Intake Session
Date: 12/4/2023 Time: 6:00-8:00 PM Location: Virtual on Zoom

Intake summary:
The intake session was conducted virtually on 12/4/2023 via Zoom. ELV is a 28-year-old Caucasian female who works full-time in education. She started working with underserved youths in a public school when she graduated college eight years ago and has since moved up to an assistant dean at a middle school. Although it can be physically and mentally stressful, she is passionate about working with her students to make a difference in their lives. She is married and lives with her husband in Denver, Colorado; she has no children.

ELV seeks yoga therapy “to help gain a better body-mind connection” and to improve her “relationship with the body.” Although undiagnosed, she has a history of orthorexia, a type of eating disorder that relates to an unhealthy obsession with eating "healthy" and rigorous physical exercise. It lasted for seven years, during which time she kept calorie counts and nutritional information using a phone app to evaluate every food intake. Although the calorie-tracking habit was discontinued about a year ago, she still catches herself calculating in her head. She emphasized that she had never starved herself.

ELV enjoys physical workouts. Once a competitive skier, she now lifts weights at a gym four to five times weekly. She loves extreme workouts for “feeling strong and active,” claiming it is not out of an obsession with body image. On some occasions, she pushes herself in physical exercise “as a form of punishment” when she falls off the track of her "healthy" eating habits, such as “unhealthy” eating and drinking at a social gathering, for instance.

She reported difficulties slowing down or taking a break, which she finds problematic. Yin yoga and restorative yoga classes she has taken in the past made her feel “unproductive,” so she discontinued.

Through the intake and goal-setting activities using the SMART method, her objectives for the sessions were clarified: her primary objective is reducing anxiety-induced stress, which is often associated with self-judgment, and her negative view of how others perceive her (“imposter syndrome”). She also wants to work on relaxation, which doesn’t come naturally for her. At work, she occasionally skips lunch, resulting in snacking, which she wants to change to maintain a healthy relationship with eating.

Assessment:
Numerous kleshas play parts in coloring Manomaya Kosha—Asmita, Abinivesha, and Raga. Being highjacked by Asmita, her mind has created an ideal image of herself (ego) that today’s culture imposes, and she spends her energy trying to elicit approval within the cultural standards. Abinivesha, or clinging to thoughts and beliefs, stirs up fear of disapproval by peers and fuels imposter syndrome. She listens to the erroneous voice: “If they knew real me, they’d know I’m a fake. Then they wouldn’t like me.” The attachment/raga to popularism could create stress and anxiety, impacting not only Manomaya but also Annamaya, Pranamaya, and Vijnanamaya Kosha. The tendency for an excessive workout (“hard to stop once get going”) hints at sensory attachment, as Raga Klesha drives her to seek to feel good physically and positive about herself emotionally. She uses marijuana regularly and relies on it for relaxation, which is another indication of Raga Klesha.

Physical assessment revealed well-developed core muscle tone and stamina. She reported “tightness in the psoas” in a high lunge position that “causes occasional lower back pain,” which can also be exacerbated by holding stress (Annamaya, Pranamaya, and Manomaya)

In energetic quality assessment, over-functioning rajas are observed in her restlessness, hardness around her eyes, and intense focus, corroborated by her statement of difficulty being relaxed.

As she expressed interest in “using yoga as a way to slow down in a chaotic life” and to counter her anxiety/stress, the primary focus will not be on her eating disorder but on stress reduction and fostering body-mind connection. The vagus nerve activation would be beneficial to improve the neurophysiological (body-mind) pathway and shift her into a parasympathetic nervous system dominant state to achieve deep rest at the end of the day to bring balance in Annamaya, Pranamaya, and Manomaya Kosha.

Overview:
How yoga therapy can help the client:
• Releases tension in the physical body, focusing on the posterior complex (Annamaya, Pranamaya, Manomaya Kosha)
• Manages stress and anxiety management by 1. Vagus nerve activation (Annamaya, Pranamaya), 2. Cultivates self-acceptance. Tones down self-critical and approval-seeking thoughts and behaviors to support her in exploration of the Self (Manomaya, Vijnanamaya)
• Manages sensory attachment to find a “sweet spot/moderation” during asana practice (Manomaya, Vijnanamaya)
• Aids in establishing a regular eating habit to nourish the body through observing mindfulness (Annamaya)
• Vinyasa-style asanas with steady breathing given in the first half of the session will keep her focused, which eventually makes relaxation accessible (Annamaya, Pranamaya, Vijnanamaya)

Agreed-Upon Goals:

Short-term:
a. Learn how to enhance body & mind connection to reduce stress and anxiety (The home practice of asana, breathwork, and relaxation – 30 mins, three evenings/week 8:30-9 pm)
• Establish a regular meal schedule (Take lunch break x5/week)
Long-term: Cultivate self-compassion/acceptance (Journaling and other practice)

Specific Care Plans:
I. Asana will be given to balance Annamaya, Pranamaya, and Manomaya by:
a. Addressing tight hamstrings, gluteus, and piriformis for lower back pain prevention. The interventions include:
• Sukhasana and Vajarasana
• “Cow – Child – Downward-Facing Dog” vinyasa
• “Low lunge, Hip Rocking, DFD, Uttanasana, Ardha Uttanasana” vinyasa
• Hamstring stretches, resting pigeon, spinal twist
• Wide-legged forward fold, Malasana squat
• Janusirsasana
b. Deactivating the psoas muscle for stress reduction by engaging the “bottom-up” pathway
• “Down dog – Up dog” vinyasa
c. Engaging the vagus nerve to help shift the body into the rest-and-digest response
• Neck movements
• Occiput and the “bunny” ear massage
d. Activating both branches of the autonomic nervous system that combats anxiety and balances brain chemistry
• “Cow – Child – Downward-Facing Dog” vinyasa
• “Down dog – Up dog” vinyasa
e. Releasing neurotransmitters that calm the mind, alleviate rajasic overdrive, and cultivate pratyahara
• Balasana (Surrender and rest)
• Janusirsasana (Find a “sweet spot” between effort and easefulness)
• Restorative Yoga
o Supported Fish Pose (It also stimulates the vagus nerve and opens throat and heart chakra for self-compassion and truthfulness)
o Supported Pigeon Pose
o Resting Butterfly Pose

II. Pranayama and other energy work will be given to balance Annamaya, Pranamaya, and Manomaya by:
1. Counter stress/anxiety and induce a relaxation response. Bringing balance into the autonomic nervous system and promoting the energetic quality towards a sattvic state. The interventions include:
• Deep Breathing
• Dirgaswasm
• Ujjai
• Brahmari (Vagus nerve stimulation)
• Alt. nostril breathing (w/Pratipaksha bhavana/Bhakti)
• Throat and Heart Chakra activation (Self-compassion)
• The Third Eye Chakra activation (Wisdom)
• Chin mudra (Awareness and concentration)

III. Meditation and other mindfulness techniques will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya via:
• Breath Awareness Practice [+ Home practice only. Audio script provided]
• Witness Practice (Kosha-by-kosha observation without judgment)
• Imagery (Lake Meditation)
• Moving meditation with breath in vinyasa
• Yoga Nidra
• Loving Kindness Meditation

IV. Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya via:

a. Svadhyaya/self-reflection that facilitates access to the root cause of stress and emotional pain, e.g., ego and miss-identification, attachment and aversion
• Journaling with prompts (Asmita/ego, Ahimsa)
• Discussion
b. Sutras
• Yamas and Niyamas (Ahimsa. + Satya and other percepts are added in the later session)
• Pratipaksha Bhavana
c. Client Education
• Pancha Maya Kosha and how yogic healing occurs
• + What are Yamas and Niyamas?
• Iliopsoas muscle complex. How to release psoas muscle.
• Stress response and vagus nerves
• Anatomy of neck muscles. How to free up the tensions and stimulate vagus nerves

+ denotes an update to the initial care plan

1. Orthorexia/Eating Disorder
a. Clinical Studies
i. Scarff JR. Orthorexia Nervosa: An Obsession With Healthy Eating. Fed Pract. 2017 Jun;34(6):36-39. PMID: 30766283; PMCID: PMC6370446.

“Similarities between ON [orthorexia]and OCD include anxiety, a need to exert control, and perfectionism. However, patients with OCD tend to report distress from compulsive behavior and a desire to change, thus exhibiting insight into their illness.8,10 Similarities between obsessive-compulsive personality disorder (OCPD) and ON include perfectionism, rigid thinking, excessive devotion, hypermorality, and a preoccupation with details and perceived rules.”

“People with anorexia skip meals; people with orthorexia do not (unless they are fasting). Those with anorexia focus only on avoiding foods, while those with orthorexia both avoid foods they think are bad and embrace foods they think are super-healthy.”

“One survey associated orthorexic tendencies with perfectionism, appearance orientation, overweight preoccupation, self-classified weight, and fearful and dismissing attachment styles.“

“There are no reported studies exploring the efficacy of psychotherapy or psychotropic medications for patients with ON. However, several treatments have been proposed given the symptom overlap with AN. Serotonin reuptake inhibitors may be beneficial for anxiety and obsessive-compulsive traits. However, patients with ON may refuse medications as unnatural substances.

Cognitive behavioral therapy may be beneficial to address perfectionism and cognitive distortions, and exposure and response prevention may reduce obsessive-compulsive behaviors. Relaxation therapy may reduce mealtime anxiety. Psychoeducation may correct inaccurate beliefs about food groups, purity, and preparation, but it may induce emotional stress for the patient with ON.

ii. Borden A, Cook-Cottone C. Yoga and eating disorder prevention and treatment: A comprehensive review and meta-analysis. Eat Disord. 2020;28(4):400-437. doi:10.1080/10640266.2020.1798172

“Results of the comprehensive review and meta-analyses results indicated yoga interventions demonstrated a small, significant effect on global eating disorder psychopathology, a moderate-to-large effect on binge eating and bulimia, and a small effect on body image concerns, as compared to the control conditions.”

b. Article
i. The Different Causes of Eating Disorders, Verywellmind
“Protective Environmental Factors: Some environmental factors could help protect people from developing eating disorders. These could include:
• Family meals
• Eating breakfast
• Emotional regulation skills
• Mindfulness techniques

2. Stress and Anxiety
a. Clinical Study
i. Anderson R, Mammen K, Paul P, Pletch A, Pulia K. Using Yoga Nidra to Improve Stress in Psychiatric Nurses in a Pilot Study. J Altern Complement Med. 2017;23(6):494-495. doi:10.1089/acm.2017.0046Clarifying The Energy of Stress, Yoga Therapy for Stress & Anxiety, R Butera, et al.
b. Articles
i. Stressed? Instead of distracting yourself, try paying closer attention, Mindfulness 101, NPR interview with Jon Kabat-Zinn
ii. Yoga Therapy for Perfectionism, YogaU
c. Other resources
i. Integral Yoga Stress Management Teacher Training Manual
ii. “How does an improved mind-body connection help me manage stress?” Science of Yoga, Ann Swanson
3. Yoga, Ann Swanson

3. Relaxation
a. Anderson, Roberta et al. “Using Yoga Nidra to Improve Stress in Psychiatric Nurses in a Pilot Study.” Journal of Alternative and Complementary Medicine (New York, N.Y.) vol. 23,6 (2017): 494-495. doi:10.1089/acm.2017.0046

4. Vagus Nerves
a. George, Mark S et al. “A pilot study of vagus nerve stimulation (VNS) for treatment-resistant anxiety disorders.” Brain stimulation vol. 1,2 (2008): 112-21. doi:10.1016/j.brs.2008.02.001
“Because the vagus nerve sends information to brain regions important in anxiety regulation (locus coeruleus, orbitofrontal cortex, insula, hippocampus and amygdala), this pathway might be involved in perceiving or manifesting various somatic and cognitive symptoms that characterize anxiety disorders.”
“Conclusions: These patients with treatment-resistant anxiety disorders generally tolerated VNS treatment, and there was evidence of acute and long-term improvement in some patients.
b. Stimulate Your Vagus Nerve With These 4 Yoga Poses and Practices, YogaU Online

5. Psoas Muscle Release
a. 7 Poses That Help Deepen Your Awareness to Release Your Psoas, Yoga Journal

6. Sutras
a. Ahimsa. Yoga, Self-Compassion, and Accepting the Inner Critic by David Schouela, Kripalu.org
b. Ahimsa journaling prompts inspired by simple-yoga.org
c. Can we regulate our internal climate? Discussion prompts inspired by simple-yoga.org
d. Weekly journaling on Asmita, The Kleshas by Deborah Adele

7. Other
a. Third eye chakra or Aija chakra, Ekhart Yoga
b. Meditation scripts adapted from Full Catastrophic Living, Jon Kabat-Zinn

• Yes

12/8/2023 Time: 6-7:30 PM Location: Virtual on Zoom

Activities:
1. Check-in. Review goals
2. Client education. Iliopsoas muscle complex
3. Seating posture Sukhasana/Vajarasana
4. Pranayama
a. Deep Breathing
b. Dirgaswasm
c. Ujjai
5. Witness Practice
6. Asanas
a. Vinyasa 1. Cat & Cow > DFD > Child > DFD
b. Vinyasa 2. Low lunge>rock hips back/forth
7. Resting pigeons
8. Yoga Nidra with feet on a couch
9. Meditation with chin mudra with a mantra “I am whole and complete” (1 min.)
10. Discussed journaling homework (Asmita/ego)

Weekly assignments, resources, and handouts for the sessions were shared with ELV in a GoogleDoc

1. Asanas
1. Cat & Cow
2. Cow/Child/Dog sequence
Cow INH> Child EXH>INH EXH Downward Facing Dog…
3. Downward Facing Dog>low lunge INH >rock hips back EXH/forth INH (both legs)
4. Supine Resting Pigeon (Hip flexor stretch)

2. Pranayama/Breathwork: 3-part Breathing (Instruction provided)
3. Yoga Nidra Deep Relaxation (with feet elevated, audio provided)
4. Journaling prompt: Who am I? Week 1 prompt only.

Resources and Handouts:
Reading:
1. Stressed? Instead of distracting yourself, try paying closer attention (Audio interview,17 mins)

Resource for asana practice:
1. 7 Poses That Help Deepen Your Awareness to Release Your Psoas, Yoga Journal

2. Home Practice Chart

ELV reviewed the session goals crafted at the intake session and confirmed their relevancy. Also, a discussion was held to establish a realistic schedule for home practice. She acknowledged that establishing a lunch schedule ensures healthy eating habits and provides sufficient nutrients for a rigorous afternoon workout.

To the follow-up question about where her “imposter syndrome” originates, she recounted her teenage years—she was a high school bully, angry, and troublemaker at home and school. That negative labeling/image “still haunts” her, and she sometimes feels as though she has been “disguising” her dark side to be liked by others. Observance of ahimsa during asana practice was emphasized to benefit her in cultivating self-compassion.

In client education, we discussed various ways to enhance the body-mind connection in relation to stress management. A 2017 pilot study that evidenced Yoga Nidra’s effectiveness in reducing perceived stress levels in psychiatric nurses was shared. Also discussed was the effectiveness of releasing tension in psoas in reducing anxiety.

Pranayama was performed without any difficulties and provided a calming effect on her hyperarousal state. ELV reported “racing thoughts” during the Witness Practice, which she could “just watch.”

Yoga Nidra was performed with feet on a couch found in the room. This supine shape puts the muscles into a slack position, allowing space for the psoas muscles to relax deeply. I allocated ample time for contraction/stretching and complete relaxation for Yoga Nidra. Some fidgeting was observed at the beginning of the progressive relaxation portion, then eventually subsided. In feedback on Yoga Nidra, ELV stated that she enjoyed it and has experienced a sense of embodiment through the practice. She requested an audio script for her evening home practice.

The mantra, “I am whole and complete,” with chin mudra, was given to aid her focus during the meditation. A suggestion was made for home practice to develop her own mantra that resonates with her. She is enthusiastic about reflection journaling on “Who am I?”

The introduction of some basic breathing techniques at the beginning of the session appeared to be effective in stimulating the parasympathetic nervous system to ground her rajasic energy. Also, to ground her energy and attention through asanas, suggestions were given on the breath observation (“refocus when the mind wanders”) and keeping easeful and joyful movements (“no need to try hard to prove to yourself”) during the Cat & Cow and other vinyasa that followed.

ELV will be introduced to restorative yoga. Verbal cues, visualization, and ambient music will help her focus the mind while promoting deep rest. Practicing Janusirsasana will provide an opportunity for developing inward attention.

• Yes

Date: 12/12/2023 Time:6-7:30 PM Location: Virtual on Zoom

Activities:
1. Check-in. Review last week’s home practice and progress
2. Client education. Ahimsa, vagus nerve, muscles in the neck
3. Asana
a. Cat & Cow
b. Down dog – Up dog (Psoas deactivate, activates both branches of ANS, Combats anxiety, and balances brain chemistry.)
c. DFD >low lunge (R/L)
d. Uttanasana > Ardha Uttanasana Wide-legged forward fold, squat (Ham, glutes)
e. Forward bend (Janusirsasana)
4. Restorative yoga
a. Supported Fish Pose
b. Supported Pigeon Pose
5. Vagus nerve stimulation – sub-occipital massage, neck lateral flexion
6. Alternate nostril breathing. Pratipaksha Bhavana

1. Asanas
a. Cat & Cow > Downward Facing Dog
b. Downward and Upward Facing Dog sequence. Downdog EXH> INH to Plank EXH > INH to Updog (x3)
c. Downward Facing Dog>low lunge INH >rock hips back EXH/forth INH (both legs)
d. From a low lunge, step forward to forward fold into Uttanasana and come up halfway into Ardha Uttanasana. (repeat x2)
e. Rest in Child Pose
f. “Head to Knee” forward bend with a strap (Janusirsasana)
g. Supine Resting Pigeon (Hip flexor stretch)

2. Pranayama/Breathwork: Alternate Nostril Breathing. Try “replacing negative thoughts with positive thoughts” while practicing Alternate Nostril Breathing (Instruction provided)

3. Journaling on Ahimsa (non-harming, self-compassion). Apply the spirit of ahimsa to your asana practice

Optional: Breath Awareness Practice and Meditation (audio provided)

ELV reported that having guests over the weekend took time away from home practice. She looks forward to catching up with the reading and journaling assignment on Ahimsa this weekend. She has been enjoying Yoga Nidra with audio recording, which helped her relax before going to bed, although she still uses marijuana. She successfully took a lunch break every day at work. She feels grateful that her coworkers supported it.

The Downward and Upward Facing Dog sequence was introduced as she appeared to have sufficient muscular strength to support the transition. A remedial cue was given not to collapse into the shoulders and to lengthen up through the top of the head in the Up-dog position; she was able to follow. She enjoyed the “hip rocking” sequence with a low lunge to feel the stretch in the hamstrings. Janusirsasana/Head-to-knee Pose revealed the tightness in her hamstrings.

Supported Fish Pose was given for the Throat and Heart chakra to promote acceptance. It was supported by a rolled-up blanket under the knees as she reported discomfort in the lumbar area.

ELV showed frustration in the Head-to-Knee Pose, trying to push her into more hip flexion. To remedy this, I had her come out of the pose entirely and instructed her to use a strap with an emphasis on sensation in the body and not the shape she projects in her head. It helped her release tension, enjoy the asana, and prevent her from injury. I also encouraged her to observe Ahimsa and let go of judgment during physical exercise of any kind.

ELV will continue practicing Janusirsasana. We will discuss the experience of the “Who am I?” and the Ahimsa journaling assignments if she is willing. I will give Bhramari pranayama for vagal tone stimulation and Loving, Kind Mediation for cultivating compassion for self and others.

• Yes

Date: 12/18/2023 Time: 6-7:30 PM Location: Virtual on Zoom:

Activities:
1. Check-in. Review last week’s home practice and progress. Sharing self-reflection
2. Client education. Review Ahimsa. Introduction to Yamas & Niyamas
3. Pranayama
a. Reviewed Alt. nostril breathing (w/Pratipaksha Bhavana/Bhakti)
b. Brahmari Breath variation
4. Asana
a. Cat & Cow
b. Down dog – Up dog vinyasa
c. DFD >low lunge (R/L) vinyasa
d. Uttanasana > Ardha Uttanasana vinyasa
e. Wide-legged forward fold, squat
f. Child > Puppy
g. Forward bend (Janusirsasana)

5. Restorative yoga - Resting Butterfly Pose
6. Loving Kindness Meditation
7. Meditation on the Third Eye Chakra

1. Self-check-in before the Home Practice using Witness Practice - body, breath/energy, mind (emotion, thoughts)
2. Continue to practice asanas to release psoas
3. Continue to practice 3-part Breathing or Alternate Nostril Breathing when you want to calm down or bring in balance
4. Continue Yoga Nidra using an audio instruction

Resource and Handouts:
Article on Third eye chakra or Aija chakra, Ekhart Yoga

ELV reported the “Who am I?” prompted journaling assignment was helpful in “sorting things out” the negative feelings and shed light on her unconscious beliefs that limit her. She shared a part of her reflection where she wrote about how others tend to label her. One of them is “brutally honest,” which prompted further discussion of Ahimsa and Satya. Other precepts were introduced briefly, using an illustration where Yamas and Niyamas are represented as tree branches. She wanted to post it in her office as a reminder and share it with her students. Supplementary reading about Yamas and Niyamas will be provided later.

She did an excellent job in self-reflection journaling, which demonstrated her heightened awareness of the voice of the inner critic versus the knower. That is a much-needed boost to the health of Vijnanamaya Kosha.

In Resting Butterfly Pose, she reported she enjoyed being supported by props under her knees. This remark demonstrated her improved awareness of Ahimsa and permitted her to relax, showing that she feels okay with not doing anything and simply being there.

With a limited amount of session time, journaling assignments served as an excellent platform for her self-reflection.

At the conclusion of the therapy session, there were some notable improvements in each Kosha layer, both subjectively and objectively: 1. ELV reported her lower back feels lighter in the morning. It was particularly noticeable when she took a long walk the day before. She also feels more nourished in the afternoon as she eats lunch regularly at work (Annamaya and Pranamaya), 2. Through svadhyaya practice and self-observation, either via asanas, pranayama, mudra, or Yoga Nidra, ELV learned how to slow down and stay present. It demonstrated her ability to be tuned to interoceptive awareness, which in turn created a body-mind pathway and improved self-regulation. That is a key component of stress management. Also, via restorative yoga, witness practice, and journaling, she learned to give her permission to relax and let go of her internal critic. The holistic experience of yoga improved the integrity of all Koshas, particularly Manomaya and Vijnanamaya.

ELV is a vibrant, high-energy, and high-intensity person with challenges staying still in relaxation, all of which were observable at the first session. I designed the therapeutic strategy to address her rajasic state while keeping her interest and focus on the session. The vinyasa-style asanas with steady breathing in the first half of the session successfully kept her focused and eventually made relaxation more accessible.

My client came to yoga therapy to improve the body-mind connection. Although “body-mind connection” has become a cliché in recent years, this is where yoga works so well. Yoga therapy’s bottom-up and top-down approach cleverly regulates the system and cultivates a more balanced state. This case study was a realization of yogic healing, through which my client was enabled to experience a sense of profound peace.

The four-week yoga therapy program for ELV has concluded, with no subsequent sessions scheduled for the future. She will create a realistic regiment for home practice based on Week 1 and 2 assignments posted in Google Doc, and continue to work on the long-term goals.