent work on physical and psychological attunement and discernment to not reacting to circumstances, positively affecting Vijajamaya and Manomaya. She is much more mindful of work-life balance and taking care of her personal life, contributing to her sense of well-being, happiness, and contentment.

Lastly, I appreciated the opportunity to expose my CT to a more holistic aspect of yoga practice beyond what is commonly projected in modern culture. I hope she will continue practicing asana as a form of meditation, as she did while exploring Pratyahara, and deepen her trust in her intuition.

We will meet for the last session on 8/24/23 8-9:00 AM. She knows someone who might be interested in yoga therapy, whom she will connect me with. Planned activities for Session 4 include: 1. Breathing into Aija Chakra meditation for insomnia (when it comes back in the future), and 2. Practice Santosha through movements and body scan to find peace and acceptance. Home Practice for the last session is “Design your home practice routine for the rest of August and September.