>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> Everyone experiences stress.

It's a normal reaction to a challenge or demand in our lives.

But ongoing long-term stress can lead to physical and emotional symptoms as well as unhealthy behaviors.

Joining us today on "Second Opinion," primary-care physician Dr. Lou Papa from the University of Rochester Medical Center... >> The stress drives us.

It's part of what we enjoy.

But stress can get to the point where it's not really driving us.

It's putting the brakes on.

>> ...psychiatrist Dr. Khadijah Booth Watkins from Massachusetts General Hospital... >> Stress is not an illness itself.

Stress can lead to illnesses.

And, again, it can lead to physical illnesses.

It can lead to psychiatric illnesses.

>> ...organizational psychologist Dr. Danielle King from Rice University... >> When we face a stressor, we over come it, that teaches us what helped me so that the next time I have a stressor, you know, that's something I can draw on.

>> ...and Katie Koshak, who is here to share her personal story.

>> It's not just you, and there are treatments.

There are options.

You know, you don't have to sit there and be alone.

>> I'm Joan Lunden, and it's all coming up on "Second Opinion."

♪ Thank you, all of you, for being here.

Katie, I want to start with you because, I mean, everybody has stress, of course, but you point to one time in your life where the stress really started having an unhealthy impact on your well-being.

Tell us what was going on.

>> Well, my first experiences with intense stress was when I started nursing school, of course.

I just had very high expectations of myself going into it.

It wasn't something necessarily that even my parents put me on, but it was just...

I don't know where it came from necessarily, like I said, but that's really what -- put pressure on myself, and then I started experiencing, like, a lot of, like, anxiety, depression, and then it just kind of, like, escalated from there, if that makes sense.

>> Snowballed?

>> Yes, it definitely snowballed.

>> So if she had come into your office, Lou... >> Right.

>> ...what kind of questions would you be asking her?

>> So, first thing, I'd want to make sure that there's not anything that's really a risk to her health.

So we'd want to make sure there's nothing physical that's causing her symptoms, either a medical condition or self-induced.

So I want to make sure there's no alcohol, drug use.

>> Yeah.

>> I'd also want to make sure if she truly has been diagnosed with depression or anxiety or hasn't been diagnosed and want to make she doesn't have that, that there's not any other worrisome symptoms -- hallucinations, suicidal thoughts, things like that.

And I'd want to know how she's managing this, how much this stress is affecting her day-to-day life.

Is she still able to focus and complete work?

Is she enjoying time with others?

How's her sleep?

Is her eating habits disrupted?

How is it affecting day-to-day function, getting through the day, enjoying life?

>> Katie, how would you have answered him?

>> It was heavily affecting my day-to-day life, unfortunately.

I mean, like, with sleeping habits, I had a very difficult time falling asleep.

I would just lay there hours and hours, you know?

I remember not eating a lot 'cause my weight dropped down below 100 pounds.

I was in the double digits, so I do recall that.

I don't remember really enjoying much time, honestly, but -- >> So it kind of, like, took over your life.

>> Right.

That's pretty significant.

>> Absolutely.

Yeah, yeah.

100%.

>> How do you define stress?

>> So, you know, stress from kind of a, you know, materials point of view is a force that's put on something that creates tension or pressure, and that's basically what happens to us.

The force for us is something physical, something emotional, you know, something outside of us -- you know, that annoying boss, you know, a pot that's boiling over -- and there's extremes of it.

You know, there's episodic stress like, you know, "I have to get ready for a dinner," and then there's stress that's always there and is constant.

We have stress to drive us, right?

A lot of us use that stress, and especially with the work you do and the work we do, the stress drives us.

It's part of what we enjoy.

But stress can get to the point where it's not really driving us.

It's putting the brakes on.

>> And I want to get to the work that you do because it's amazing, but, Dr. Watkins, I would love for you to tell us, what's happening in the body when we're really undergoing stress?

>> Yeah, so, like you said, stress is a natural, normal part of life.

Stress helps to keep us safe, it helps us to know when we're in danger, helps us perform well, and when it takes over, you will start to notice big changes in your body, like you feel like it's harder to go to sleep, you maybe feel more irritable and cranky, you have trouble eating.

Stress impacts your physical health.

People tend to have a lot of G.I.

upsets, they get ulcers, they have a lot of nausea and queasiness, headaches, high blood pressure.

Stress can really wreak havoc if it is not controlled and managed in a timely manner because it starts small and then it starts to, like, you said, snowball into this big thing that is hard to get our handle on, and before you know it, your whole life is impacted -- how you approach things.

More in the context of stress, the things that you avoid doing, lots of things that you need to do, whether it's responding to e-mails, showing up to classes.

Those things just create so much stress and anxiety that people just tend to avoid them to feel a little bit better.

So stress can really have a tremendous emotional toll on the lives of many.

>> Biologically, what's happening?

>> So, biologically, when we have stress, there are things that are happening in our body that get us to respond, that drive our heart rate up, drive our blood pressure up, make us more aware.

You know, just as Dr. Watkins says, it's there to drive us, but it's also there to protect us, right?

It's part of our kind of animal instinct.

You know, "There's a saber-toothed tiger here.

I need to respond to that."

>> That adrenaline rush, right?

>> People know as the adrenaline.

It's, you know, that adrenergic, autonomic system that's driving us, gets us wide awake, gets our pupils dilated, gets our heart going, gets us in that fight-or-flight mentality to get ready to do something.

And that should only happen a couple times.

It shouldn't happen consistently, and that's the concern is being in that high-drive state, you know, where, you know, you basically have the brake on but you're stepping on the gas pedal all the way is just not healthy.

>> Dr. Watkins, is stress itself an illness?

>> Stress is not an illness itself.

Stress can lead to illnesses.

And, again, it can lead to physical illnesses.

It can lead to psychiatric illnesses.

You know, being stressed and overwhelmed can lead to diagnoses of anxiety, whether it's panic or generalized anxiety.

People who are under unrelenting stress can have depression, and, at its most severe, stress can lead to something which we call post-traumatic stress disorder, which we tend to talk about in relation to combat veterans, but everyday people can experience that based on their life experiences and their sense of feeling endangered or, you know, in a sense of where their life is threatened.

>> Well, Dr. King, let me bring you in here because you look at people with stress both individually and organizationally in businesses.

So what are the main causes of this kind of stress?

>> Yeah, it's really interesting that stress has both this very personal nature while also, you know, there are many trends out there that we know about.

Personally, though, things that trigger stress for me may not for someone else, so I think it's valuable for each of us to learn, you know, as an employee, as an individual, "What are the things that create this physiological effect of me feeling overwhelmed and feeling stressed?"

And in the research, there are some trends about, "What are the most common stressors?"

And we know there are three main role stressors that occur in most occupations, and those include role overload, so feeling like, you know, you just have too much to do, you can't accomplish it all in the time that you're given.

Another is role ambiguity, so not having clarity on what's expected of you or, you know, how you're going to be evaluated, that can understandably cause stress for people.

And then also role conflict, and that is when I'm asked to do kind of conflicting things.

It's kind of like when we feel, you know, "I'm expected to be in two places at once, and that's not possible."

So those are the most common stressors we see in organizations.

>> And there might be some people saying, "Well, I've felt some of those," but at what point does it really become a health concern?

>> One thing, I think, that's important to remember is that, you know, stress happens.

We all experience stress, so we can all have these kind of proactive things in place 'cause we know it's coming, right?

But when I would say we really need to step in and understand that there may be an issue is when, "A," these things become chronic, and, "B," when we start to see symptoms of burnout, and burnout looks like emotional exhaustion, right, like waking up tired every day, feeling completely drained at the end of your workday.

Burnout also looks like depersonalization, like starting to feel really cynical about your job, not feeling like you enjoy it at all, and reduced personal accomplishment, so feeling like, you know, you can't get anything done, you can't do anything meaningful.

When we start to feel any of those often, that's something where we should think about this as a really serious issue to get ahead of.

>> Dr. Watkins, you don't have to have stress to have mental illness, but can chronic stress lead to mental-health issues?

>> It's this funny dynamic.

So we're genetically loaded to either be vulnerable or to be, you know, fairly resistant to certain things.

So some people can experience a tremendous amount of stress and never really have any anxiety or physical manifestations, and some people can experience very little stress but yet feel extremely anxious, and that is based on how they are genetically built.

Then you couple that with, you know, the cumulative effects of stress, so whether it is stress at work, where it's day in and day out, or whether it's home stress, you know, whether your basic, you know, needs are not being met, those stresses.

So it's not necessarily stress in and of itself, but it's the various factors.

If you've had an environment where you don't have connections, where you have never seen it modeled for you how to manage adversity, how to approach adversity, and how to overcome adversity, it's very difficult for you to do that or even to conceive that it's possible.

So all of these factors layered together will predispose someone to experiencing stress in a way in which it becomes harmful for them physically and emotionally.

>> Well, when you think of going into a stressful job, I think of Katie here at the end of the table.

You're a nurse.

>> Yes.

>> So let's just start.

When the pandemic hit, you volunteered to work on the COVID ICU ward.

>> Correct.

I did.

I volunteered.

We all got the e-mail saying, you know, "Hey, we're staffing --" we call it the HIDU, highly infectious disease unit, but it was all, you know, these very sick COVID patients, and they didn't want to just force people to do it, of course, so they asked for volunteers, and I was one of the first ones in the beginning, you know?

>> What was that like?

>> In the beginning, it was alright, 'cause, honestly, in the beginning, I feel like it hadn't hit us very hard yet, yeah.

>> So when the numbers started going up and, you know, equipment was sometimes not available for everyone... >> Yes, correct.

>> ...and you had to deal with death on a daily basis, what did that do to you?

>> It did a lot.

It was really difficult some days -- a lot of days.

Like, just slowly we filled right up, and before we knew it, the patients were sicker than we'd ever seen.

And I hadn't worked medical ICU in probably a little over a year, so it was not necessarily my forte in the beginning, right, but very quickly, we didn't have enough nurses, and then we didn't have enough masks and gowns, and there were days where I had to plan when I was gonna see my patients, which was less than I was used to, you know, so, all of a sudden, I feel like I'm not giving my patients the care that they should be getting, and that was really hard.

It was hard watching a lot of patients who had previously been sick.

I mean, some of the patients who had been there in the beginning, who had -- maybe they came back positive, right, but they couldn't go home because they were positive, and maybe their spouse was negative, and they would just turn so quickly from totally fine, walking around, speaking to us, you know, we're having a personal relationship with them to they're on a ventilator, we're proning them, nothing's looking good.

>> Proning them, meaning lying facedown.

>> Yes, exactly, to help with oxygen.

>> Which is one of the treatments.

>> Oh, this is one of the ways that you increase their ability to breathe, right?

>> Yes, yes, exactly, and one of the things we actually ended up making was we made even, like, a prone team.

So then I volunteered for that, too, so I was one of the prone-team leaders.

So, literally, our job was we went around the unit, and we were just proning and supinating, so putting them back on their back.

We were just doing that all day for 12 hours.

>> Basically trying to keep people alive.

>> Mm-hmm.

Yeah.

Pretty much.

>> Dr. King, this is your field, the effect of stress on workers and the effect of resilience for workers.

How would you define "resilience"?

>> I think of resilience as psychological and behavioral effort that we continue to invest towards our goals, despite adversity.

So, in times of challenge or setback or failure, do we stay locked in to whatever our goal is?

Do we continue to invest effort?

And I prefer that definition in part because it's what's under individuals' control, right?

It's, do we continue to invest effort?

Do we choose to do so in the hard times?

>> Well, what do you think makes some people just more resilient?

>> I think that's a really interesting question.

And what I actually find most often is not that it's an individual difference, that some people have it and some people don't.

What I often see is that -- And personally, I'm sure we can all relate, that there are some times when I feel like, you know, "This was resilient," or, "We can be really proud of how we responded to this difficulty."

But then there may be another time or another context where we're like, "Okay, that knocked the wind out of my sails.

You know, I wasn't able to overcome."

And so what I see in those two groups, the differences, are that, you know, when we have the resources we need, when we have support, as in social support, family and friends to lean on, when we have organizational support, and when we utilize our individual resources, like engaging in the activities that help replenish us, like exercise or trying to, you know, get as much sleep as we can, engaging in psychological detachment from work when we go home as much as possible -- when we utilize those resources and when we have resources available to us, that's when I most often observe resilience.

>> I just want to ask kind of the same question of you, Dr. Watkins.

When an individual comes to a psychiatrist, do you find that that resilience is really sometimes what makes the difference?

>> Resilience is huge.

And I agree with the way that Dr. King described it, and I see it as something that protects us and something that helps us to prevent just completely falling apart in the context of adversity.

And so we do a lot -- We put forth a lot of effort trying to teach resilience and skills that build resiliences 'cause I see resilience as more so like a muscle.

You know, some people are more naturally and it comes easily for them, but some people have to work a little bit harder at it.

And it does boil down to, a lot of times, the resources.

I mean, when we think about what life was life in COVID, some of the resources that we had at our disposal were no longer available to us -- so, some of the hobbies that we did, you know, just basic taking care of ourselves with respect to sleep and exercise -- I mean, gyms were closed, if you were someone who depended on going to a gym.

You know, your diet might have shifted.

You might not have been eating as well.

And all of those things really allow you to be your best self, and when those things are taken off of the table -- and there we're not talking about connection and community -- that is a huge part of resilience, being connected, not feeling alone, having people to support you and being able to support other people.

We do feel better when we give.

So, those things weren't there, and it was really hard to help people to find what they needed to be resilient.

>> From a viewpoint of a primary-care physician, have you seen that people, just with all this uncertainty, have become less well... >> Oh, absolutely.

>> ...and less resilient?

>> Absolutely.

I think Dr. Watkins hit on it exactly.

I mean, you know, we rely on our routines and our social networks to make us resilient, right?

Suddenly they're all gone.

Your only real network is sitting on your dining room table, which is your computer, and you're staring at it all day long.

And even the most resilient person was tested, right?

'Cause all you really had -- even the stuff you would do to get away, you really couldn't get away.

There was no place to go.

>> Right.

>> Right?

You couldn't go anywhere.

>> And there were no answers.

>> Right, there was no -- And it just fed into itself, so you weren't sleeping 'cause work never really ended because work was at home, right?

It was in the dining room.

You never left it.

>> When people come to you, when patients come to you, and it's about stress and unmanageable stress, are they ordinarily looking for medication?

>> They are, unfortunately.

There are medications to help with stress and the stressors in very specific situations, you know, like flight anxiety and certain situations.

But it's really kind of a slippery slope to get into that because a lot of those medications have a lot of side effects, and some of them can be addictive.

The ones that are not take some time to work, and the reality is it's -- You know, a lot of patients say, "I just want to get over the stresses here."

You need to have some way to address the stress.

>> Well, Dr. Watkins, I know you've always said "skills, not pills."

>> Skills are not pills, and so in thinking about stress, whether we do medication or we don't do medication, we have to be able to teach people how to have skills to manage stress.

You know, before that, know what your signs of stress are, like what you do when you start to get stressed.

So, do you start to lose sleep?

Do you start to eat more or less?

Knowing your signs will help you to be able to intervene early, before you get to the point where you feel like you need medication.

And needing medication is not a failure or not even a sign that you're not resilient because knowing your needs and asking for what you need to support yourself is also a sign of resilience.

And so we have to start there.

But there are medications that we use because, again, there's some people who are just genetically more vulnerable, and even in the lowest of stressful situations, they will, you know, develop more significant responses and look more like someone who has anxiety disorders or depression.

And, again, then there are people who have had stress upon stress upon stress, and they are able to manage and not develop into something more significant.

>> Well, Dr. King, is there actual, like, scientific evidence that shows how much resilience matters?

>> Absolutely.

And so what we've seen in past research is that resilience has a host of positive effects, both for individuals, for teens, for organizations.

So, individuals have the opportunity to learn, right?

When we face a stressor, we overcome it, and that teaches us what helped me so that the next time I have a stressor, you know, that's something I can draw on.

It also affects our satisfaction, our commitment, our performance.

So, of course when we remain engaged with those goals and we're able to overcome and manage the stress, we're more effective in the workplace.

And then for organizations, it's just critical for survival, right?

All of us have experienced adversity at some point in life, and just about every living person will across our career.

So it's really valuable for us to be able to take that experience, learn from it, and then utilize those skills in future times of adversity.

>> So, on that note, Dr. King, what can businesses do to help with this so that they create, you know, an environment where people feel supported?

>> There are a lot of things that organizations still can do.

One tool that I really like and I also research is voice -- so, talking to employees to understand, you know, "What are the stressors?

What are -- What is your evaluation of the stress level?"

Right?

Because it's different among -- You know, 10 people could experience the exact same thing, and everyone would have a different reaction.

So, getting to know your team, your people, and how are they doing, how are they feeling, and what do they need, as we talked about as different for different people, is valuable -- so, giving people a voice.

And also integrating conversations like this into the way that we train, develop, and evaluate leaders so that leaders establish a culture of care and a culture of support and a culture that, you know, acknowledges that it's okay to experience difficulty and it's okay to take time if we need to and that the bottom line isn't the only thing that matters here in this organization.

The final thing is that organizations can, you know, offer tangible resources, like employee resource groups, where people come together and they talk about shared identity like race and gender or motherhood and, you know, what are their unique challenges and what resources are helpful, and employee resource programs that fund things like therapy -- that's something that most people do find helpful, as well.

>> So, Katie, how are you managing your stress these days?

>> I go to therapy regularly.

I see a psychiatrist who helps me manage, like, my medication list and whatnot.

Other than that, though, I do try to engage in, like you said, skills not pills.

So, like, I picked up yoga, for instance, as, like, my own thing that I can do by myself, for myself.

I also, you know, picked up more art skills, art supplies, things that I can do at home, that I enjoy doing, and that I can do at the end of, like, a stressful day.

Or if I have, like, a bad day, you know, it's something that'll actually, like, bring me down, calm me down, play some music while I do it.

>> So, what advice, Katie, would you give someone out there who says, "My stress is probably a little bit more than normal and I'm not managing it"?

>> One of the biggest things that I'm for now is taking a step back.

I feel like, in nursing and especially, like, first responders and stuff like that, we're always very go, go, go.

>> Yeah.

>> We want to take on the next challenge.

We want to see, you know, where can we take ourselves next?

But something I actually talked with my psychiatrist recently because I had been experiencing more stress, and she was like, "You know, it's okay if you're just kind of having to take care of yourself for these next few months, however long you need."

And I feel like especially, like, nurses who are feeling really burnt out and stuff like that -- you know, they need to hear that, and they need to know that it's okay.

>> And there's just, I think, a general sense sometimes of people don't want to reach out because they feel there's a stigma to it.

>> Right.

Absolutely.

And it's a shame, and that's one reason why I wanted to be here, too, was to kind of talk about it, you know?

As somebody who has been diagnosed with general anxiety, depression, and PTSD, I wanted to talk about it because I feel like that's the first step sometimes, right?

And then owning it.

So, it's not taking over me, you know?

It's a part of me, but it's not all me.

And for other people to realize that maybe and to see it's not just you.

And there are treatments.

There are options, you know?

You don't have to sit there and be alone and there's better ways to do it and there are resources to go to.

>> Absolutely.

>> Great, great advice to end on.

Thank you so much for sharing your story.

And thank you so much for all the work that you do to keep people healthy.

>> Thank you.

>> So important.

And thank you to all of you doctors today.

I also want to just thank all of the medical advisors who are with us every step of the way to ensure that we bring you evidence-based, accurate medical information.

And of course to all of you at home, thank you for watching.

From all of us here at "Second Opinion," we encourage you to take charge of your health care.

I'm Joan Lunden.

Be well.

♪ ♪ ♪ ♪ ♪ >> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion" with Joan Lunden is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.