Allowing Imperfection with Bonnie Robson, MD

[00:35] Jennifer Milner: Hello and welcome to Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other artistic athletes. This is Jennifer Milner here with co-host Dr. Linda Bluestein. Before we introduce today's guest, we'd like to first remind you about how you can help us help you. First, subscribe to the Bendy Bodies podcast and leave us a review. This is helpful for raising awareness about hypermobility and associated disorders. Second, share the Bendy Bodies Podcast with your friends, family, and providers. We really appreciate you helping us grow our audience in order to make a meaningful difference. This podcast is for you.
[01:16] 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 across 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.
[01:38] In addition to serving on the editorial board for the journal Medical Problems of Performing Artists, Bonnie has served on numerous committees and boards, including the PAMA Board of Directors, the IADMS Education Committee, 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.
[02:11] We spoke with Bonnie previously on what has been our most played episode to date, Episode 10, Cultivating Psychological Skills. Today we are speaking with Bonnie about perfectionism. Hello, Bonnie, and welcome to Bendy Bodies.

[02:38] Bonnie Robson, MD: Thank you so much. I'm really pleased to be here.

[02:42] Jennifer Milner: We're thrilled to get to talk to you. So, Bonnie, let's start with some definitions. What is perfectionism? Is it a personality trait? Is it a psychological attitude? What are we talking about?

[02:56] Bonnie Robson, MD: Perfectionism is what we're going to address today, and hopefully we'll leave with a better understanding. It can be described as a pursuit of excellence or the search for perfection itself. Dancers tend to be perfectionistic, so that's why we're talking about it. So do individuals who have perfectionistic traits select dance training because of its exacting standards, or do people who study dance learn to set higher and higher goals for themselves and demand more of themselves?
[03:32] Another way we think of perfectionism is learning to be self-critical, often employing self-talk. And then there's the multi-dimensional model, which can be a combination of three types of perfectionism: the self-oriented perfectionism, the other-oriented, and the socially prescribed.
The self-oriented one is the classic one where you worry and you make excessive demands on yourself. The other-oriented — the dancer sets standards for those around her. She says, "They aren't doing well enough. That teacher should be clearer. She's not counting right. So how can I possibly meet the standards when others are not meeting them?" And the socially prescribed, in which the dancer experiences intense pressure from all those around her to live up to their ideals. "I couldn't face my mother if I don't do well." The dancer believes that those other people hold those ideals and tries to live up to them.

[04:49] Jennifer Milner: I've never heard it broken down into those three different descriptions like that — the self, the people around them, and then trying to live up to other expectations. That's such a clear image. And I know that people with hypermobility and hypermobility disorders tend to suffer — we have higher numbers of anxiety and perfectionism and OCD, which is why Linda and I wanted to have this conversation. So we are so grateful that you are having this conversation with us, because that describes me at various stages of my life. All three of those describe me at various stages of my life.
[05:25] I think that's something that a lot of people can relate to, but especially it seems not just me as a person, but as a dancer. It seems like dancers definitely tend towards perfectionism, whether it's that perfectionists gravitate towards dance or dance makes us into perfectionists. It's hard to know which one came first. But are there any gender differences? Do you see perfectionism more in men than in women, or women than men, or is it kind of equal?

[05:56] Bonnie Robson, MD: Yes, there's that. And I just want to pick up on your idea that perfectionism in dance — we're going to explore more of that. You talked about anxiety. Think about perfectionism and think how closely linked they are to anxiety. We'll explore that duality. And you're right, female dancers are more perfectionistic than males, and more than other artists, both students and professionals, except for perhaps some musicians who are very perfectionistic in their individual pursuit of excellence. Female dancers are even more perfectionistic than athletes.

[06:43] Jennifer Milner: Who — like gymnasts who have to do those turns?

[06:47] Bonnie Robson, MD: Yes, there is a gender difference.

[06:50] Dr. Linda Bluestein: Interesting. And I wonder what attracts us to dance, because, Jen, I was thinking the same thing — that, yeah, that can describe me. As a dancer being drawn to dance because of those exacting standards, but then that may be making us express that trait even more in that environment. So chicken and egg, but then also causing it to be even more exaggerated because of the environment that we're in.

[07:14] Bonnie Robson, MD: That's interesting.

[07:15] Dr. Linda Bluestein: There's also something very comforting about those boundaries and about those impossibly high standards. At least there was for me as a dancer — to say, oh my gosh, I'm going to have to try to achieve this, this, and this. It was almost comforting just to be able to see that, and to know I've got this uphill climb, but I see those expectations so clearly laid out. So while we understand that a lot of times it's negative, there was some comfort to that for me as well.

[07:47] Bonnie Robson, MD: And about anxiety — I heard one teacher say, you always come back to the studio, it's safe in the studio, and that's where you get the comfort. Many movement practices do not have a predictable pattern to the class, but ballet has a predictable pattern. You know what's coming next, usually, and that's comforting.

[08:14] Dr. Linda Bluestein: That's interesting.

[08:16] Bonnie Robson, MD: The routine — you always start with pliés and tendus and left hand on the barre.

[08:20] Dr. Linda Bluestein: And yeah, as you're saying that, I feel like I'm going back to my childhood and I can picture that comfort of returning to home. It really was a second home for me. So that's really interesting.

[08:31] Bonnie Robson, MD: So the perfectionism trait can be negative, of course, but is it ever a good thing? Is there anything wrong with setting high standards or trying for the perfect arabesque, for example?
[08:45] As with many things, a little can be a great thing. For example, I was thinking of music on the radio. You hear a song — oh, that's the one I like — and you turn the volume up a little. Oh, it feels good. I'm going down the road. Oh, I'll have some more. And I'm really enjoying it now. And then I'll turn it up just a little. Ooh, that's unpleasant. A little more, and it's really uncomfortable. Turn it up even more and the ENT specialists tell us you're going to have tinnitus and you risk deafness. Certainly musicians have to be very aware that they don't suffer early deafness because of high volume.
[09:31] So that happens in dance with perfectionism as well. That's just an illustration, but you think of an inverted U — a little mountain. As you start out in dance, you're seeking high standards. You get focused, you get concentrating, you try to do better, and you actually feel better, and it's progressing, better and better, until you do that perfect pirouette. You are so pleased. I can try just a little harder. I'll just throw a little more energy into it. And what happens? Bunk. You increase to the peak performance, and after that there's deterioration and fall-off in the performance.

[10:22] Jennifer Milner: That's very interesting.

[10:24] Bonnie Robson, MD: So is there such a thing as good perfectionism, or bad perfectionism? And how can we tell the difference between the two?
[10:34] There's good perfectionism, and those of us in psychology like to talk about it as positive, normal, facilitating. The dancer, just as you've described, has pleasure in going to the studio and trying — maybe today is the day I'll get my splits. I've waited, I've worked at it. The goal of having a trait encourages a dancer to be organized, on time, warmed up, and focused, and teachers love that.
[11:07] But there's also negative perfectionism, as you'd expect, and we call that neurotic, debilitating, or maladaptive. It's an all-or-none attitude — either you're perfect or you're not. The person tends to devalue their accomplishment and focus on what they have yet to achieve, rather than seeing, "I'm approaching a perfect pirouette. I'm approaching so much better. I'm not falling over. I'm actually balancing. This is great." Instead it's: "Oh, I didn't make it yet. I'm such a slob. When am I going to get this? Everybody else has got it."
[11:46] Or they have an "I should" syndrome. "I should do better. I should have been less tense. I should have been brighter." And I bet you've got some examples of the "I should" person. Can you think of somebody that this has affected negatively?

[12:05] Jennifer Milner: Absolutely. When I work with dancers, a lot of the time you see them deal with the shoulds rather than the accomplishments. And for me — this is definitely not the medical definition of it — but for me, it's whether or not your perfectionism is personal or a kind of clinical tool that you use. As you described, you can have that perfectionism that brings you up to this point, and it's not personal, so you can step away from it.
[12:38] Just yesterday, actually, I was working with a lovely dancer who's at quite a high level, and she was working on some famous pirouettes from the Black Swan variation. It's quite complex going into the second piece of the pirouettes. She and I were working on it together, and she said, "I can't get it. I have this, this, and this." We worked on it together, and she got to the point where it was almost quite there. And then we did it again, and she did it again, and it was beautiful. She just sailed through it, and the look of satisfaction on her face — I said, "Do you want to do it again?" She said, "No, I'm good." And I thought, look at that. It was such a healthy way. She didn't get frustrated, she didn't get angry when she was working through it. She just tried it again and she fixed it. That, to me, is that sort of impersonal perfectionism — she could use it as a tool and then set it aside.
[13:25] And for so many dancers, that sense of "I didn't get it, and I'm getting frustrated, and I should do it again until I do get it and it does get perfect" — the more that you try and push yourself and don't look at your own personal warning signs that you're getting frustrated and impatient, that you're starting to throw yourself through it, that you're not being careful physically — it's become personal and you can't stop until you feel like you've achieved it. And then even if they achieve that, they say, "I should do it again." Or a whole different "I should" is: "I'm exhausted, but I should go run my variation because everybody says you should run it three times a day so that you're strong enough for whatever competition is happening." They feel like they're less than. And it gets to the point where they're not even less than as a dancer, but they're less than as a person to themselves. And I think that's what you're talking about.

[14:27] Bonnie Robson, MD: Yes. The "I should" leads to "I'm guilty. I didn't do enough. I should have done three, I only did two, I let the team down, I'm ashamed, I have trouble making decisions." It's a kind of negative self-talk or troubling thoughts. And what you said — that they make it personal — that's so important. We must think about that.
[15:03] These negative thoughts that sneak in — when we're not paying attention, they can be relieved by mindfulness practice and training. But mindfulness training takes — everybody's talking about it, but it takes a long time to learn. It's another thought-process movement thing, and it isn't something you can learn overnight. It requires group sessions.
[15:32] So I propose for now a faster, temporary solution. Let's use thought stopping for these nasty thoughts. A technique to get rid of the thoughts is: first, recognize you've got them. And then to wash it out, even using a gesture like this can help. Toss it away. Have a little mini shower. Yell out loud. I love being in my car when the thoughts come, because then I can say things really loud and nobody can hear me. So the negative thoughts are gone, and that's great, but now I've got this space left. If I don't fill it up, other negative thoughts will come jump in — "Oh look, space!"
[16:30] And so I need to fill this up with positive thoughts right away. This is a hard skill to learn. It takes practice to take the negative thought and turn it into a positive. "I haven't got that routine yet. Well, just a minute. If I take it and break it down a little more — maybe I can spend some time tonight. I can focus on how my teacher's been helping me and follow what she's been saying. She's rooting for me." I might even write that on a card and put it up on my mirror: "My teacher is rooting for me. She believes I can do this, or she wouldn't have asked me." On a variation, that card on your mirror can help build self-confidence. "She believes in me. She knows I can do it. I can do it."
A further distinction has been added by Shannon Norden-Bates in terms of the positive and the negative. They talk about performance strivings and performance concerns. Strivings are the pursuit of high standards that we've noticed. Concerns are worry about performance fears and evaluation — you're always feeling that little camera up here watching you. "Oh look, she did it wrong again. Oh look, she isn't standing up straight. Oh look, her shoulders are hunched." It's an observing ego, but it's a negative one, and it reacts a lot to imperfections.

[18:31] Jennifer Milner: You know what struck me about what you said at the beginning of this topic — about being in your car and being able to say things loudly to combat those negative thoughts? I know this sounds a little unusual, but a lot of dancers, especially in the pre-professional and younger age groups, don't realize that they have thoughts. They're not comfortable or used to hearing their own voices. We as dancers feel voiceless. We're not supposed to speak up in class, you're not supposed to argue with your director — we don't have that voice. Some of it is just becoming comfortable with figuring out what you personally are thinking. When you hear those voices in your head, is that what you think, or is that what your director has said, or is that what your parents have said? Learning to recognize: are those negative thoughts my negative thoughts? Is that really what I think? And learning to just hear your own voice — it can be revolutionary, I think, for a lot of dancers.

[19:32] Dr. Linda Bluestein: I think that's so true.

[19:32] Jennifer Milner: I remember I was definitely well into adulthood when I realized: I am not my thoughts. I can think something, but that doesn't mean that that's what I believe. It is kind of an interesting thing that we're not taught as we're growing up.

[19:53] Bonnie Robson, MD: I'm really glad that you pointed that out, because right — we can think a very bad thought, for example, but that doesn't mean that we believe it to be true or that we actually want that. We can separate ourselves from that.

[20:05] Dr. Linda Bluestein: That's super interesting.

[20:05] Jennifer Milner: So Bonnie, can you talk a little more about the variables that steer a dancer into either adaptive or maladaptive perfectionism — what the differences are, what we should be looking for, and what the factors are outside the dancer that can affect how they choose to strive for success?

[20:07] Bonnie Robson, MD: Well, Linda and Jennifer, dancers, have already alluded to this. The first variable that differentiates between good and bad perfectionism is the dance culture itself. The culture demands an ideal body. The culture demands flexibility — and those of you out there in the Bendy Bodies group know about this. It demands turnout. Now it's not so much now, but dancers work to achieve a certain body, an aesthetic, stamina, strength. Gradually this culture is easing up on these standards, but there's no doubt they were there.
Dance education employs self-scrutiny — just what you're saying: I have to think about my thoughts, I have to think about what I'm doing. Since the millennium, there's been attention to the motivational climate in dance education, which is wonderful, and we're all rooting for that. It's had a significant impact on how much perfectionism we're seeing. It is known that the social environment where mistakes are noted and outstanding performance is valued sets the stage for negative perfectionism and the linked anxiety I talked about — anxiety about performance. So they're very closely aligned. It's the culture. Jen, what do you think?

[22:01] Jennifer Milner: Well, I think yes to all of that, of course. I was saying something to Linda earlier in a text conversation about the culture — just looking back, even to when dance was so supremely glorified. Thinking about every little girl wanting to watch The Red Shoes and wanting to be in the red shoes, which is kind of disturbing now when you think about it, because she is in an abusive relationship both personally and professionally with the director of the ballet company, and she literally dances herself to death to please him. And yet we were all like, "Oh, that's amazing, she's so lucky. She's dedicated." And then even moving forward — Linda, you had mentioned Center Stage, the movie that aimed to take a healthier look at it. I thought that Black Swan, the movie with Natalie Portman, did a good job of showing some of the reality of it, and showing that the reality of it is not healthy — they weren't trying to glorify where she was emotionally and mentally.
[23:20] But so much of our culture, so many of the TV shows, the reality TV shows that follow different studios — even if they don't intend to, kids sit down and watch that. If you're watching a TV show about a big dance studio and they're consistently casting the kids who have the most flexibility, or who are the most assertive and dominant in the dressing room, or who stay after every day and come early every day even when they shouldn't — when they should be going home and resting — who push through the pain, and if those are the ones who are getting cast the most and getting all the plum roles and getting pushed up front, then the little girls and boys watching those TV shows at home are going to go, "Oh, that's what I have to do. That's what I should be doing."
[24:08] Even if their own studio isn't like that — their own studio could be lovely — they see so much of it in that culture, they see so much of it on social media, that it's really hard to avoid getting those messages these days, even if your personal studio is trying its best to approach it in a healthy way.

[24:26] Bonnie Robson, MD: And I think "reality" — I like to use air quotes for "reality" because reality TV — it blurs the line, especially for the young, super-young impressionable dancer. With social media and everything, it can definitely increase those challenges.
[24:50] So there are some other factors — extrinsic factors outside the self. One artistic director said to me, "It's all about casting." From the very first Nutcracker, everybody wants to be Clara, and some people hold on to it for years that they never got to be Clara, and so they're not quite good enough. And Clara is often chosen simply because she has long hair and fits the costume, but students don't know that.
[25:23] As students grow older, they're likely to experience more competition in their own school because they're getting better and staying. Then in the summer intensive, more competition. At larger competitions or conventions such as YAGP, students — and again, you're watching online to see how these people live, and they even do backstage footage of what they're feeling. Unhealthy competition can promote perfectionistic attitudes. And interestingly enough, that in turn decreases creativity. Teachers report that groups that used to have fun and really enjoyed traveling to a competition can instantly turn and become self-critical when faced with superior competitors. Their teachers say they just fall apart. And teachers are looking to us for psychological skills that these students can learn so they can get rid of this unhealthy rivalry.
[26:35] Sanon and Bates looked at two types of learning environment: the task-oriented, a kind of climate that promotes individual learning where everybody is of equal value. It's cooperative and collaborative, and students are encouraged to set their own intentions. I love that, Jennifer — when your student said, "That's enough, I've done it, that's my goal for today." And long-term goals — how they're going to get to the gala, the exams, the audition. But to stay with this type of learning.
[27:07] The second type of learning is ego-involving, a climate that's often seen in elite conservatories. It promotes negative comparisons. The teacher may ask for somebody to demonstrate to show how to do it, or worse, the teacher may ask somebody to demonstrate in order to point out the negatives. And equally demeaning — and I've seen this happening in some settings, particularly in Irish dancing lately — everybody gets a trophy no matter what. They get some sort of award, and that's actually very demeaning.
[27:48] In many elite conservatories, competition is just accepted. Apprentices are competing to get into the company. This culture may extend as far as rivalry between teachers to have more winning students. And in that kind of environment, it's easy for students to shift from task-focused to outcome-focused. And I wonder if you've seen this in a studio, Jen, or if people have reported moving from one studio to another because of this kind of thing.

[28:28] Jennifer Milner: Absolutely. I see a lot of it, most of which I won't talk about in public, but it's there even in the best schools. There's that little bit of ego, and it's so hard to let go of that. The healthiest schools I see are the ones that say — if a dancer is injured, I've seen some schools say, "Well, can you just get through Nutcracker?" And I've seen other schools say, "Hey, there's going to be other Nutcrackers. You get healthy." Not realizing the implications of what they're saying, putting that burden unintentionally on the child to make their Nutcracker look better.
[29:22] I know a school — not one that I work with regularly — that several years ago had a dancer with a very clear eating disorder. Several of the dancers had said, "We're concerned," and the school said, "Oh yes, so are we," and then turned around and had her be their face at their competitions. They would say one thing, but then clearly something else was happening because they thought, "Sure, that's unhealthy, but she looks so good, let's put her forward." The dancer — that was ten years ago — the dancer is healthy now, and it was a healthy outcome. But it's so hard for studios to not say, "I know, but—" and to put our egos on the back shelf.
[30:19] I'm just as guilty of it. I want to see my dancers do well. But the ego-driven studios, the ego-driven companies, the places where you can see that the director is starting to get a little bit of a god complex — casting capriciously, making clear examples of bringing up a sixteen-year-old through the ranks and casting her in principal roles to say, "I can do whatever I want" — and that poor girl has to live with the social pain that comes with that when the rest of the company has to deal with it. You definitely see that.
[31:00] I do think that especially over the past year, with all of the mental health issues coming to the forefront in dance, that's starting to be addressed. I think dancers are starting to get that voice and to see: just because the director wants me to do this, just because my teachers are pushing me to do this — maybe that's not the best. I do see that the task-driven approach is starting to become more prevalent. Hopefully, as dancers find their voices, it will continue to be that way.
[31:29] As dance studios and dance teachers let go — and there's another one of my soapboxes — let go of saying, "Well, this is the way it's always been," or "This is how it was done to me, so they should have to go through this too. I didn't get to use gel pads in my pointe shoes, so neither should they. I suffered with lamb's wool." Well, they didn't have gel pads then. Learning to let go of that and see what's important for the kids — that's so important and so valuable.

[31:58] Bonnie Robson, MD: I was waiting to see if Linda had an example she was burning to share, but I'd like to share one. This year I met a wonderful teacher named Kim McCaddo of Elevated Dance Project in Idaho. I have to share her name because of the wonderful innovation she and her co-director Melissa Larson have brought. They're looking at teaching life lessons through dance rather than the other way around — healthy lifestyle, community awareness, self-compassion. These are all things we'd want to share with children of nine, ten, eleven, twelve — respect for others. They focus on these themes throughout the whole year. They work on building confidence, learning responsibility, compassion and kindness, and respect. I love this. They actively encourage everyone around them, including their competitors. Their dancers will often line up when competitors come off stage and high-five them as they go by. We're beginning to see studios like that which are saying, we're not here to turn out winners, we're here to learn.

[33:20] Dr. Linda Bluestein: That reminds me of a saying that I heard the other day — and I might not get it exactly right — but it's easier to raise healthy children than to fix broken adults. So many of these dance educators and studio owners do have this opportunity to have a huge impression on young people. I think that's so fabulous, Bonnie, that example that you shared.

[33:26] Bonnie Robson, MD: It really is wonderful what they're doing.

[33:57] Dr. Linda Bluestein: So we've talked about perfectionism, we've talked about the stress that comes with that, and what is the relationship between perfectionism and stress and anxiety and how those all fit together?

[34:10] Bonnie Robson, MD: So you've brought it just where we're going. Stress is related to anxiety, so the pursuit of perfection can be a crucial part of developing that stress bubble. Stress puts a dancer at risk for injury, mental disorder including depression, and even suicide. Anxiety around dance leads to eating disorders or reduced energy availability. Further, perfectionism is related to social anxiety — not just anxiety — and social anxiety in psychiatry we think of as stage fright, as performance anxiety, where people actually cannot go to the place where they're going to perform. They can't concentrate, they're distracted, and naturally if they do go, they have a poorer performance than they could give.

[35:18] Dr. Linda Bluestein: That's really important, because we know that people who have hypermobility are at greatly increased risk of anxiety.

[35:22] Jennifer Milner: At least most of the studies show something like eight to sixteen times increased risk of anxiety. And there was even a study back in 2012 in the British Journal of Psychiatry that showed differences in key emotion-processing brain regions, including increased volume of the amygdala.

[35:43] Dr. Linda Bluestein: And so there's a lot of really interesting research out there on hypermobility and different conditions, like even obsessive-compulsive disorder and ADHD, attention problems and things like that.

[35:59] Jennifer Milner: This is a super important topic for the hypermobile population.

[36:05] Bonnie Robson, MD: And as you say, the amygdala is way down in the bottom here, and it's the emotional center, but it fires off information up to the prefrontal region, which is your judgment, your planning, your organization — and they all go out the window if you get too wrapped up.

[36:25] Dr. Linda Bluestein: So that's where the thought stopping is probably really important to do sooner rather than later, because once you — I'm so glad that you're talking about the stress, because stress is also a huge activator of mast cells and causes degranulation of mast cells. And once you get that, and then you get the release of cortisol and all the other physiologic things that happen in the body once we're under stress, it's harder to stop it, right?

[36:49] Jennifer Milner: So if we learn to stop those thoughts earlier rather than later, when there are all these physiologic things happening in the body — it's biology. It's not about judging ourselves harshly. But if we can recognize those thoughts earlier, I think that's probably a really key strategy. Linda, is there a podcast that tells us more about that, so we can hear more at another time? About the mast cells and the physiology of the anxiety and the stress?

[37:28] Dr. Linda Bluestein: There's a fantastic journal article that talks about that, that I can put a link to in the show notes, and I happen to know the author quite well. Maybe Jen and I can see if we can get an interview with that person.

[37:42] Jennifer Milner: Maybe there will be a podcast.

[37:44] Dr. Linda Bluestein: Yes, that would be nice. It's a really challenging thing because these conditions are often not recognized for so long. People go to these appointments and they're told —

[37:53] Bonnie Robson, MD: they're basically told that they're crazy. Well, what does that do? That just increases your stress level, which is part of the problem in the first place. It really creates a vicious cycle.

[38:05] Dr. Linda Bluestein: And we also know that people who are hypermobile have increased interoception, so we have increased awareness of what's going on inside our body. As these things are happening, we're more and more aware, whereas people who are not hypermobile are kind of oblivious. Sometimes I feel like I can feel every single cell as it's moving through my body, and my husband — he'll be bleeding from something and have no clue. "Honey, you're bleeding."

[38:30] Bonnie Robson, MD: "Oh, am I?"

[38:32] Dr. Linda Bluestein: So we'll have to make sure that we have an episode specifically about that, because it is so important to remember that our bodies can sometimes be our enemies — they can fight back.
[38:49] But I was going to go on to talk a little bit about something you can do in terms of preventing perfectionism from getting in the way of performance. And that is the task analysis that the folks at Kim McCaddo's studio were doing. Training as little as ten minutes or half an hour a month — not every day, ten minutes a month — can help you set reasonable goals through task analysis. And we've done the research: it significantly improves performance.
[39:31] Once the goals are set, a dancer can plan and use time management. If a dancer has a featured role or is to perform a solo in the spring, the earlier she is cast, the better. She needs to plan. If she's nervous, she may procrastinate — very risky, but very tempting. "Well, I'll do it later." No, no, no. If she breaks it down now and is able to accomplish the elements, then she can work on the feelings and emotions. She doesn't have to spend time with the worry, spend time with the negative thoughts.
[40:12] So now we're talking about outcome goals and process goals. Process goals are the ones she's going to set up. They're much more effective than outcome goals. Outcome goals are: "I'm going to dance a perfect performance." But process goals help to maximize performance, and they're possible and within the dancer's control. We use a little acronym called SMART. They're specific, they're manageable, they're achievable, they're not unrealistic — I can't do thirty-two French fouettés tomorrow night, that's never going to happen. They're relevant to what you want, and you have a target date to finish. So that's the SMART way to proceed with task analysis.

[41:06] Jennifer Milner: That's great.

[41:08] Bonnie Robson, MD: And what about parents? How can they recognize that their child is stressed and anxious, and what can they do about that?
[41:18] Ballet parents — again, you can have good ballet parents and bad ballet parents, and not all parents who are concerned about their kids or come to ask questions from the staff are negative or pushy parents. Sometimes they're genuinely concerned that this dance culture is bringing out some traits in their children that they're not sure are healthy.
[41:45] So for the parents: if you're looking at your dancer who seems to be overworried — are they constantly seeking reassurance? Are they so overworried that you can't help them calm down? Are they really afraid of the performance? Would they rather give up the chance? Most dancers, even though they're very nervous, still want it. They realize this is an opportunity. They want to be out there. That's what they're working for. We're talking at a time of the COVID pandemic, and many dancers do not have the opportunity to be on stage. I've been talking to some of the dancers as they go back and have performed again, and the euphoria they feel in returning is so wonderful. So a dancer who doesn't want to perform is unusual. A dancer who would give up an opportunity to perform — that's unusual.
[42:53] For parents: are they so tense that when they walk into a room, other people recognize it? Their aunt or uncle says, "What's wrong with Martha today? She seems very tense." They also have difficulty sleeping. Now, all athletes have trouble sleeping before an event — that's been documented — but we're talking about real trouble sleeping. They can't get to sleep, then they get to sleep, they have early waking, they can't get back to sleep.
[43:24] A performance psychologist or counselor can often help sort this out. Parents may want to ask about that from the studio. Some studios have a counselor on their wellness team. What the counselor can also help the parents with is recommending whether a more intensive management of the anxiety needs to be sought, rather than working through psychological skills training. Do you need a medical referral? As Dr. Linda said, we mustn't forget the physiology. As much as we might be trying, there may be something that physiologically needs to be done.
[44:08] There's another variable I'd like to talk about, and that's about individual child development, or what we call ontology, the growing up. A man named Dean Nelski notes that much early reinforcement for outstanding performance leads to performance anxiety, to perfectionism, and to performance becoming the basis of your self-esteem. Applause is love. The little dancer does the first recital and gets flowers, and grandma comes, and everybody's excited. As the dancer progresses, she gets better roles, the public comes, she goes to a competition, gets a scholarship. But then one day there are some critical notes and the whole thing falls apart. Why? Because she had based her whole self on her ability to dance. She didn't have other things.
[45:16] So it's very important that dancers and parents acknowledge that dancers not be uniformly just dancers. I think about A Chorus Line and the main dancer saying, "I am a dancer. All I need is the music." That was her life, that was it. A dancer like that only feels accepted if she's doing well. If she has a down period, her self-esteem falls off. It's dependent on other people's view of her, not her own view of what she's enjoying. Did you have a good time? Did you enjoy it?
[45:53] Linda, do you have any examples of that, where the dancer feels — that's it, that's what she is — and if she has to think of a future career, there's nothing else?

[46:05] Dr. Linda Bluestein: Oh my gosh, do I ever. When I was dancing and started getting injured, my entire identity was wrapped up in dance. So when I was sixteen, seventeen, and wasn't able to dance — I remember I would still go to class, because at that time you were supposed to still go and watch. And I would just sit there and cry through the entire thing, and I would just cry at home, and I didn't know what I was if I couldn't dance. That was a difficult phase to go through, figuring out: if I can't be a dancer, then what am I going to do with my life?
[46:44] Yeah, I can completely and personally relate to that. I think as much as we can have different parts of our identity — I also love to learn new things, I love animals, I'm a mom and a wife, all these different aspects of myself besides dance — that's really helpful.

[47:08] Bonnie Robson, MD: And those of us in dance medicine are so grateful that you didn't continue dancing or just teaching, that you're here to help us understand some of the aspects of medicine. It's wonderful.

[47:21] Dr. Linda Bluestein: I think that's one of the funny lessons in life — sometimes some of the worst things that happen to us can later be things that we grow from. They talk about post-traumatic stress disorder, of course, but also post-traumatic growth.

[47:39] Jennifer Milner: Both then, and when I wasn't able to work anymore as an anesthesiologist, that was pretty devastating to my self-esteem. I went through a really difficult phase then also. And little did I know that I would be doing this and be able to reach so many more people. Sometimes things in life turn out very differently than what we expect, but that's where keeping an open mind is super important — broadening our horizons.

[48:07] Dr. Linda Bluestein: Absolutely. A lot of times when I work with my pre-professional dancers, I will always ask them — maybe our second or third session — "If you weren't dancing, what would you be doing? Or what do you think you would want to do when you're finished with your dance career?" Not saying "if you don't make it" or "if you get injured," but just: what would you do?
And there are always the dancers who say, "You know what, I really love architecture," or "I think I would want to..." — they've already thought about that. They have a whole personality outside of dance, even though they may be pursuing it quite passionately. And then there are the ones who get that deer-in-the-headlights look, like, "Why did you just say that? That freaks me out. I can't even think about that. I don't want to think about that." And those are the ones we're going to have some long conversations with. You see those very distinct personalities. And the perfectionism can be in both of them, but as we said, it's either personal or it's impersonal, and you see that distinct difference.
[49:08] What if, though, Bonnie, what if the perfectionism is in the parents? We've talked about parents helping their kids with stress and anxiety, but what if the parents are the perfectionists, and how does that rub off on the pre-professional dancer?

[49:22] Bonnie Robson, MD: Very dangerous. It can actually embed the perfectionism in the child who already has some perfectionistic traits. The parent says, "Oh, that's good, that's good. Why don't you take notes from what your teacher says? I'll get your pad and pencil." So while in many things I'm recommending journaling and taking notes, in this instance it's an example where the parent is pushing and concerned.
[50:01] I think psychoanalytic theory comes in here a little bit, where the dancer uses perfectionism as a defense against feeling defective or inadequate. In both of those instances — where the parent is pushing too much, or where the child is saying "I'm not okay, I've got to be more perfectionistic, otherwise I'm useless, I'm nothing, I'm no good" — they set unrealistic goals and then prove their own point. You can't make that goal. So you are inadequate at that because you've just set an unrealistic goal.
[50:50] Often in situations where I see a child who's anxious, I will ask: "Are you the most anxious worrywart in the family?" And they say, "No, I'm not the worrywart — my mom is the worrywart," or "my brother is the worrywart." And then we have a little talk in the family about where did all this worry come from. It can be generational right back. That usually requires some work with an expert around family therapy and helping the family readjust their goals.

[51:28] Dr. Linda Bluestein: And that's really interesting, because being around anxious people makes us more anxious, right? That energy. And since there's a hereditary component to both anxiety and hypermobility, it makes sense that that would be something present more in families.

[51:48] Bonnie Robson, MD: There's one other thing that has come out in the research that I might want to just tuck away for teachers. Perfectionists tend to get discouraged — some group of them — when they don't meet the standards they've set, and they tend to drop out. Very talented young people will say, "I'm so awful, I just quit," and they're gone. Rather than saying "I'm useless," they say, "I'm not going to have any more to do with that. I'm done with soccer, I'm done with hockey, I'm done with dance." One has to be aware of that — studio teachers especially — if you don't want to lose the people you thought had good potential.

[52:37] Dr. Linda Bluestein: Well, I remember very clearly — I hated working on fouetté turns because I wasn't good at them, and I would rather not do them than do them and not be good at them. I remember being fourteen, and my best friend would say, "Hey, let's stay after in the studio and work on fouetté turns." And I'd say, "No, no, you go ahead, you can stay and work." And she would go in there and look terrible and fall and she didn't care — she'd get up and just kept practicing and practicing. And I just didn't want people to see me less than perfect. I didn't want to work through that sloppy, messy phase. So I was never amazing at fouetté turns. I could knock them out barely, but it was never something fantastic.
[53:17] And those are the things I look back and regret. I regret not allowing myself to fail, not allowing myself to try things that I knew I wouldn't be good at, and not giving myself that grace. Those are the things that I think my perfectionism kept me from — maybe from developing entirely different skill sets in dance.

[53:37] Bonnie Robson, MD: But you know, you do — you are talking about mastery. You've mastered the turns enough so that you were confident enough to stay in the profession and do them. Mastery is so related to getting yourself up to the point where you say, "I can do this. I have enough energy. I feel I can do this." And that's what you're talking about. I wish I'd had more energy to say, "Take a chance, try it. Nobody's going to see me. I'm going to fall over, but there's me in the mirror." Take a chance. See if this would work. See if that would work.
[54:16] So getting yourself aroused enough for the performance, for the audition, for the exam is very important, and that takes practice. That might be a whole other session — about arousal and energy and how to build enough energy. It is a body sensation, and it's crucial to practice. While dancers plan and organize, it's not enough. You have to try. You have to give yourself a chance.
[54:54] There is a new kind of thought coming out through self-compassion. Many teachers are saying before a class, "Give yourself this class with self-compassion. Allow yourself to make mistakes, to try things, to be good enough." I love "good enough." So if you walk away from today saying, "I was good enough. I stayed through that whole thing. I was a little bored and I wanted to leave, but I stayed and I got to the end" — you're good enough.
[55:23] I have just one little thing I'd like to share, and I thank you so much for letting me talk on like this. I came across an anonymous saying lately: "A dream written down with a date becomes a goal. A goal broken down into steps becomes a plan. And a plan backed by action — taking a chance — makes dreams come true. You will master that task and move on to the next one." I love that when I found that.

[56:11] Dr. Linda Bluestein: That is so great. I'll have to get you to email that to me. Well, Bonnie, it sounds like if I'm going to do a really crude sixty-second summary of all of this, we are acknowledging that there is perfectionism out there, and that one of the first things we have to do as artists is acknowledge it — if that's something we are wrestling with — and maybe begin to recognize and form our own thoughts, and choose what thoughts we have, and try to take control of not having the negative thoughts and filling that space with positive thoughts instead. Being able to say: are those my thoughts, or are those someone else's thoughts? And then trying to train our brain to help alleviate stress, as you talk about doing the training and learning to not take failure personally. If we fail on that turn, that's okay. As you said, it's okay to be good enough and it's okay to say, "That was good enough, and I tried, and I failed, and that's okay." Is that a fair summary?

[57:18] Bonnie Robson, MD: I think we'll all take the image of your dancer saying, "That's enough. I did what I came to do today. I don't have to take on a whole new set. That's enough."

[57:35] Dr. Linda Bluestein: Being able to walk away — that's so hard. And as parents, because there'll be different ages of people listening to this — for anyone that's a parent, it's so important, Bonnie, what you were saying about if we have that perfectionistic attitude as a parent, how that can impact the child. We all love our children and we want to raise them well, but sometimes we don't realize the things we're doing that are detrimental until much later, when they're a lot older. So I think that's really, really helpful for parents, especially parents of young children.

[57:43] Bonnie Robson, MD: Absolutely.

[58:11] Dr. Linda Bluestein: Well, this has been so great to chat with you today, Bonnie, and we would just so appreciate you coming on again and chatting with us about this super important topic — perfectionism.

[58:24] Jennifer Milner: Yes, thank you so much, Bonnie.

[58:26] Bonnie Robson, MD: You're welcome. And that's what it was — it was a chat of sharing our thoughts, and so that's why it was so great. Thank you for having me.

[58:35] Jennifer Milner: Of course, anytime. And you all have been listening to Bendy Bodies with the Hypermobility MD.

[58:41] Dr. Linda Bluestein: Today we have been speaking with Dr. Bonnie Robson, psychiatrist and performing arts medicine specialist. Bonnie, thank you again so very much for taking the time to come on the Bendy Bodies Podcast today and sharing your expertise with us.

[58:53] Bonnie Robson, MD: Thank you.

[58:53] Jennifer Milner: Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other artistic athletes.

[59:05] Dr. Linda Bluestein: Please leave us a review on your favorite podcast player.

[59:08] Jennifer Milner: Remember to subscribe so you won't miss future episodes.

[59:12] Dr. Linda Bluestein: Be sure to subscribe to the Bendy Bodies YouTube channel as well. Thank you for helping us spread the word about hypermobility and associated conditions.

[59:20] Jennifer Milner: Visit our website at www.bendybodies.org for more information. For a limited time, you could win an autographed copy of the popular textbook Disjointed: Navigating the Diagnosis and Management of Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders, just by sharing what you love about the Bendy Bodies Podcast. On Instagram, tag us @bendy_bodies, and on Facebook at Bendy Bodies Podcast.
[59:40] The thoughts and opinions expressed on this podcast are solely those of the co-hosts and their guests. They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever.

[1:00:07] Dr. Linda Bluestein: This podcast is intended for general education only and does not constitute medical advice.

[1:00:12] Jennifer Milner: Your own individual situation may vary. Do not make any changes without first seeking your own individual care from your physician. We'll catch you next time on the Bendy Bodies Podcast.