Intake summary:
The intake session was conducted on 9/14/23 via Zoom. ELB is a 50-year-old white female who lives alone in Austin, TX. She works remotely from home as a data processor and researcher. She holds RYT-200 but has never taught a class. Her primary complaints are undiagnosed lower back pain, chronic stiffness/tightness, and “congestion” in the arms, hands, hamstrings, and TMJ. Secondary complaints include low sleep quality and depression, for which she takes a very low dose of Zoloft.

ELB reported her pain in the distal hamstring of the left leg is 4-5 out of 10 (10 as unbearable pain). Standing still and long sitting exacerbate the pain. She works eight hours/day on a computer, sitting or standing at the desk. Her workout routine comprises a “boot camp” aerobics class and Afro-Cuban dancing, which do not address her chronic tightness. The pain in the lower back often wakes her up in the middle of the night (x3/week). To cope, she comes to a position of Child Pose or “Cross-legged” Forward Fold to fall back asleep. The pain persists 1-2 weeks before her period and 1-3 days afterward, likely hormonal.

She reports “mini bursts of maniac energy from time to time.” “I get hyper, buzzy, which actually feels good initially, but then I realize it’s not real happiness.” The elation is usually followed by a “compensatory hang-over,” leaving her feeling depressed. The persistent stiffness in the body makes her feel stressed and worried about its projection.

ELB experienced the childhood trauma of being neglected by her parents. Working with a psychotherapist on the trauma has been helpful in “making peace with” the emotional pain. When asked to describe how the experience affected who she is right now, she replied, "Defensive and guarded.”

Assessment:
ELB suffers from physical pain, tightness, and discomfort affecting Annamaya kosha. The tension in the body may be attributable to tight fascia and/or muscles, as ELB describes the nature of the pain as “pervasive, dull, and not in the joint.” It should be noted that osteoarthritis runs in the family. Poor neck position (“Forward head” or hyperextension of the upper cervical) was observed when asked to recreate how she sits at a desk, which can lead to TMJ dysfunction. She presented weakness in the right arm muscles, tightness in the biceps and lower lumbar area, and limited ROM in bilateral hip flexion and shoulder flexion/extension.

Imbalance in Pranamaya and Manomaya is presented as rajasic depression, which might be more accurately defined as mood swings, with which ELB agreed. From the Ayurvedic perspective, the prominent air quality of Vata dosha is observable from her body language, posture, and body type (light, constantly moving). When asked to articulate where she holds negative emotions, she responded, “In my head and heart,” She will benefit from unclogging Apana Vayu via extended exhalation and grounding practice to direct the energy down and outward.

Samskara is rooted in her childhood trauma, affecting the deep layers of Manomaya, but also Vijnanamaya and Anandamaya. To augment her work with a psychotherapist, yoga therapy can support her by releasing tensions in her physical and energetic body and redirecting mental activities to find healing.

The health of Vijnanamaya and Anandamaya is greatly afflicted; she is identifying with the physical and emotional body and collapsing into the energies of fear, guardedness, and frustration, suggesting the influence of Avidya Klesha. Leveraging her yoga teacher background, we will study key teachings in sutras and the Panchamayakosha Model to guide unraveling the root of suffering. They will be used as a guidepost in goal-setting activities. ELB stated she is receptive to yogic philosophy and journaling exercises for self-inquiry.

Initial Care Plans
Agreed-Upon Goals:

ELB will…

Short-term: Learn how to apply yogic tools to release tension in the physical, energetic, and emotional body and feel grounded
Long-term: Cultivate a relationship with Bliss Body (Anandamaya kosha) to experience a deep sense of happiness and peace through regular yoga practice

How Yoga Therapy can help my client:

• Releases tightness in the body and establish a steady movement (Annamaya)
• Help establish a steady rhythm of breathing and movement of vayus. Reduce rajasic energy and induce relaxation response (Pranamaya)
• Promote a grounding effect through meditation as a mental anchor (Manomaya) +Teach techniques to regulate internal states.
• Build stronger discriminative faculty to redirect mental activities (Vijnanamaya)
• Develop regular meditation practice to reweave the connections between body and mind and cultivate a relationship with the True Self (Anandamaya)

Note: “+” denotes updates to the initial plans

1. Asana will be given to balance Annamaya, Pranamaya, and Manomaya by:
a) Freeing physical tension by working with muscles and fascia in the Langhana-type asanas via flowing sequence and grounding postures to regulate her Vata imbalance
b) Releasing tightness in TMJ
c) Stretching muscles and fascia in upper and lower extremities and lower back, which may alleviate LBP during PMS
d) Inducing relaxation response via targeting the posterior structure stretching

• Joint Freeing Exercise
• Sun Salutation “as moving meditation" with breath and w/mantra (Bhakti)
• Low Cobra variation, Vamping Pose (TMJ release)
• Puppy Pose, Seated Forward Bend, Spinal Twist, Resting Pigeon, Gate Pose (Posterior stretch and lateral stretch for tightness in lower ribs)
• Garudhasana, Apanasana variation (Fascia release)
• Malasana (unclogging Apana Vayu, eliminating negative thoughts and emotions)
• Viparita Karani, Supported Inversion, Half Plow (Insomnia)
• Restorative yoga*: Supported Child, Supported Spinal Twist
*Restorative yoga was added to the care plan as an alternative to the “Cross-Legged Foreword Fold” she has been using to fall back asleep

2. Pranayama and other energy work will be given to balance Annamaya, Pranamaya, and Manomaya by:
a) Promoting a steady rhythm of breathing and movement to reduce excessive vata quality.
b) Toning down rajasic energy, inducing relaxation response via PSNS activation, and improving sleep quality

• Deep Belly Breathing
• Dirgaswasm
• Ujjai
• Alt. nostril breathing w/ext. exhalation +Pratipaksha Bhavana [added after the Follow-up Session 2]
• Anuloma Ujjayi (Inhalation using Ujjai)

3. Meditation and other mindfulness techniques will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by:
a) Cultivating a grounding effect using a mental anchor to regulate the internal state
b) Building stronger discriminative faculty to redirect mental activities
• Body Scan
• Witness Practice (Jnana yoga)
• Walking meditation barefoot on grass or soil (Also engages the Apana Vayu flow)
• Meditation with imagery, “Lake” (self-regulation)

4. Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by:
a) Deepening the understanding of self-regulation through Svadhyaya
b) Promoting a regular practice to reweave the connections of the gross and subtle layers and cultivate a relationship with the True Self

• +Discussion of Panchamayakosha (Raja & Jnana yoga)
• Sutra Study: 1.2, 1.3, 1.4. Discussion about regulating our internal states. Journaling assignment (Raja & Jnana yoga)
• +Sutra 2.33 Pratipaksha Bhavana. Journaling assignment (Raja & Jnana yoga)
• Yoga Nidra (Jnana)
• Finding Sangha (Raja)
• Moving meditation with breath and w/mantra (Bhakti)
• Prompted journaling on the sutra study (Raja)

1. Resources that informed asana practice:

a. Lower Back Pain:
i. Yoga for Back Pain by Loren Fishman, MD, and Carol Ardman
ii. IAYT Research summary: Yoga Therapy for Lower-Back Pain

b. Muscle Pain and Stiffness:
Muscle Pain: It May Actually Be Your Fascia, John Hopkins Medicine
c. TMJ Tension:
Yoga Practice for Relieving Jaw Tension, Yoga International

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

2. Meditation
a. Three Stages of Meditation Handout, SequenceWiz.com
b. Lake Meditation by Jon Kabat-Zinn

3. Sutras
a. Yoga Sutra of Patanjali I. 2-4
b. Yoga Sutra of Patanjali II. 2-3 (Kleshas)
c. Patanjali’s Words: The Five Kleshas (Causes of Suffering) by Rev. Jaganath Carrera, Integral Yoga Magazine
d. Pratipaksha Bhavana. Yoga Sutra of Patanjali II.33 Inside the Yoga Sutras by Rev. Jaganath Carrera

4. Prana and Doshas
a. Understanding Prana, David Fawley
b. Vata Recommendations for Yoga Practice, SequenceWiz.com

5. Others
a. Grounding
Could walking barefoot on grass improve your health? Some research suggests it can. The Washington Post

“Research has shown barefoot contact with the earth can produce nearly instant changes in a variety of physiological measures, helping improve sleep, reduce pain, decrease muscle tension and lower stress.”

Included in the article: Oschman JL, Chevalier G, Brown R. The effects of grounding (earthing) on inflammation, the immune response, wound healing, and prevention and treatment of chronic inflammatory and autoimmune diseases. J Inflamm Res. 2015;8:83-96. Published 2015 Mar 24. doi:10.2147/JIR.S69656

b. Raja Yoga Teacher Training Manual, Integral Yoga

• Yes

1. Check-in. Follow-up questions from the intake. Discussion to co-create specific therapy goals.
2. Witness Practice
3. Sutra Study: Sutra 1.2, 1.3. Shared Dropbox doc
4. Mantra chanting: OM to remind us about Bliss Body
5. Asanas: Warm-up, Joint Freeing, Garudhasana arms only (Fascia release), Sun Salutation (Moving meditation with breath), Downward Facing Cobra (TMJ release), Balasana, Puppy, Half Plow, Hamstring Stretch (Posterior and lateral stretch). Supported Child (Restorative Yoga)
6. Pranayama: Deep Breathing/Dirgaswasm, Ujjayi
7. Review Home Practice. Readiness assessment and the SMART goal-setting

Weekly assignment is shared with ELB in a GoogleDoc

1. Asana practice
a. Chair Joint Freeing Series page 1-2 (Lower and upper extremities)
b. Practice Surya Namaskar with breath. Instructions for the Sun Salutation - with Downward Facing Cobra for tight jaws
c. Garudhasana with dristhi 15-30 sec./each side
d. Hamstring stretch Supta Padangusthasana (Reclining Hand-to-Big-Toe Pose) using a strap (3-5 mins; hold it longer for the leg that feels tighter)
2. Pranayama
a. Ujjayi (Ocean Breath)
3. Meditation
a. Attend Meditation group x2 week
4. Weekly Journaling on Sutra 1.2, 1.3, 1.4. Journaling prompts are here
5. My Home Practice Chart

Resources and Handouts:
For Practice: Integral Yoga Hatha Class on YouTube, Sun Salutation section ONLY*. SS starts at around 8:00.
a. Sutra 1.2-1.4 simple yoga article
b. Three Stages of Meditation

Date: 9/17/23 Time: 8-9:30 AM Location: Virtual

After a few follow-up questions, we spent nearly half the time discussing and setting goals. The topics/prompts include:

a. Summary of the intake/assessment
b. How does yoga look at a person? What is Panchamayakosha?
c. How can this model support healing in both physical and emotional pain? How can we connect with real happiness?
d. Sutra 1.2-1.4. What does the sutra tell us about turbulence in the mind?
e. Identifying goals

ELB found the short and long-term goals relevant and wants to work on them. Study on the sutra 1.2-1.4 appeared to conjure strong emotion, evident in her facial expression. She responded, “This is what I am looking for,” and teared up. To a question, “Where in your life do you experience the lack of freedom?” she responded, “It’s the way I think. I think too much and hold negative thoughts in a cyclical pattern.” Awareness practice and Pratipaksha Bhavana can be the first step to unlocking her harmful thought pattern.

Per my suggestion at the intake session, she found a local meditation group and is considering attending in person. Using the SMART method, we discussed the weekly home practice regimen and identified a realistic goal (x2/week, not daily). She appeared to be motivated by the home practice, including journaling.

Each Asana and Pranayama was well-tolerated as she already had familiarity. Restorative yoga was given at the end of the session for profound rest and lower back release. Supported Child was given as an alternative and more relaxed position to her “Cross-Legged Forward Fold” that she uses to fall back asleep.

It turns out her teacher training didn’t offer much training on Raja yoga. I was excited that my limited knowledge of Raja and Vedanta philosophy facilitated her emotional release and initiated self-reflection. She made good progress towards healing. Today’s handout and journaling assignment would deepen her understanding of Sutra 1.2-1.4 and aid contemplation.

We will continue the discussion about Sutra 1.2-1.4. A new mantra chanting will be given as Bhakti practice to enhance the idea of connection with the Bliss body.

• Yes

Date: 9/21/23 Time: 8:30-10:00 AM Location: Virtual

Activities:
1. OM. Check-in. Follow-up on changes, including tightness/pain in the body, mood swings, and emotions.
2. Witness Practice
3. Svadhyaya discussion. 1) Discussion about regulating the internal state, 2) Practices for awakening Anandamaya kosha – Seva, Bhakti, and meditation
4. Asanas
a. Joint Freeing and Warm-up
b. Vamping pose for TMJ
c. Gate Pose for tight ribs
d. Sun Salutation with mantra (Bhakti)
e. Garudhasana
f. Malasana
g. Resting pigeon w/wall
h. Viparita Karani
i. Spinal twist
5. Yoga Nidra
6. Pranayama
a. Alt. nostril breathing w/ext. exhalation
7. Mantra chanting: Om Shanti

8. Reviewed Home Practice for the week

Weekly assignment is shared with ELB in a GoogleDoc

1. Asana practice
a. Chair Joint Freeing Series page 1-2 (Lower and upper extremities)
b. Practice Surya Namaskar with breath. Instructions for the Sun Salutation
- with Downward Facing Cobra for tight jaws
c. Garudhasana with dristhi 15-30 sec./each side
d. Hamstring stretch Supta Padangusthasana (Reclining Hand-to-Big-Toe Pose) using a strap
(3-5 mins; hold it longer for the leg that feels tighter)
2. Pranayama
a. Ujjayi (Ocean Breath)
3. Meditation
a. Attend Meditation group x2 week
4. Weekly Journaling on Sutra 1.2, 1.3, 1.4. Journaling prompts are here
5. My Home Practice Chart

Resources and Handouts:
For Practice: Integral Yoga Hatha Class on YouTube, Sun Salutation section ONLY*. SS starts at around 8:00.
a. Sutra 1.2-1.4 simple yoga article
b. Three Stages of Meditation

ELB reported improved discomfort in the lower back and legs and feeling physically stable. She used self-awareness skills to handle an otherwise triggering situation by “telling myself that my responsibility is to calm myself.” This precipitated discussion about “we are not emotion/mind, body…” and the teaching of the sutras 1.2-1.4. I commended her progress and increased awareness. While referring back to the kosha model, we analyzed what had happened and how she had skillfully handled it by highlighting the power of Vijnanamaya. She was taking notes.

She reported she practiced Sun Salutation twice a week with breath. Restorative Child Pose was helpful for the lower back and comforted her emotionally. She did not attend any meditation group sessions but took a long walk in contemplation and practiced meditation at home for 10 minutes a few times a week.

She woke her up last night thinking about disturbing interactions during the day. “My body was tired, but my mind couldn’t stop ruminating,” I suggested a few tips to help fall back asleep (Pranayama with extended exhalation, restorative yoga pose, reading a book, etc.) Pratipaksha Bhavana can also be beneficial for this.

Today, Sun Salutation with the mantra OM AIMEE NAMAH was given to add the brilliance of Bhakti to her asana practice. The mantra is thought to cultivate inspiration, wisdom, and creativity, to which she responded positively. The Vamping Pose relieved her neck tension.

To break the cycle of negative thinking, a suggestion was made to first work with the physical body. It can be as simple as just moving the body, dancing, or activating asanas. Another suggestion was to perform asana that requires concentration, such as Garudhasana. That will establish a base for pranayama and/or meditation.

Svadhyaya and the sutra study work particularly well with this client. Her progress was noticeable in working with Vijnanamaya kosha and self-regulation. As she appears to respond well to praise and encouragement, I highlight her progress thus far.

Pratipaksha Bhavana will be added to the care plans to address negative thought patterns and rumination. As she responded well to Yoga Nidra, the Lake Meditation by Jon Kabat-Zinn will be given to enhance the knowledge of Anandamaya kosha.

We will discuss how to develop a relationship with her version of the highest good, such as rituals like lighting a candle or saying some affirmations that can be incorporated into daily life.

• Yes

Date: 9/28/23 Time: 8:30-10:00 AM Location: Virtual

Activities:
1. OM. Witness Practice
2. Check-in. Follow-up on changes, including tightness/pain in the body, mood swings, and emotions. Reviewed improvements against the baseline
3. Asanas
a. Sun Salutation “as moving meditation" with OM AIMEE NAMAH
b. TMJ release
i. Low cobra facing down
ii. Vamping Pose with Warrior II
c. Garudhasana
d. Janusirsasana, Paschimotanasana with extended exhalation, Ardha Matsyendrasana
e. Restorative Yoga: Supported spinal twist
f. Savasana
4. Guided meditation with imagery (Lake Meditation)
5. Pranayama
a. Alternate nostril breathing with extended exhalation and Ujjai (review)
b. Anuloma Ujjayi
c. + Pratipaksha Bhavana
6. Review: Building connection with Anandamaya kosha
7. Meditation (5 mins)
8. Wrap-up. Plans for yoga practice going forward

Weekly assignment is shared with ELB in a GoogleDoc

1. Journaling
Pratipaksha Bhavana. Prompts provided
2. Design your daily regimen
a. When I have 10 mins for yoga, I’ll do…
b. When I have 20 mins for yoga, I’ll do…
c. When I have more time for yoga, I’ll do…

ELB has been practicing meditation daily for ten minutes and stated, “The benefits are immediate.” Tightness in the legs, forearms, hands, and jaws is still there; however, she is not “too stressed about it.” She reports the Witness Practice effectively calms her down and gives her a sense of centeredness. Sleep disturbance has gotten shorter with fewer episodes; she now reads a book when she can’t fall back asleep instead of ruminating in bed for hours. Restorative yoga’s Supported Spinal Twist has been helpful for the lower back pain as she feels the release. She didn’t do journaling last week.

We had a follow-up discussion on Anandamaya kosha and how we can work towards realization through meditation, seva/selfless service, and connecting with the higher version of ourselves. The lake imagery meditation precipitated further discussion on the True Self.

ELB and I agreed that she learned to cope with her lower back pain through asanas and pranayama. Although it didn’t significantly improve the stiffness in her body (except for a minor improvement in the legs), the program had a lasting effect on her self-efficacy. She was amazed that some simple practices could make a noticeable difference to her. Hearing from the client that the overall program exceeded expectations was encouraging. She is motivated to keep up with the practice by herself.

I feel blessed to be a vehicle to impart my knowledge of Raja yoga to the client. As she was ready to receive it, she responded to my suggestion positively (with emotions), which set the direction of the therapy session. With clear objectives in place, which is to zero in on the utmost subtle kosha, I supported her in lifting Avidya's influence to identify herself with Anandamaya kosha through various practices. The discovery of the Sutra 1.2-4 and this essential teaching profoundly impacted ELB and may last for the rest of her life.

My approach addressed each layer. Improved balance in Pranamaya kosha is evident in her sleep quality, although the asanas didn’t significantly improve her body's tightness. ELB excelled in her work with Vijnanamaya kosha and Jnana yoga throughout the program, benefitting from the Witness Practice, Yoga Nidra, Svadhyaya, and even from pranayama and asana practices. She demonstrated her acquired self-efficacy to manage her negative thought process and emotional fluctuations of the mind field, citta.

This case study was an actualization of the power of the teachings of Raja yoga in a yoga therapy setting. In the post-session survey, ELB responded with positive feedback on the yoga therapy she received, affirming my assessment of the successful program outcome she participated in.

“I felt like a mess when you showed up in my life. You listened to the details I shared with you and came up with a comprehensive plan that addressed my concerns as a whole human being, all layers combined and interconnected. Your suggestions inspired me to look for meditation resources I hadn't considered before and to strive more diligently and regularly to pursue simple actions that would have healthful benefits. I am very grateful for your calm, insightful, kind presence and feel confident that you will continue to touch many lives as a yoga therapist!”

The four-week yoga therapy program has concluded with no subsequent sessions scheduled. ELB will design her regular yoga practice, including meditation, based on the weekly assignments she has been working on.