Client is a 58-year-old cis Caucasian female, married and retired. She was diagnosed with follicular lymphoma in 2022, and describes her current treatment as "watch and wait," as her doctors have advised her she can live with this for decades. Her goal since diagnosis has been to make lifestyle changes that optimize her physical, mental and emotional health. She has high cholesterol and is pre-diabetic, but currently on no medications. She continues to reduce cholesterol through dietary changes, and despite a family history of heart disease, her cardiologist has no present concerns.

In 1979 she was hit by a car, resulting in a broken pelvis and left shin. She believes the accident could contribute to the low back pain she has managed since 1987, going to physical therapy and occasionally taking muscle relaxers when the pain is extreme. She was in a car accident in 2010 that resulted in a C5/C6 fusion, as well as the diagnosis of a snapping scapula on the left side, after her left shoulder impacted the door.

Since her 2022 diagnosis she has begun a meditation practice, which she uses to help manage her stress, which tends to peak before oncology appointments.

She has a regular exercise routine consisting of a daily mile walk in the morning at a brisk pace, followed by exercises she learned during physical therapy that target her arms, core and glute complex. She has some experience with yoga, but is intimidated by forward bending for fear of causing additional low back pain. Breath assessment revealed no restrictions, and initial physical assessment showed no significant restrictions in joint ranges of motion or instability.

While this case study will only track the first three sessions, my care plan includes guiding the client through an 8-week series based on a YCAT course, every week highlighting aspects of a different limb of ashtanga, and supporting the client in integrating yoga into her life on and off the mat.

YCAT: Yoga for Cancer and Chronic Illness - Level 1 Manual
The Breathing Book - Donna Farhi
Integrative Anatomy for Yogis - course designed and facilitated by Gil Hedley and Rachel Scott
https://www.spineclinic.com/pdfs/Trunk_Stabilization.pdf

Session 2:

Roffe L, Schmidt K, Ernst E. A systematic review of guided imagery as an adjuvant cancer therapy. Psychooncology. 2005 Aug;14(8):607-17. doi: 10.1002/pon.889. PMID: 15651053.

Kapogiannis A, Tsoli S, Chrousos G. Investigating the Effects of the Progressive Muscle Relaxation-Guided Imagery Combination on Patients with Cancer Receiving Chemotherapy Treatment: A Systematic Review of Randomized Controlled Trials. Explore (NY). 2018 Mar-Apr;14(2):137-143. doi: 10.1016/j.explore.2017.10.008. Epub 2017 Dec 21. PMID: 29506956.

Session 3:

https://integralyogamagazine.org/patanjalis-words-pratipaksha-bhavana/
Hebrews 14:14, NIV

• Yes

The session began with giving the client space to share challenges she has been facing with her extended family's health over the past month. (A family medical emergency had delayed this session over a month from our initial intake.) While this took more time than I had anticipated, it was important to her.

Prior to the first practice of the session I shared Rumi's poem, The Guest House with the client as an encouragement to "meet...at the door laughing" and "invite in" any sensations, emotions, thoughts and experiences that arrive during this and any of our sessions together.

I guided the client through an awareness practice, encouraging her to simply notice without trying to change sensations present across the koshas - first in her physical body, then her emotional and intellectual layers, moving to her energy, and then returning awareness to the breath. I gave her the option of finding the posture that was most comfortable for the practice, and she chose supine. While the YCAT Awareness Practice does not follow the panchamaya kosha model "in order," so to speak, I appreciate the way it is structured from the perspective of how a client might notice their koshas as they experience the practice - noticing any emotions present and in response to spending time focusing awareness on the anamaya kosha.

Next I offered her a breath inquiry practice encouraging attention to the pause at the end of the exhalation. She shared that she usually focuses on the inhalation with her breathwork, and enjoyed exploring the exhalation and the pause at the end. I let her know that we will spend some time in every session engaging with the pranamaya kosha through pranayama practices and breath explorations.

The client mentioned that she had been feeling more discomfort in her low back recently, so instead of working from a tabletop position I opted to turn her tabletop supine and introduce her to the deadbug as a movement for both core stability and breath awareness. I directed her to explore working with her breath an energy, as if she were "lying in thick mud" - pushing energy out as she extended opposite arm and leg, drawing energy in as she pulled arm and leg in; inhaling as she lengthened and expanded her body, exhaling as she contracted, feeling the engagement of her deep core muscles.

I then encouraged her to find her most comfortable posture for Yoga Nidra and guided imagery, using the Integral Yoga Nidra scripting for progressive muscle relaxation, and weaving in the Favorite Place Imagery script from Belleruth Naperstack, followed by five minutes of allowing the client to rest in silence before bringing her out of deep relaxation.

Since we began the session with a check in, I decided to end the session with a "check out" of sorts - asking the client how she felt about the session: what is the appropriate level of physical challenge without being too little or too much? Is there something she wants more of in the sessions? She indicated that she would like to find a practice to help let go of the physical, emotional, mental and spiritual burdens she is carrying with her mother-in-law's health challenges. With her love and desire to move every day, I encouraged her to think about a physical ritual she could use to help her let go of what she does not need to carry - whether it is when she is washing her hands leaving a visit with her mother-in-law, or doing a short grounding practice outside before she walks up the steps into her front door. In addition I would create some additional options for her to explore for our next session so she could find the practices that best support her.

The client was prepared and excited for the session, willing to explore every practice with enthusiasm, and open to sharing her experience and insights.

I still find myself over-planning the content of the session - I imagine part of this due to my inexperience as a novice yoga therapist in training, but also my pitta dominant dosha who struggles with slowing down and my own balance between movement and stillness, doing and being. As I cultivate greater sattvic balance in my own practice and life, I will be curious to follow how it influences my yoga therapy work.

The client is very interoceptively aware, with a natural understanding of ahimsa when it comes to finding the balance of effort and ease in her body with her movement frequency, intensity and duration. I feel like I can best support her goals in our time together by always offering a short movement practice she can incorporate into her routine, whether daily or weekly - while focusing on more subtle practices of pranayama and meditation that she can weave into her day to be more present and aware across all koshas. For session 2 I would like to introduce some standing balance postures - with her love of nature and the outdoors I think she would enjoy Vrikshasana and Garudasana. I would also like to explore Virabhadrasana II with her as a pose to support strength and balance across all koshas, especially when she experiences an increase in anxiety prior to an oncology appointment.

At the end of the session she asked me if I was familiar with guided imagery to "fight cancer." I responded that felt guided imagery could be an extremely helpful tool for her, and that I would look into any studies done including it - as well as include an imagery intake in our next session so that I could craft a guided imagery for her.

• Yes

The session began with a check in, where the client shared she felt like she has found more ease in releasing the weight she was carrying across all koshas with her mother-in-law's health challenges. Before beginning session practices I asked her questions from my imagery intake in order to prepare a guided imagery for her in our next session. The client felt the questions were "deep" and enjoyed exploring what she most connected with through each of her senses.

I guided her through the awareness practice, where she again chose a supine posture, and afterwards shared she felt the practice to be very "comforting."

Since she chose a supine posture, I encouraged her to continue with it for a breath awareness and inquiry practice to help her feel how the diaphragm moves differently - displacing and creating space - depending on what muscles are engaged around it: first with hands on her belly, encouraging the chest and ribs to be soft but quiet while feeling the belly expand; then with one hand on her chest and the other along the side of her ribcage, now encouraging expansion through the ribcage while keeping the belly quiet; finally with hands gently resting on the collarbones, encouraging movement through the upper chest while keeping the belly and ribs soft but quiet. The encouragement for her in this practice was to feel how her body has the capacity to breathe in many ways depending on her circumstances and activity.

Next I led her though three standing balance postures: Vrikshasana, Garudasana, and Utthita Tadasana. She practiced each pose first balancing on her right side, which she called her "weaker leg." Next I introduced Virabhadrasana II as a posture both for building and experiencing strength across the koshas. I introduced an imagery experience for the pose that I credit to Judith Lasater. The warrior is grounded and centered - feeling the strength of the lower body, with each leg engaging and supporting differently. With the outstretched arms and gaze towards the forward fingertips, the warrior is still connected to the past, and looking towards the future, while anchored in the present moment. I encouraged her to explore how the pose made her feel physically, energetically, emotionally, and intellectually, and we discussed how practicing this pose could benefit her during those times of increased anxiety - especially before medical appointments.

Homework for this week was to continue working with Vrikshasana, Garudasana and Utthita Tadasana as often as she liked, whether daily or at least two times during the week, seeing what she noticed happening in her body with physical engagement of the muscles (anamaya), where she experienced the movement of her breath and flow of energy in each pose (pranamaya), and any thoughts or emotions that come up (manomaya).

I also encouraged the client to, at various times throughout her day, during various activities, see if she could notice where she felt her breath moving in her body. If she liked she could describe it as "belly breathing," or "chest breathing," or notice where she felt the muscular engagement to shape the movement and direction of her breath.

The client shared she had continued practicing the deadbug exercise, including it with some of the other exercises she does for her core and upper body.

The first snow of 2024 began falling during our session, and with temperatures quickly dropping below freezing I let my personal anxiety of driving in the weather get the best of me, and did not include deep relaxation at the end. While I would have liked to have offered it as the session felt incomplete to me as a result, I made it home just as the roads were beginning to dangerously ice. While I much prefer the ability to work in-person with a client, weather situations like today make me appreciate the possibilities offered by virtual sessions as well. So far all of my client sessions have been in-person, and I do plan to incorporate virtual sessions during practicum for the experience as much as the convenience.

Other than the above, I felt both the pace of the session and the content was appropriate to support the client's goals and her energy. I intentionally
tried not to over plan the session, and in so doing found myself feeling less rushed - or trying to get everything in - and resultingly felt more present and connected with myself and the client. I felt that each activity offered the client a supportive experience and gave her an appropriate amount of homework for the week.

Having completed the imagery intake, my homework for the week is the craft a guided imagery for the client to use as a tool to continuously support health and healing in her body. Also, I have not yet introduced tools from Raja Yoga which could also support her in both her goal of fighting cancer as well as deepening her meditation practice. I feel like the practice of sutra 2.33, pratipaksha bhavana would be a very accessible practice for the client. I plan to continue working with the asanas introduced in session 2, expanding on Virabhadrasana II with movement into Utthita Parsvakonasana and Viparita Virabhadrasana, which with the client's love of the outdoors and sunlight, I will interpret as Sun Warrior for her.

• Yes

The session began with a check-in, with the client reporting that while her mother-in-law's health continued to decline, she was continuing to manage the physical, energetic, emotional and mental demands well. She shared that her meditation practice had gone "well" this week, and she had particularly enjoyed a guided meditation that she had found on YouTube, "Meditation and Movement" which used the image of a tree to connect with growth - "where you were versus where you are." She finds her morning meditation practice to help her feel grounded - and I encouraged her to continue with it.

I guided her through the awareness practice, where she again chose a supine posture, and afterwards shared she felt that she was sensing her body "better." When her attention was focused on her energy level, she noticed her energy "feeling heavy... like after a meal." She also shared that she felt her body was "asking for exercise," and she has been paying attention to her movement choices during the week more. Whether taking a walk outside or performing some of her exercises, she is mindful not to "push too hard," which I celebrated with her as a great learning.

For our Raja Yoga practice I shared with her sutras 2:33-2:34, Pratipaksha Bhavana, and gave her a copy of Rev. Jaganath Carrera's article from Integral Yoga Magazine so that she could revisit it during the week. With her background in the Christian faith I shared how Pratipaksha Bhavana mirrors the encouragement found in Philippians 4:6-8.

For our Pranayama practice we explored Ujjayi breath, which is also known as "ocean breath" or "victory breath." I offered the suggestion that she could practice Ujjayi anytime she felt anxious, as a way to take victory over the anxiety by calming her mind and body through her breath.

For our Asana practice we revisited Vrikshasana, Garudasana, and Utthita Tadasana, which she had continued to practice during the week. With Virabhadrasana II, we explored flowing between Utthita Parshvakonasana and Surya Virabhadrasana as she reached for the healing rays of the sun.

Homework was to continue exploring the asanas, with more awareness to the breath. Try practicing each asana with Ujjayi breath and see what she finds: how does the breath change the experience of the asana? How does the asana influence the breath? Continue these practices with an attitude of playful curiosity, noticing without judgement.

I encouraged her to continue her meditation practice, which seems well-established and yet flexible enough to meet the demands placed on her each day. I also encouraged her to continue exploring Pratipaksha Bhavana with any moments she notices herself feeling anxious or disturbed in any way. What does she notice in terms of shifts in her anamaya and manomaya koshas with this practice?

The client was engaged, curious, and willing to explore each practice with enthusiasm. She had incorporated last week's asanas into her movement over the week, and was eager to continue in the upcoming week with what we practiced today.

I felt what we accomplished during the session was an appropriate amount of content without being too much. I still feel like I am finding my ease and confidence as a yoga therapist, reminding myself that I am here to offer practices to support the client, without attachment to how the client chooses to incorporate them into their life.

It was truly an honor to work with Anne. I still found myself walking into each session and leaving after wondering if I had offered something useful. It is still a challenge to set my Self aside, the desire to perform well, and focus on being on service with no attachment to the outcome. I also still feel very "clunky" with my documentation, but I must move forward knowing that the learning comes with the time invested one client at a time, one session at a time.

We met for an additional session on 29 January 2024, with the hopes of continuing for 4 additional weeks. We began once again with a check-in, in which she reported her mother-in-law's health was continuing to decline, but she and her husband were both managing their time and energy well. I guided her through an Awareness Practice, where she reported feeling "peaceful across my layers...a wholesome peaceful feeling." She shared that she has really been listening to her body, incorporating gentle movement throughout her day when she felt her body speaking to her, "Please stretch me." I encouraged her to continue to listen to her body. honoring her physical, mental and emotional energy available each day.

For asana practice we explored Surya Namaskar at the wall to offer options for supported forward spinal flexion. The client felt more ease and length through her low back, and more importantly, felt safe exploring forward bending at the wall. In addition we practiced Supta Matsyendrasana with support of blocks, bananasana, and some gentle joint activation practices for the hips, knees and ankles.

I introduced her to Nadi Suddhi, showing her options of using her right hand to gently close the nostrils, as well as a "hands free" version opening and closing her palms resting on her lap as she focused her attention on her left or right nostril respectively. She enjoyed the balance of feeling both calm as well as energized without being rajasic.

Update: Ann let me know prior to our scheduled session on 8 February that we needed to indefinitely suspend our sessions due to the rapid decline of her mother-in-law. I thanked her for her willingness to explore the tools of yoga with me, and encouraged her to reach out when and if she would like to continue.