The regular practice of extended exhalation pranayama as a strategy to lower daily anxiety and stress.

The practitioner will teach extended exhalation breathing to the client in one session, with instructions for the client to implement this breathing daily in the morning and again before sleep each night. Client and practitioner will meet one week later to discuss the client's observations of stress and anxiety following the daily practice.

A 23 year old man that has a history of extreme trauma, including incarceration. Client has no health conditions. Visual assessment indicates shallow/reverse breathing. Client indicates that anxiety is worst at the start and the end of each day. Client indicates that he has trouble falling asleep because his mind is "racing."

I would meet with the client during a 45-minute session focused on stress management. The client has been participating in a four-week stress management group series with me and requested one-on-one yoga therapy sessions. During this session, we would start with a joint freeing series to begin to access the parasympathetic response. We would then move into self-reflection/Jnana Yoga focused on the client journaling moments that frequently trigger stress and his typical sympathetic nervous system response to stress. We would discuss his observations. We would then move to a standard Yoga Nidra practice with tensing and releasing, followed by extended exhalation breathing.

The branches of Integral Yoga used in this session are Hatha, Jnana, and Raja. This practice will cover all of the koshas, even allowing the client to experience some form of anandamaya kosha for a brief moment in Yoga Nidra and pranayama as stress is relieved. The body, breath, and mind can become more aligned by including all of these branches, allowing for the client to experience an even deeper benefit of regular practice of extended exhalation breath. It is critical for this client's busy lifestyle to have an accessible practice that he can utilize as part of his already existing sadhana.

We met during week three of the group stress management series that this client was participating in with some of my other clients. I conducted a visual scan of the client's body and posture, with particular focus on the shoulders and observation of the flow of breath. I observed that the client was reverse breathing, taking shallow short breaths. His skin was sweating as he talked and his nails were chewed, indicating to me that anxiety may be a regular problem for the client. This client expressed that he was struggling with practicing the extended exhalation breath that I taught as part of the series thus far and felt like he was "doing it wrong." I reassured him that we would work on it together and get to the root of what was happening. As the session went on, his breathing and body posture fully relaxed. He said the breathing practice would work well in his day.

The client will continue to practice the extended exhalation breathing for five minutes twice a day--once at the start of the day following his usual meditation practice and then at the end of the day just before bedtime. He is also encouraged to use this in moments of high stress, including at work if that's accessible for him. We will meet following this session to discuss how the practice went and make adjustments if any are needed.

I did apply my intended plan once I met with the client. This lead to the client being able to apply the practices that I shared in the session to a real life scenario and in a timely fashion. The client indicated that they felt immediate relief as we moved through each section of the session and he was excited to incorporate this into his daily life. I observed physical relaxation of the shoulders, which had previously been elevated towards the ears. I also noticed that the breath deepened naturally before we even moved to extended exhalation breathing.

I did notice that the client came into the appointment very stressed, so we spent some time talking at the beginning about the heightened stress level. I decided in that moment to adjust the topic for the self-reflection to be specific to what happened before he came to our session. I conducted a good bit of research before my first session with the client to be sure that I was prepared leading up to the session, I have attached a few of the medical studies that I used as I developed my plan. I decided during the session that I would share the study "How Breath-Control Can Change Your Life" with the client because he is an avid learner and said he wanted to better understand how something as "simple as deep breathing" might help lower his stress response. We discussed this study during the session and it was a powerful moment.

Yes, I would approach it largely in the same way but with a couple of changes. I might come already prepared to discuss a medical study that I used to come up with the plan as part of the session with a client. In this case, the client really appreciated how much work I had put into coming up with something just for them and demonstrating that there was a medical study to support what I was offering really improved their experience. This may not work with every client, so I would be flexible about how I present this information and may not utilize it with every client. In my Yoga Nidra instruction with this client, I will modify it to offer the option to keep the eyes open with a gentle gaze because he struggled with eyes closed. I would also get feedback about how his body felt during Yoga Nidra. I would possibly skip tensing in Yoga Nidra in the next few sessions because his body was extremely tense and this seemed to be painful for him.

• The-body-in-isolation_-The-physical-health-impacts-of-incarceration-in-solitary-confinement-PMC.pdf
• PTSD-symptom-reduction-with-mindfulness-based-stretching-and-deep-breathing-exercise_-randomized-controlled-clinical-trial-of-efficacy-PubMed.pdf
• How-Breath-Control-Can-Change-Your-Life_-A-Systematic-Review-on-Psycho-Physiological-Correlates-of-Slow-Breathing-PMC.pdf