Cultivating Psychological Skills with Bonnie Robson, M.D.

[00:11] Jennifer Milner: Welcome to Bendy Bodies. This is co-host Jennifer Milner here with Dr. Linda Bluestein for another episode of this dance-specific series. Today we are so fortunate to be chatting with psychiatrist and performing arts medicine specialist Dr. Bonnie Robson. Bonnie has served as a consultant to numerous ballet schools and companies, has performed original arts-related research, and is a popular invited speaker at national and international conferences that span the globe. Her mindfulness approach to performance and psychological skills training programs have been included in the curricula of numerous universities and postgraduate arts programs, in addition to serving on the editorial board for the journal Medical Problems of Performing Artists.
[00:54] Bonnie has served on numerous committees and boards, including the PAMA Board of Directors, the IADMS Education Committee, the Healthy Dancer Canada Membership Committee, and the Dance USA Task Force on Dancer Health. Bonnie has received numerous awards for her contribution to arts education, including a Lifetime Achievement Award and the Bill Dawson Award. Although Bonnie is currently retired from clinical practice, she continues to dedicate her time to educating performing artists about how to achieve and maintain optimal resilience.
[01:27] Also, please note that this is information and not medical advice. Bonnie — she asked me to call her by her first name — is extremely knowledgeable through her extensive research and work with the dance community, and we are so fortunate to have her on the Bendy Bodies Podcast today. And on a personal note, I am thrilled that the three of us are reunited after we presented together on hypermobility at the most recent IADMS conference last October.

[02:06] Bonnie Robson, M.D: Hello and welcome to the Bendy Bodies Podcast. Thank you so much. I'm really pleased to be here and admire the work that you've been doing at Bendy Bodies.

[02:18] Jennifer Milner: Oh, well, we love doing it, but I have to say it's good to have our third musketeer back with us. So Bonnie, these are clearly very stressful times for people. What can you tell us about stress and why many people are feeling more stressed than ever before?

[02:39] Bonnie Robson, M.D: Well, as you say, everybody is in this together and everybody's feeling stress. Some people are coping better, and that's the thing about stress. It's an inability to cope, or to think you're not going to cope, with what you perceive as a threat. And it could be a threat to your mental health, which I'm interested in, or your physical health, or your emotional well-being. And people have been saying, "My emotions aren't quite what they used to be, but I'm doing really well. I'm doing lots of stuff. I'm taking exercise and I'm eating healthy, but still I'm feeling a little funny." So it's kind of an imbalance between the demands you have and your coping abilities.
[03:23] And today we have a lot of stresses. The stress of isolation, of not knowing what's going to happen next — and that's a biggie. Fear of the infection, of course; that's realistic. And frustration with not really being given the goods, the news. Is this real news? Is this not news? So inadequate information and not having the supplies can be very irritating — not having what you normally expect.
[04:01] And for the dancers that we're talking to, a lot of you are troubled by finances. You know, you can't have healthy food if you don't have enough money. And many people lost their contracts or jobs when the isolation occurred. So that brings a really big one up: the loss of purpose. If I'm not dancing and I'm not a dancer, what am I?

[04:32] Jennifer Milner: Yeah. I'm hearing a lot of that in conversations with my dancers — this is that time of them saying, what is my identity and what does it look like? And you mentioned we're all sort of in isolation right now, a lot of us are on shelter-in-place. What are the risks of this sort of physical and social isolation?

[04:53] Bonnie Robson, M.D: Well, you can be more emotional. Some stress is good, but too much can slow you down and make you not want to handle things. For people who were pretty stress-tolerant — you know, they could bounce back, they could handle criticism; that's what dancers do — we're now saying, what do we do now to handle the stress when I'm just feeling at sixes and sevens and not getting things done?
[05:22] So getting as much normality into your life as you can is helpful. You want to have a regular schedule — and everybody's talked about this, but are we all really doing it? Getting up at the right time, the regular time every day, using an alarm clock if we need to. Scheduling our day — and we can talk about that later, about how to set up your day so you can maximize your energy.
[05:50] But some of the things dancers can do, if they find their stress level is high, is rely on taking some dance classes. And I know most people have tried all the different kinds, and it's very exciting, isn't it, to try a dance class with someone you've always wanted to learn from. Also, yoga is online, and yoga breathing is wonderful. Journaling, planning the day, keeping a routine — for dealing with stress, that's the best part. And do use your body skills, because people who use their bodies all the time and then suddenly they're in isolation can use body skills in new ways. I like tricks like body scan and progressive muscle relaxation — those all use your body to help you deal with the stress.

[06:47] Jennifer Milner: I'm thinking about dancers specifically and this sense of physical isolation — being kept out of the dance studios — and then social isolation. Dancers tend to be hardwired a little bit differently as far as how they respond to things. We're taught in dance studios to respond to authority very well, so we follow that chain of command. We're taught not to show our emotions, perhaps, and to deal with them in a very "just deal with it yourself" kind of manner. So I'm wondering if there's anything like that that gets magnified during social and physical isolation, perhaps even more so for dancers than for other people.

[07:36] Bonnie Robson, M.D: Well, the social isolation — let's deal with the dance class and bringing it into your kitchen. What's missing is the teacher in the room. And even if the teacher can see you a bit in the gallery view, it's not the same as having that person there, just as you've said. And so it's not as rewarding to be in the program of the class, the yoga class or the dance class or the Pilates, whatever.
[08:07] But you also talked about social isolation, and I think what's important to me is: while we're all alone, we're not lonely. We don't have to be lonely. It's important for us to talk to friends and family. And again, dancers — you know you like the silence. You find it very hard to talk to somebody, especially about emotions. But please let me encourage you to do that, to tell people how you're feeling so you get some feedback. You might tell somebody about an experience you had walking your dog, and they say, "I had the exact same thing. Oh my goodness." And that's so validating and makes you feel so good when other people are saying the same thing.

[09:03] Jennifer Milner: Well, and I am noticing that with my dancers — when I work with them on a physical level — almost all of them have lost a fair amount of balance. And I don't even mean complicated dancing balance. I mean standing on one leg balancing. That has been lost, and I was talking to a friend of mine just yesterday, Alicia Head, about this. She said she was reading some preliminary papers saying that when you stop doing the complicated movements, you start to lose your vestibular balance quite quickly. And when you start to lose your vestibular balance, your suboccipital muscles start to tighten up, so you get neck tightening, which can lead to headaches and all that.
[09:49] But we were brainstorming what's going on with the dancers losing their balance. And one of the things I realized is dancers are so conditioned to have constant feedback. And even in these great dance studios that they've set up, or their parents have set up for them in their homes, they don't have mirrors all around. So when I have dancers do things, I can tell when I watch them move that they are not as aware of where their bodies are in space anymore, because they're not getting that constant feedback.
[10:16] All of this to say that we are not getting constant feedback in other ways as well. Dancers aren't getting poured into verbally over Zoom, and they're not getting that feedback in the dressing room, talking to each other and comparing aches and pains. So that's part of social isolation that I don't think dancers are thinking about — that we're not getting that verbal feedback. As you said, being alone is different than being lonely. And even just getting that feedback of, "Yes, it was hot when I went outside today too," starts to give you that framework of your surroundings and of your life. So I agree, that's so important.

[10:57] Bonnie Robson, M.D: Yes, and dancers have learned over time — especially the older dancers who've grown up in studios where they were taught not to show their pain — it can be really hard to put into words what you're feeling, and not to feel vulnerable and inadequate. So again, we're all in it together.
[11:16] And some people — I've noticed, and I don't know if you've noticed — are taking on more than they normally would, not being less functional. They're working, they're taking on: I can do that, I can do that, oh sure, I could do that. And we're getting too much. One woman I talked to was working from 5:30 in the morning till 8 at night every day. And where is she working? Just as we are now, online. And something has come up called Zoom fatigue. Have you heard of Zoom fatigue?

[11:59] Jennifer Milner: Yes, people have been talking about that.

[12:02] Bonnie Robson, M.D: It's where the brain makes changes because when we're trying to talk to people online, we can't pick up the normal social cues — the little things, your eyes dart one way or you nod or whatever — and it's really hard to pick those up when you're using the Zoom camera. And so the work is doubled and the cues are very hard to interpret. Yes, you get Zoom fatigue. Yes, headaches.

[12:38] Jennifer Milner: And for people who are so used to getting that kind of constant feedback, that can leave you in a very bewildering place. And as you said, some people will overfill their time trying to justify what they see as their idleness, right?

[12:55] Bonnie Robson, M.D: Exactly. Just because you're a nice person and you think you have the time, maybe you don't. So this could be something really positive for all of us — to learn to say no, so that when we return to work, we practice saying no. Like, "I'm sorry, I can't do that, I'm already busy that day."

[13:21] Jennifer Milner: Yeah. I think when we return to work, things are going to be so different. It's going to go through these huge swings from one side to the next and back again. Okay, so looking at this isolation — one of the big questions I have is about sleep. Are you seeing impaired sleep as an effect of this sort of shelter-in-place time?

[13:45] Bonnie Robson, M.D: Oh, you got it. Sleep is one of the things people are complaining about. The first person who told me about their sleep problem said, "I woke up in the middle of the night — I never do that — and there felt like there was this huge stone on my chest, and immediately I thought, oh, I'm sick." But no, it was a feeling of isolation, a feeling of anxiety, maybe a feeling that I'm not really coping well.
[14:20] For dancers, it's good for them to get 7 to 9 hours of sleep, but they don't always get that because dancers come home late, have to settle in, calm down a little bit if they've had a performance, and then the next morning they'll be up early for a technical rehearsal or a class. So the sleep is so important. I think, Linda, you were talking about sleep affecting people's immune system.

[14:55] Dr. Linda Bluestein: Oh, yes, absolutely. And people like dancers who are so used to being so physically active are going to kind of crash when they finally do get into bed because they are so physically exhausted — which, even if their circadian cycle is off, because of course for dancers it's harder for them to be on the ideal cycle, as you pointed out they often have performances and things late in the evening. But yeah, sleep is critically important for proper, optimal immune function. So that is something that I think a lot of people are really struggling with, even if they know that they should be getting up when the sun is up and staying up ideally, not napping — or if they do nap, making it very, very brief, 20 minutes or less.
[15:45] And one of the biggest problems with that is our screens. We're using our screens so much more rather than interacting with each other. And the light from the screens suppresses melatonin production, which is what regulates our circadian rhythm and tells us it's nighttime, it's time to fall asleep. So that's something that a lot of people are really struggling with. Bonnie, do you have suggestions?

[16:16] Bonnie Robson, M.D: Well, I do, but before that — there are three other kinds of sleep: light sleep, deep sleep, and REM sleep, and we cycle through those 4 or 5 times a night, as I understand it. Even if we have 7 or 8 hours of sleep, only about 20% of that time is deep sleep, and that's the one I think helps with your immune system and your physical recovery and even growth. So we do need the sleep.
[16:51] What are some things that can help? You have a regular bedtime. Just as you get up early, you try to have your bedtime at a regular time, and allow yourself whatever time you need each night to unwind, to get ready for bed. We would never try to put a child to bed by scooping them up, putting them in their pajamas, taking them in the room and saying, "Night night, go to sleep." That's not going to work. We all know that. You remind them that they're going to have a bath now, and they're going to get into their pajamas, and then they're going to have their little snack. And we should have a little snack — not a huge meal, a little snack. Healthy fruit, a few crackers, even toast and jam, the nutritionist tells me, is acceptable as a bedtime snack.
[17:45] No electronics, as you said — that's really important. And some people find a bath helps. Now there's controversy about exercise. Do you remember they said don't exercise right before bedtime? But there's been some research coming out lately, actually in Texas, showing with athletes — and dancers are definitely athletes — that mild exercise is not bad. Yoga, and they even have some yoga poses that help. The pose of the child is good. The legs up the wall is good. Double pigeon, which is a funny way you sit cross-legged — you can just pull it up online. And shavasana, the typical pose that yoga teachers use at the end of class, which everybody looks forward to. And that prepares you for bed, actually.
[18:47] And there are things you can do again with your body. My favorites are body scan and progressive muscle relaxation if you're having real trouble falling asleep.

[19:05] Jennifer Milner: I love focusing on mindful breathing. That's some work that I've done with my dancers, and I encourage them to do some nice deep, really great diaphragmatic breaths as they're trying to go to bed, to try to stimulate that vagus nerve and sort of switch their body into that parasympathetic state. And the thing is, dancers don't consider everything that you just listed exercise, right? If it doesn't stretch them out or get their heart rate up or increase their turns, it's not exercise. So you don't have to call it exercise, dancers. You can just call it physical mindfulness, or whatever you want to call it.

[19:43] Bonnie Robson, M.D: Or relaxation, stretch, whatever. Right.

[19:50] Jennifer Milner: I don't want them to hear the word exercise and think they should go do some cardio, because going through those gentle movements and focusing on that breath can be quite helpful. So thank you for spelling all of that out. Are there issues that might come up that you have seen increase over social isolation — like sleep abnormalities or anything like that? If you've already got something like sleep apnea or just regular insomnia, can that be exacerbated in situations like this?

[20:23] Bonnie Robson, M.D: Yes, and the waking up, the insomnia, the difficulty falling asleep — and if you're already prone to periodic limb movements or restless leg syndrome, those can be problematic for you at this time, and then you worry more. So you wake up in the night, get up, you go into the next room, all worried.
[20:47] Again, this would be a time to check out your sleep hygiene. How's your room? Is it completely dark? Is it quiet? Is it cool? Sometimes people just let their beds go because who's going to see? But it really does help to get your room ready, to have your bed made, to have it all ready for your sleep. And I was going to ask Linda to tell us again about restless legs and any supplements we might consider to help with our sleep.

[21:28] Dr. Linda Bluestein: Oh yes, magnesium is wonderful, and so many people have a magnesium deficiency. Not knowing any individual person's circumstances, but in my clinical practice I do put a lot of my patients on magnesium, and I also put a lot of people on melatonin. We talked about melatonin a little bit earlier — it's a really important hormone for regulating the circadian cycle. The interesting thing is melatonin also has beneficial effects on the immune system. There are numerous people who have come out with recommendations, and there's a lot of scientific studies showing that melatonin has beneficial effects even at doses that can be quite high relative to what we would normally recommend. I've put some information about this in my blog, and the Institute of Functional Medicine has some great information if people want more details about dosing and things like that.
[22:31] One thing that I think is important to mention — that we would want to avoid, especially in excess — is alcohol. A lot of people feel like, "Oh, I have a drink and then it helps me fall asleep." It's possible that it makes you sleepy and can make you feel drowsy, but it actually reduces the amount of REM sleep that you get, so it doesn't actually help you get quality sleep. And alcohol actually impairs the immune system. So that's something that I think is important for people to be aware of at this time.
[23:09] The other thing I wanted to mention in terms of a supplement is something called palmitoylethanolamide. Now that's a really long word, but it's called PEA for short. Just be careful if you Google PEA — you're going to come up with a lot of different PEAs — but there's information about this in my blog and we'll have it in the episode details. This is an endocannabinoid; it acts on endocannabinoid receptors and has a lot of different beneficial effects. It can actually help improve sleep, decrease pain, and also stabilize mast cells. And it's also on the Institute of Functional Medicine's list of supplements for coronavirus.
[23:55] It's really fascinating to me because basically the things that I had already been recommending to my patients for decreasing inflammation, decreasing pain, specifically for mast cell activation syndrome and other things associated with being hypermobile, are the same list of things that the Institute of Functional Medicine and other organizations are recommending for boosting your immune system. It kind of reminds me of a saying that I heard once at a urology meeting — my husband's a urologist — and the speaker was saying, "What's good for your heart is going to be good for your prostate." It's reassuring to me that things that are good for reducing inflammation and for making our body generally healthier are also going to be helpful for immune functioning.

[24:49] Bonnie Robson, M.D: Before we leave sleep, we should talk about dreaming, I think.

[24:53] Dr. Linda Bluestein: Oh yes, definitely. What should we know about dreaming? And are people having more vivid dreams nowadays?

[25:00] Bonnie Robson, M.D: Oh yes, they are. People who have not had dreams before frequently are waking up with dreams and are startled and anxious. Dancers' anxiety dreams are pretty typical — that's how their body is recognizing stress. They say, "I'm ready to go on stage, but I don't have my costume on." "I'm on the way to the theater, but I'm in traffic and I can't get there in time." One dancer — it was not quite as related to dance, but she was getting lost and couldn't find her way, and it seemed like she was little, and her parents — she had never been lost. This has never happened to her in reality, so she'd never had that experience before, but it was very vivid.
[25:47] So you wake up distressed, and what are you going to do in order to get back to sleep? Go into another room, stay warm, do some of your mindfulness practice, as you said — practice your breathing. There's a yoga breath which is very hard to describe over the air because you have to practice it, but many of you know it, where you put your middle index finger in the middle of your forehead, and then using your thumb and your ring finger, you alternately close each nostril, breathing in, close the nostril, breathe out the other nostril, and so on. And that is exquisitely calming and very good to use in that situation.
[26:48] I like to finish my dream in a positive way and take the new ending back to bed with me. Many, many people report that if they don't, when they fall asleep, they go right back into the dream where they left off, just like Netflix. So finish it positively, review your sleep hygiene, practice your body scans, your PMR, your mindful breathing. The next night, take a positive image to bed with you. I like my safe place, and we can talk a little bit about developing a safe place later — that's one of the psychological tricks of the trade. And make sure that you go through your whole sleep hygiene before going to sleep the next night so you're not replicating having another night of anxiety dreams. They're not bad dreams exactly — they're just horrible situations that you have no control over. Huh, I wonder why.

[27:55] Jennifer Milner: Right, exactly — and they can leave you feeling exhausted and stressed and anxious all day sometimes.

[28:03] Dr. Linda Bluestein: That's really interesting, and I should mention that melatonin can actually cause you to have more vivid dreaming. Yeah, and it is quite interesting because melatonin — and another medication, low-dose naltrexone, which requires a prescription — can also cause more vivid dreaming. So I love your idea about rewriting the dream in your mind and finishing it on a positive note. Because I think that is one challenge that a lot of us are having. Maybe before, we would go to bed and have some thoughts in our mind, but at least it was more positive. There were a lot more knowns than unknowns. And now we might be going to bed having more difficulty doing a cleaning-out-the-hard-drive and shutting things down.

[28:55] Bonnie Robson, M.D: That's why you need enough time. You can't expect yourself to just go — as you said, the very physical dancer can't wait to get to bed and falls asleep, has a very short sleep latency time — time to fall asleep — but maybe not so much now.

[29:10] Dr. Linda Bluestein: So do you have any suggestions for making up for that huge difference in amount of activity? That will have a really dramatic impact on neurotransmitter levels in the brain, and that's not anyone's fault. I think that's one important thing that's helpful for people to realize — not to blame themselves and add that on top of everything else.

[29:36] Bonnie Robson, M.D: Yeah. I think something that helps is what I like to think of as self-rewarding activity. That involves another psychological skill called goal setting. And you may have, as a dancer, had a journal — a dance journal — in which you wrote down the positive things that happened to you so you could look back and review them and bring those into class at a later time. I propose that we do the same journaling and preparing for the day in our mind.
[30:18] Certainly before bed, writing down all the things that you have to do tomorrow and then putting them aside will help you not worry about, "Oh my goodness, I've got to call so-and-so" — you've already dealt with that. So that'll help with your sleep.
[30:33] But when you're getting up in the morning, and we've already talked about having our routine — brushing our teeth, doing all our regular things, having breakfast and supplements, and so on — each day should be planned with short and long-term goals. So maybe a short-term goal that I know I can do tomorrow, that I have wanted to do for some time. For example, my favorite example is cleaning out the fridge. Now, hands up all of you who want to clean out the fridge today.

[31:05] Dr. Linda Bluestein: My hand is not up, for the record.

[31:08] Bonnie Robson, M.D: Neither is mine, actually, but that's okay. But you can break it down — we can use a trick called task analysis. Overall we're going to clean the fridge, but we make it a little bit smaller: I'm not going to clean the whole fridge. I'm going to just clean the vegetable bins tomorrow. And then I'm going to go for my walk.
[31:37] Now, if possible — not everybody can walk. Some people are on the 23rd floor of an apartment building, and so they're only going to go down once a day, if that. And even active dancers find that a long haul back up. The alternative is to take the elevator, which is functioning, but a lot of people find that very risky. So they would prefer to walk up the 23 flights of stairs. So you may have to plan what you're going to do when you go for your walk, because you're only going to go down once a day. Make your schedule flexible — it's not like, I must do this at 11 o'clock. A little flexibility in there, a little wiggle room, but achievable and a little bit challenging.
[32:38] The fridge is definitely challenging. Dancers are not usually very good at limiting themselves. If they put it on the schedule, they want to do it and they want to do it well. If they're to clean the sink, they want to clean that sink to their standard, which is usually very high.
[33:03] You put a routine in and then you try to follow it. Having written down all the things in your journal that you're going to do — including, you know, I'm going to make myself a healthy salad for lunch, and I'm going to make time for that — can be very rewarding because you check it off. I ate a healthy lunch. I've even had some of my dancers posting pictures of the healthy food that they're making now that they have time. Beautiful things that they've taken a lot of time over, and taken time to set the table and take the picture.
[33:35] And bodies love regularity. So do dancers. Dancers are giving to their body if they give it a regular routine, because your body likes that. If you have pets, you'll know that they know exactly what time it is when it's dinner time — they're there and ready and waiting, and don't you be late. So don't wait till suppertime and then say, "What have I got here? What's left over? What can I do?" That's too late. Do your plan and stick to your plan. That is tremendously helpful in getting through the day.

[34:33] Jennifer Milner: Now, I want to circle back to something that you said there, because you talked about the value of self-rewarding activities. And I love that phrase. But that phrase, at some points in my life, would mean a pint of ice cream. Not that there's anything wrong with a pint of ice cream, right? But I know some dancers might hear this kind of conversation and start thinking about the journaling and find it a way to sort of obsess and overdo things in what they consider a safe and comfortable way. So how do we find that balance of motivating ourselves to do stuff, but not too much? And finding self-rewarding activities that are gratifying — like going for a walk — but not, "I must walk this speed to keep my heart rate up to burn this many calories." How do we find that balance as dancers?

[35:25] Bonnie Robson, M.D: Yeah, I think that's right on, Jennifer. We have to set the task in tiny units and reward ourselves — say, "Yes, I did that. That is good enough." And "good enough" is a lovely phrase. I don't have to be the best. In fact, if you strive to be the best always, you're going to find that it interferes with your performance and you don't do as well.
[35:56] So even doing your jigsaw puzzle — you don't have to finish it today. You can plan to do a certain amount of time on your jigsaw puzzle. Everybody seems to have found jigsaw puzzles lately. They are very self-rewarding: when you finish and you get the piece in, every time you put the piece in, that counts.
[36:21] And write down what you've done. If I finish cleaning that fridge, I write it into my journal, and I make sure to tell my friends and family when I'm talking to them what I did. Because they're going to say, "How are you? What are you doing?" And I might say, "Oh, I'm fine, nothing." But that's not true. Look at all I did — but I need that journal to remind me of all the wonderful things I've done this past week.

[37:56] Jennifer Milner: Yes, I agree with that. And I think taking it in small, inconsequential bites is great, because if you only write down the big things — like I walked six miles or any of that — then it's a really unrealistic place to be.
[38:16] I will say I've been through a couple of very difficult times in my life. When my husband and I went through a hard time with him being out of work for almost a year, with a new baby and all of this, there was a point that I hit where I said, "I have to write down all the good things that are happening to us right now, because there are so many wonderful small things happening, and I don't want this hard time to be over and for me to just look back and say it was so awful." We have to remember that there was some beauty, some really lovely things too — maybe it was just a friend surprising us with a meal.
[38:52] So for me, during this sort of time of isolation, it's super helpful to focus on the small good things, the small lovely things, and not try to set my sights quite so high. So I really love self-rewarding activities as small things. I love that.

[39:14] Bonnie Robson, M.D: Some people are making lists of what they're grateful for, and apparently gratitude — again, writing down your positive lists — is very helpful. It's been found to be very, very helpful. You wouldn't think just doing that could be such a simple thing, but you know, what am I grateful for? Well, I'll tell you, I'm grateful for being able to wear perfume. Today you can't wear perfume, and I love perfume, and I've been going around wearing perfume in the house and smelling ever so nice.

[39:49] Dr. Linda Bluestein: Yeah, that's a good point because we tend to think about the big things. And I think one of the things I see with a lot of people is that normally we would think of things we'd be looking forward to as big things — like trips or a big performance or, you know, for us, actually, Jennifer and I are supposed to be right now at this very moment — right now we are supposed to be together in Banff, speaking at a conference. And Bonnie, I know you know all about this. You were instrumental in getting this organized. And of course, this is one of the many things that was canceled.
[40:27] So I think that what you're saying, Jennifer, is so important, because that also helps us to focus on the little things we can be looking forward to, and not just on those big things. Because I think when, Bonnie, you were talking about people getting on a regular schedule, it can be hard to get out of bed in the morning if you feel like there's nothing to look forward to today.

[40:51] Bonnie Robson, M.D: It's another day. Yeah, no, it's not. Today's the day that I do something special. I'm going to call my friend Martha today, and I'm going to have time today to do my special yoga class.

[41:10] Dr. Linda Bluestein: So, speaking of feeling really overwhelmed — I know you've talked, Bonnie, about taking your emotional temperature. Would you be able to touch on that a little bit and help people understand when they know that they are really needing additional help, and what kind of resources they might be looking for, either for themselves or for someone they care about?

[41:35] Bonnie Robson, M.D: Thanks. I do want to talk about emotions and overload. When I say take your emotional temperature, I'm saying look at how you're feeling. If your temperature's too high, your heart rate is actually up, you're worried, you're impulsive — going around, but while you're impulsive, you don't have much energy, you're tired. And interestingly, you're more clumsy. If your emotions are too low, your movements are slow. You have slow decision-making, Jennifer, as you mentioned. You have a floating sense of your concentration — I just can't seem to stay at it. One of the dancers I talked to is trying to do her income tax, which is not a pleasant thing anyway, but she can't sit down for even 10 minutes to keep at it. It's just like she can't get it done.
[42:33] So it's difficult to focus on a task. And again, journaling, using your journal to write down your feelings and following along — checking out what helps you bring your emotions either up or down as you need. What changes do you make in your activity? Are you hydrated? Are you eating properly? Are you putting your exercise in at the right times? When during the day are you having low emotion — just can't get going, I just don't feel like it — or high emotion — I've got to get this done? You can hear in my voice the different change.
[43:20] Emotions relate to mood changes, and if you think they're out of control — if you're having intrusive thoughts that you can't control, if you're having impulsive thoughts — you might want to check out how you're coming across with a friend. And if you don't feel comfortable talking to a friend, there are helplines available. I'm going to mention four of them that I have. There's the Befrienders — International Befrienders — and there's the BBC Action Line in the UK. In Canada, there's the AFC, which stands for Actors Fund Canada, and in the States, there's the Actors Fund — they have a special dance section, with trained social workers who are answering the phones and know about dancers. So I recommend the Actors Fund. They're also offering financial support and very concrete suggestions for people. They'll also connect you with helplines in your area — so if you're in an isolated part of the country, they'll find what's closest to you.
[44:43] Similarly, what if you've got a friend or family member who seems to be out of emotional control? Check with them about how they're feeling. And what if you've had a depression before? We've all had depressions. Maybe you've had some treatment before. Maybe you've been over-anxious before and had some emotional illness. Now you're worried that it might recur under this terrible stress.
[45:23] Write down what happened, who you saw, where you saw them, and a telephone number if you have it. If you took medication, what the name of it was, if you can remember, and the dose, and what was positive and what was negative about that medication. Because if you go to talk to somebody, they're going to want to know what was good for you, any side effects you had, and remember to put down any allergies you have. Then put that note in a safe place where you can have easy access to it, and then you can forget about it. Because if your emotions get out of control and you want to talk to somebody or see somebody, you can just quickly get that information out and take it with you.

[46:08] Dr. Linda Bluestein: I think that's particularly valuable because it helps just to know that you have something available just in case. And although that's not the same thing as having the actual prescription — in the States anyway, I don't know what's happening in Canada; Jennifer and I are both in the US, and of course, Bonnie, you're in Canada — I know here we are doing a lot more in terms of telemedicine these days. And so, although there are still access issues for sure, in some ways I think access might actually be better during this time because a lot of people are offering telemedicine visits.
[46:45] So I think it's definitely worthwhile contacting your primary care provider and seeing if they would be willing to write you that prescription to have just in case, or at least reaching out to them. I know I've talked to people who haven't even called to see if their provider is doing telemedicine visits, and once I encourage them to do it, they say, "Oh yeah, I was able to get an appointment, no problem." So yeah, that's —

[47:15] Bonnie Robson, M.D: And even checking in with your counselor — if you've had a counselor in the past, just checking in to make sure they're there. Then you know it's available. Then you say, "Well, okay, if I ever need her, I can call." Yeah, that's a great idea.

[47:26] Jennifer Milner: I love that. Well, Bonnie, you have given us a lot of different things that we can put into our toolkits to handle this time of uncertainty and stress. You've talked about the small rewards we could give ourselves — the self-rewarding activities. You've talked about the mindful breathing, ways to cope with our dreams, working on our sleep, and getting ourselves into a healthy mindset. And I really like what you just discussed — preparing a CliffsNotes version of what's going on with us mentally, what prescriptions we might be taking, and all that, to have ready for that time when we might move forward with talking to a professional of some kind.
[48:18] I wanted to circle back to something you mentioned earlier when you talked about developing a safe place, because that was really interesting to me, and I would love for you to elaborate on that. What do you mean by that?

[48:32] Bonnie Robson, M.D: Well, everybody — I feel, and I've said this all my life — everybody should have a safe place they can go to. A safe place is using imagery. And dancers think, "Oh well, I don't use any imagery. If somebody tells me what to do, I do it, like the balloon on top of your head." Well, you imagine that, but you're given those cues. A safe place is somewhere where you can go to reduce your anxiety. You can go anytime and anywhere. It takes a while to develop a safe place — I say it takes about a week to learn to find your safe place.
[49:06] A safe place is someplace you imagine and you put yourself in it. You think about: where would I go where I would be really safe and it would be wonderful and I have no responsibility, no obligation? I can have anything I want there. It could be a place outdoors or indoors, but it's my place. It can be any weather. Some people love walking in the rain — their safe place would definitely have rain. It can be snowy, for all you snowboarders. It could be a wonderful special hill for you. For most people, they like warm and sunny, and many people choose a beach.
But if you choose indoors, what furnishings do you have? What colors? What scents? Are you going to bring somebody to your safe place? Are you going to be alone with no responsibilities? Are you going to have a pet with you? Imagine yourself going there, and you can stay for a short time and come back. After you've done a week of this — making any changes every day that you want — you can decide if this is your forever safe place or if you want to change it, and you make the adjustments. Then at the end of the week, you keep that and you can use it every day, twice a day for short periods. This is not meant as someplace where you'd go for a prolonged meditation. Does that ring a bell with you? Does that make sense — somewhere you could go safely?

[51:02] Jennifer Milner: Yeah, absolutely. And that's a skill we can develop now during this difficult time and then carry it with us anytime we want to. It's not something that has to be just for extreme times — as you said, it can be anytime you need a break, anytime you want to take that break.

[51:21] Bonnie Robson, M.D: I certainly go there just before bed, just before sleep.

[51:25] Dr. Linda Bluestein: I was thinking the exact same thing — that whether a person is in pain or having difficulty falling asleep, or maybe they're having a procedure done, if you can put yourself mentally in that safe place, you're going to have an easier time falling asleep, you're going to have less pain, and you're going to get through a procedure more easily. Because you are psychologically able to calm your nervous system in a way that is super beneficial, as both of you have talked about earlier, with engaging the parasympathetic nervous system.
[52:01] And you can use this to fall asleep. And also, we all wake up in the middle of the night from time to time — we don't remember it most of the time because we fall back to sleep quickly enough. But if you wake up in the middle of the night, this is a perfect thing to do to help yourself fall back to sleep.

[52:19] Jennifer Milner: Yeah, I feel like these are all such great, concrete things that we can do during this time when we feel so helpless. I really love this list that you have put together. I also want to say — I know that a fair amount of what you've covered may seem obvious, like working on staying positive and keeping yourself active and going to sleep at the same time and not drinking too much alcohol. These are all things that we kind of know. There's a difference between knowing them and doing them. Putting broccoli in your fridge does not make you a healthy eater if you're throwing that broccoli away every week. So knowing these things — everybody goes, "Yeah, yeah, I know what I should be doing to help myself get to sleep." But I just want to encourage everyone to actually try some of these things. Whatever motivation works for you, just try some of these things, because these are really great tips, and I really appreciate you passing them on, Bonnie.

[53:23] Bonnie Robson, M.D: Well, I'm so glad you mentioned mindfulness early on. We may not have time to go right through that whole process here, because it really takes 8 weeks of training. But you mentioned it, and it is a wonderful skill to have and to develop. People who are interested might look up mindfulness, because it's a lovely, lovely skill.

[53:43] Dr. Linda Bluestein: And Bonnie, I think we should go into mindfulness. I think that a lot of people, when they first try it — kind of like with the safe place — when they first try doing a mindfulness meditation, they might have difficulty with it and think, "This is not for me." But they're probably the person who needs it the most. And Jennifer, you really hit the nail on the head — we know a lot of these things, but we just don't do them. So Bonnie, if you would be willing to go into mindfulness, what people can do, why this is so important — I think this is just information that people really need.

[54:30] Bonnie Robson, M.D: Well, I'm happy to talk about it, but again, reminding you that you can train online and there are lots of trainings available. See if you can get a credited practitioner who has taken the course, because my local drugstore has an online mindfulness training session, and that's great — but remember, to really make it effective — and all these things we've been talking about, these skills, they're not for everyone. Some of you may say, "Well, that didn't help." That's fine. Not everyone — it's not cookie cutter. Not everybody is going to find it helpful.
[55:20] But paying attention in the present moment, being aware and nonjudgmental, curious and observant — these are all words that refer to mindfulness. It started with a Buddhist tradition 2,500 years ago, so if somebody's been doing it for 2,500 years, there must be something in it — sort of like chicken soup. People must get some effect from it. Some, not all.
[55:53] And then it came back really strongly around 2005 with the work of Jon Kabat-Zinn — and again, you can look up some of the books on mindfulness if you want to. Be more creative about it. You actually create a way of directing your attention internally, and at first your mind goes everywhere, and that's fine. I hear a bell, I smell the flowers — actually, we're starting to have some flowers now. Isn't that wonderful? We can see them. But I need to bring myself into the present moment. So when I said flowers, that was distracting. So I need to come back to me, come back into me, and just be present inside. If my mind wanders, I bring it back, nonjudgmentally. I say, "Hmm, isn't that funny — I was thinking about something else."
[57:00] So to get started, I actually teach people to practice noticing with their five senses all the things that are around them. I hear this, I feel this, I see this — just run a dialogue of what your brain is doing. And then let all that go, float away on little tiny purple clouds, and bring yourself inside — just to see if you can stay in with active attention and what's happening in you. Oh, I'm breathing. Oh, I wasn't thinking about that.
[57:39] A mindfulness practice, once you've trained in it, helps with memory retention and it improves your sleep, just as you said, Jennifer. So it's something you might want to consider training in. It takes about 8 weeks to really get the sense of it. So you have to practice — and dancers love to practice something. Put that in your schedule. Remember the schedule you're making? Ten minutes of mindfulness practice after lunch.

[58:06] Jennifer Milner: Great. Well, it sounds like such an easy subject, right? Like, it's just mindfulness. It's being present in the moment.

[58:14] Bonnie Robson, M.D: Very hard.

[58:15] Jennifer Milner: But as you said, it's very difficult to do. And you mentioned it being like an 8-week course that you can take, so it is something that will require a fair amount of practice. Especially because in our society today, it is difficult for us to be present with our phones and everything. I've noticed some of my dancers when they're taking a group class — they might have their cell phone off in the corner and they might be checking it in ways that they never used to if they were in the dance studio.
[58:44] So it is difficult for us to be fully present. And I think right now, partly because we feel like we're not fully present even when we are with someone — when we're Zooming, there's that sense of dissatisfaction, like eating a diet cookie instead of a real cookie. Yes, I'm interacting with you, but I'm not fully present with you, so I'm still distracted with my phone or something, because we're not in the same place. So I think mindfulness is incredibly important right now and very germane to what we're going through. So thank you for that description of it.

[59:20] Bonnie Robson, M.D: Very powerful, if you can get it.

[59:24] Dr. Linda Bluestein: And maybe that's something that can come out of all of this. We definitely, in our society, get bored so easily nowadays, and our impulse is to pick up our phone. So at the same time that we're connecting over our electronics, maybe we can also set as a long-term goal that during this time we'd be working towards looking inside.
[59:46] And as we've been talking about with dancers — they don't use their voice in their dance, so they're not used to speaking up for themselves or necessarily being as tuned into what they're feeling inside their bodies. So maybe they can view this as a time to really look inward and do some of the work that will benefit them after they are back in class and back in rehearsal and in performance and things like that.

[1:00:13] Bonnie Robson, M.D: And you know, dancers tend to — just in thinking about that task and saying this is hard to learn, and you're going to have to work at it and be present in the moment — dancers might say, "Oh, I can't do that. I wouldn't be able to do that. That's not for me." And so one of the things that we haven't spoken about is getting rid of some of the negative thoughts.
[1:00:40] Dancers love negative thoughts. If I say, "Tell me some of the things about your body that you like," they'll say, "Oh well, my shoulder's all right, but my ankle's terrible and I have awful feet and my back — my spine — they told me, 'If only you had a decent spine, you could be a real dancer.'" It's easy; they just turn it on.
[1:01:03] So we're really good at thinking about negative things. The first thing is key: recognizing that you're doing the negative thoughts and countering with positive thoughts. The things we've used already are the special breathing — and there's another breathing where you breathe in just a little bit and make a little constriction in your throat so there's just a little noise as you're breathing in. And then when you breathe out, that's called Ujjayi breathing, and it's like the ocean coming in and going out. If you can practice that, it will help you stay a little in the present moment — and that's a great thing. And then start giving yourself positive thoughts to replace those negative thoughts.

[1:02:07] Dr. Linda Bluestein: Bonnie, I am so curious about this. I know that our self-talk does tend to be so much more negative than positive. Is there a reason for that? I've heard that challenging our negative self-talk can be very beneficial and can really help us feel better. We tend to be so hard on ourselves. We say things to ourselves that we wouldn't say to our friends. Do you have insight as to why we tend to say those negative things to ourselves?

[1:02:39] Bonnie Robson, M.D: No, I don't know why we do that. I've actually found that I've been saying, "I don't know," a lot these days, and I think that's a positive — I can turn that around into a positive. It's a good thing for me that I've noticed how many times I say, "I don't know. I don't know where we're going. I don't know what's happening." But hey, here's a positive: I'm privileged that I can meet with you and talk about these things and share these ideas. Isn't that great?
[1:03:14] So you can take the negative and turn it into a positive. And failing that, you can brush all the negative thoughts off your arms and off your legs and off your feet — just brush them down with your hands. Get rid of them. Brush them out of your head. And stop — tell your thoughts to stop. Stop it. I don't want to think about that now. And turn it into a positive. I can handle this. I can do this.

[1:03:47] Dr. Linda Bluestein: I've done things before — I can do it. And as you're saying this, it's reminding me of something that the first time I heard it really struck me: that we are not our thoughts. The first time I heard that, I thought, what? We're not? But that's true, right? Sometimes we can overly identify with our thoughts and think, "Oh, because I thought that, I must believe it." But sometimes we can think something that shouldn't belong to us, that we don't want to belong to us, and that doesn't need to belong to us.

[1:04:24] Bonnie Robson, M.D: I just wrote that down. "We are not our thoughts." I can refer to that again another time and keep that positive thought going.

[1:04:34] Dr. Linda Bluestein: Because sometimes, I think, all of us have a thought that we don't want to have — it just spontaneously comes up and then we don't really know how to handle that, especially as dancers. We tend to be perfectionistic. We wouldn't be dancing if we didn't want to achieve a high level of perfection and accuracy of movement, because otherwise it's so hard — why would you do it otherwise? It's too hard to do it if you didn't have a little bit of that mindset anyway.

[1:05:11] Bonnie Robson, M.D: Yeah, that's to remind us: when we get those intrusive thoughts — the ones you're talking about, the ones you don't want — maybe talk to somebody else about it, share that thought. It feels bad, and so you don't want to tell people about it, but it might be helpful to share that thought. And then that person will come back with something that's useful to you.

[1:05:41] Jennifer Milner: And I work with a sports psychologist who works with dancers, and I heard her say to a group of dancers once that you can have these negative thoughts and just let them drive past you like a car. Right? The car will just drive on by. And she said, when you watch the cars go by, that's fine. Recognize the car, acknowledge it, let it go. If you let the car stop and you get into it and start riding around in that car — that's the difference, you know. Then you're inhabiting that thought.

[1:06:07] Bonnie Robson, M.D: Oh, that's a good image. I love the image.

[1:06:10] Jennifer Milner: Yeah, I do too. And so that's something I'll talk to my dancers about. And I think as dancers, we're just naturally drawn to the negative because that is what shapes us as dancers. Critiques make us dancers.

[1:06:22] Bonnie Robson, M.D: Give me another correction. Exactly.

[1:06:25] Jennifer Milner: And when someone is correcting you, it means that you're worth their time. And when someone isn't giving you any comments, you're not even worth them trying to correct you. And so we take those corrections and start to crave what we start to see as negative feedback. But there's a way to take truly negative feedback — like, "I was terrible at that turn" — and turn it into constructive feedback you're giving yourself: "I did not make that turn, but I can fix this and see what happens." Constructive criticism is different from negative thoughts, and we as dancers have to learn to see the difference between one as an avenue for making us better and one as an unhealthy habit.

[1:07:12] Dr. Linda Bluestein: Yeah, that's great. And Bonnie, if we could wrap up with one last thing — Jen's talking about this idea about the car. I love that. I think that's such a fantastic image. And imagery is something that a lot of Olympic athletes use and it's used in a lot of other venues, but I don't know how much dancers do that. And I think right now, when we are limited in our options — taking class, performances — we're used to, as you're talking about, not having the teacher in the room and having each other's energy. We definitely, as dancers, feed off of that. Can you wrap up by telling us a little bit about how people might be able to use imagery to help them during this time?

[1:08:01] Bonnie Robson, M.D: Yes, because dancers may think — as we just said, their negative thought may be, "Well, I don't know how to image. I couldn't do that." Well, yes, you can. Everybody can.
[1:08:08] I would ask you to go and find your toothbrush. Have you found your toothbrush? And then I would like you to say what color it is. I bet you knew what color your toothbrush was. That's imagery.
[1:08:26] So now I want you to think about all the wonderful times you had in dance, and out of all those wonderful moments — remember that feeling of flow, when the dance was just flowing out of you, when you were your dance and it was you, and it was a magical moment. Can you image that? Can you bring into that image the sounds that you heard? Was there music? Bring in whatever else you heard — doors? People? What could you see? Were you in front of a mirror or were you on stage? Could you see lights? And what could you feel? Could you feel the floor? Could you feel, as you turned, the wind going around you? Could you feel your costume? And the scents — what could you smell? Bring in all your senses — your proprioception. That's a hard one for some of the Bendy Bodies, and you're working on it. And where are you in space?
[1:09:37] Bring all of those sensations into your image, and then re-experience that again — feeling that wonderful, special moment just for you. And that's how you use imagery to feel better, to improve your self-confidence. You've been there, you've done well — take satisfaction in it.

[1:10:03] Dr. Linda Bluestein: Beautiful. Yeah, that's fantastic. Wonderful. Well, this has been such a thrill to get to chat with you today, Bonnie, and with you, Jennifer. It's so great to have the trio back from our presentation in Montreal — that was so much fun. And Bonnie, can you tell us where people can find out more information about you or connect with you?

[1:10:33] Bonnie Robson, M.D: Well, we are doing — with the Mental Health Committee of the International Association for Dance Medicine and Science — weekly webinars that are coming up. You can get them through the newsletter of IADMS and on Instagram, and they're on YouTube. Each week a different topic is handled: one week on emotionality and emotions and what to expect, another week on stress, and there's going to be one on sleep. Oh, and one we didn't talk about today: living in isolation with children, which is really important. It's going to be remembered as the most wonderful time that you and your children were together, and also maybe one of the most awful times. Definitely. And your pets — they can be good and they can be difficult.

[1:11:23] Dr. Linda Bluestein: Yeah, definitely. I was talking to a friend the other day who has relatively small children at home. They're both now working from home and they have, I think, a 5- and 7-year-old at home, and it is really, really —

[1:11:46] Bonnie Robson, M.D: "What are we going to do now, Daddy?"

[1:11:49] Dr. Linda Bluestein: Well, not only that, the schools are saying, okay, we want you to do all of these things plus all these extras —

[1:11:55] Bonnie Robson, M.D: Six hours a day.

[1:11:57] Dr. Linda Bluestein: Yes, because they said to me — it's not just a matter of having the kids busy and occupied. They expect all this extra work for you to be doing, when normally you were used to shipping them off to school. And so it depends so much on the age of the children, right? Different challenges at different ages for sure.
[1:12:24] So, well, wonderful. You've been listening to Bendy Bodies with the Hypermobility MD, and today our guest has been Dr. Robson — Dr. Bonnie Robson — psychiatrist and performing arts medicine specialist. And it has been so great to have Jennifer Milner, my guest co-host, on the show again today as well. I really appreciate both of you taking the time to share your knowledge and having this great conversation. Thank you very much for inviting us. Of course, anytime.
[1:12:56] Well, we'll catch you next time on Bendy Bodies with the Hypermobility MD. Thanks so much. Please go to bendybodies.org for links to all the episodes and to access the show notes. If you enjoyed this podcast, please share, leave a review, and consider rating us 5 stars. Don't forget to subscribe so you will be notified of all new episodes. Feedback is greatly appreciated and can be emailed to [email protected]. Go to hypermobilitymd.com to sign up for my newsletter. Thank you to Rhett Gill for production and sound editing, to Andrew Savino for composing our original music, and to Jennifer Arsenault for designing the Bendy Bodies website and cover artwork. This podcast is for informational purposes only and is not a substitute for medical advice. Please see your own medical team prior to making any changes to your healthcare. Thanks for tuning in, and we'll see you next time on Bendy Bodies with the Hypermobility MD.