Nomi C. Levy-Carrick, MD, MPhil, is a clinical psychiatrist who specializes in psychiatric consultation in medical settings. From 2011 to 2015, she served as mental health director of the World Trade Center Environmental Health Center in New York City. Her clinical and research efforts focus on trauma and resilience, particularly in medical settings.
Levy-Carrick now serves as associate vice chair of Ambulatory Services for the Brigham’s Department of Psychiatry and as co-chair of the Mass General Brigham Trauma-Informed Care Initiative. She is also the psychiatric consultant to the Critical Illness Recovery Program within the Division of Pulmonary and Critical Care Medicine at the Brigham.
Levy-Carrick spoke with CRN and shared her reflections on the 20th anniversary of the Sept. 11 terrorist attacks and the importance of supporting resilience through trauma-informed inquiry.
Where were you on Sept. 11, 2001?
NLC: I was a medical student at Weill Medical College at the time. In the late afternoon of 9/11, I went with a couple of classmates to several emergency rooms around New York City to see if there were a way to volunteer — but patients weren’t coming in. We were slowly coming to terms with the gravity of what that meant. After a disaster, it helps to know what your role should be, but in that moment, it was hard for me to know what mine could be. I’d gone back to medical school to be effective in these kinds of disaster responses. But it felt like those skills were years off. When I became the mental health director for the World Trade Center Environmental Health Center, I came to understand that the patients I could help would still be there needing care years later.
What was it like to serve as mental health director of the center 10 years after 9/11?
NLC: It was a privilege to be involved in caring for people who were directly affected by 9/11, even a decade later. It made me realize that it’s never too late to find a way to make an impact. The sad and sobering thing was that the physical and mental symptoms were still there. What we know is that people may experience health conditions and health consequences many years after what may look like an immediate crisis. Being attentive to that and being present when people come forward with need is important.
Much of your work focuses on how mental and physical health are intertwined. What are some examples of this from 9/11?
NLC: It’s important to keep in mind that 9/11 was a terrorist attack and an environmental disaster — that interaction became salient. Our mental health and our physical health are closely related at a neurobiological level. To address either one of them, you need to address both. For example, after the World Trade Center collapsed, there were a lot of respiratory symptoms reported. Asthma exacerbations can also feel like anxiety exacerbations — in the moment, it can be hard for an individual to distinguish between them. It’s challenging for patients. They may be carrying around their trauma triggers in their body. Addressing physical symptoms may help someone resolve mental health distress. But the symptoms can also be confounding — if you’re having a panic attack but think that you’re having an asthma attack, you may inappropriately use your asthma pump. You may end up with ineffective treatments and symptoms that last longer than needed.
What are some findings from your research stemming from The World Trade Center Health Program?
NLC: It became clear that one of the factors that may influence the connection between physical and mental health is the inflammatory response and the relationship between inflammation and stress response. One of the things our team at the Environmental Health Center did was to look at C-reactive protein (CRP) levels — a biomarker of inflammation — in WTC survivors and their correlation with post-traumatic stress disorder (PTSD) and respiratory symptoms. We saw a positive association with PTSD severity, and this raised questions that have been further elucidated about potential common pathway. Depression also has elevated inflammatory markers associated with it. Some of the same inflammatory cytokines elevated in depression and PTSD are also elevated in respiratory illness, and that may have important implications for diagnosis, treatment and even prevention.
In addition to neurobiological implications, this research can help patients have a framework for understanding how their physical and mental health symptoms are inter-related. Understanding that there are bidirectional impacts, and that some of their mental health vulnerability may have been secondary to their progressive physical illness, and vice versa, was validating.
What have you learned from your observations and interactions with patients affected by 9/11?
NLC: One striking lesson learned is how resilient people can be, even when they are suffering. There are many trajectories following these kinds of exposures, and PTSD is not inevitable. When it happens, it’s serious and warrants special attention. And there are many paths to healing. For some people, feeling physically better was an important piece. For others, it was therapy and medication. For others, it was community engagement in some way. For most, it was a combination of these.
For some, the therapeutic arts became really important. There’s a lot of social isolation that comes with chronic illness. Art therapy became another entryway — a space where people could come together and express emotions and memories they couldn’t necessarily put into words. An effective treatment program needs to provide a range of modalities, recognizing that different people need different things at different times.
How does your work in New York City inform the work you do today at the Brigham?
NLC: The work I do at the Brigham now on trauma-informed care considers how people’s trauma history and life experiences affect the way they engage with medical care, and it’s very much informed by the clinical work I did then. A person may avoid a medical treatment that could make a big impact on their quality of life or be lifesaving, or they may go around feeling terrified that a symptom may be a sign of something much more catastrophic in terms of their physical health. Creating interdisciplinary spaces can be a game-changer in understanding how best to support an individual in their health care journey.
I think about moments of crisis and how to help people follow a trajectory that will support them down the line. It’s not inevitable that everyone who experiences trauma will end up with PTSD, so we have an obligation to think about early interventions that may be helpful. And to approach that with humility. After 9/11, there were a lot of mandatory debriefings that turned out not to be helpful. That highlights why research remains so important in the wake of disasters — we’re constantly learning about what may be helpful and what isn’t. An impactful response to a disaster will be very multifaceted because helping people find the right door in, and recognizes that prior experience will impact engagement, is what helps to make a system trauma-informed and helpful.