From Siggy Freud to Magnetic Pulses

 “WOW!” is the reaction I have when I think how the field of mental health has changed since I became a practicing psychologist back in the 1960s. Furthermore, we are at the dawn of another wave of revolutionary treatments. 

The dominant approaches to helping people that I learned in Graduate School were psychoanalysis and behaviorism. Make no mistake about it, the theories of Sigmund Freud and BF Skinner are interesting and helpful; but they offered us only limited, highly structured ways of dealing with depression, anxiety, and OCD. To make matters worse, therapy was less accessible, and stigma discouraged many from seeking help. 

Modern psychopharmacology only began in the 1950s, so psychiatry had only a few medications—antipsychotics, anxiolytics, and MAOIs—with serious side effects. Up until 1966, lobotomies were being performed to control various behaviors by altering sections of the brain's frontal lobe affecting social conduct. A mentally ill sister of President John Kennedy was subjected to this irreversible procedure in 1941 to reduce depression and aggressiveness, but it was a horrible failure. Electroconvulsive (ECT) or shock therapy was around in the 1960s and is still used to treat severe depression but it is invasive, painful, and not always successful. 

Thankfully, the fields of psychology and psychiatry have expanded and given us new tools to help our clients. In medicine, Prozac, the first SSRI or selective serotonin reuptake inhibitor, was approved in 1987 by the FDA. SSRIs represented a significant step forward because they are safer and more tolerable. I have written before of my own personal experience with the SSRI Paxil which was prescribed for me when I was diagnosed with atrial fibrillation in 2001. It helped to calm me and regulate my mood and reduce the symptoms associated with afib. But it also caused side effects, such as nausea, decreased libido, and weight gain. After several years, I was able to successfully wean myself from the drug with no lasting sequelae. 

Psychology, too, expanded the field of talk therapy with the introduction of cognitive behavioral therapy or CBT in the 1970’s. This enabled therapists to challenge cognitive distortions by emphasizing the connection between thoughts, feelings, and behaviors. Without a doubt, CBT is the touchstone of the therapeutic work I do; and I use several evidence-based varieties such as Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT). 

Technology has made mental health care more accessible than ever. Teletherapy, online support groups, mental health apps, and digital CBT platforms allow individuals to receive care at home. During the pandemic, I continued seeing clients remotely, and I still do about a third of my sessions online. 

Over the past few decades, we have also learned more about the brain’s neuroplasticity—its ability to reorganize and adapt. In sum, individuals facing mental health challenges today have access to a wide array of exciting and effective treatment options, including cutting-edge techniques such as transcranial magnetic stimulation (TMS), that were once unimaginable. 

I only recently became aware of the treatment called Transcranial Magnetic Stimulation (TMS) that is non-invasive but can affect brain functioning. TMS is primarily used for Major Depressive Disorder (MDD) (especially treatment resistant depression). 

A number of my clients have found relief through transcranial magnetic stimulation. The FDA has approved TMS for OCD, anxiety, migraines, and even memory enhancement. Insurance often covers it. Intrigued, I even looked for references to magnets in Jewish texts—turns out, the Talmud suggests King David’s 75-pound crown may have floated above his head thanks to a magnet. If it worked for him… 

Earlier this year, my wife and I decided to consult a memory center; we had concerns about age-related memory lapses. We visited the Brain Health Center in Englewood, NJ, run by Galina and Dr. Jeffrey Shenfeld. This Center offers a comprehensive suite of memory diagnostics as well as personalized treatment plans and ongoing support. They put my wife through the full battery including cognitive tests, PET scan, MRI and brain imaging. After extensive testing, they found amyloid plaque in her brain—often linked to Alzheimer’s—but her memory was excellent. We opted for a gentler approach: TMS. I asked, “Can I try it too?” That’s how I ended up with what looks like a salon hair dryer on my head during one of my 36 treatment sessions. 

TMS uses magnetic fields to stimulate nerve cells in mood and memory related brain regions. The exact mechanism isn’t fully understood, but it appears to activate underactive areas. The Brain Health Center uses the state-of-the-art Brainsway Deep TMS System developed in Israel. The first session, which lasts about an hour, involves “Motor Threshold Mapping” to find the right spot and dose. I sat in a comfy chair, wore earplugs, and had a cap placed on my head. I felt a tapping sensation on my head and a clicking sound, followed by a pause. The technician used pulses to locate the motor cortex and adjusted the strength until my fingers twitched. Then they targeted the dorsolateral prefrontal cortex (DLPFC) for memory.

 Here's what happened during each treatment: 

• I would sit in a comfortable chair, wearing earplugs, with the cushioned helmet against my head. 

• When the machine was on, I felt and heard rapid soft tapping on my scalp. The pattern would be a few seconds of tapping followed by a pause. The pattern would repeat. 

I would describe TMS as feeling like a series of pricks or pulses, or a woodpecker gently tapping on the head, which takes a little getting used to but is generally not uncomfortable I remained awake and alert during the procedure and either watched soothing videos on the screen or did NY Times puzzles on my phone. Deep TMS sessions typically lasted around 15 minutes. 

After each session, you can resume your normal daily activities. You might have a headache for a brief time afterward. Research has shown that the effects are longer lasting by increasing the treatment to more sessions. Booster sessions and/or an annual repetition are strongly advised. 

So, is TMS effective? To what extent are people helped by TMS? Did I see any change in myself because of the treatment? People’s experiences with transcranial magnetic stimulation (TMS) can vary widely. For some, it can take several weeks before improvements are noticeable, which can be discouraging. Others see a noticeable change after several sessions. There are reports, even from some of my patients, that depressive feelings are lifted, mood lightens, motivation increases, and brain fog is reduced after the entire 36 sessions. Indeed, there is a growing body of scientific evidence supporting the efficacy of TMS. Placebo-controlled and rigorous double-blind studies have demonstrated that TMS produces measurable improvements in cognitive function and mood for individuals who haven’t responded to traditional treatments. 

I saw a change in my recall after just a few sessions. I would describe myself as generally having a spotty memory at best. I forget details of books and articles, and I am not particularly good with names. Shortly after I had started TMS, my wife and I went with friends to the Peace Café on the Upper West Side, one of our favorite dining spots. As we were being seated, I saw someone at the next table who looked familiar. I knew I had seen him at the movies or on television, but I could not think of his name. When later he and his group got up to leave, I made eye contact with the man and said, “I enjoy your work.” He nodded, did not break his stride and left. I clung onto the image of this man in my mind as we had a lovely afternoon with friends. Later at home I still was fixating on the image when the name “Saul” popped into my mind. Aha, I knew then that I had seen Bob Odenkirk who had starred in “Better Call Saul” and other shows, and I knew that I would not have recalled his name this easily before transcranial magnetic stimulation. 

One could argue that any positive experiences with a new treatment like TMS could be due to the placebo, Pygmalion or Hawthorne effects. The Hawthorne effect explains that people's behavior can be influenced by the simple fact of knowing they are being studied, rather than by the specific treatment. . The Placebo or sugar pill effect refers to real improvement that occurs from expectations about treatment rather than the treatment itself. The Pygmalion or Self-Fulfilling Prophecy Effect focuses on how high expectations from a figure of authority (like a teacher or manager) can lead to increased performance. 

I will be the first to admit that I am very suggestible and wanted the TMS to have an impact on my brain functioning. Even if the placebo, Pygmalion and Hawthorne effects were to account for some changes, I truly feel there was a fundamental difference in my mental processing that went beyond any observer effects. 

Some Karan history can explain what I mean: This month I am observing the Yahrzeits of my beloved parents. Rose and Herman Karan had limited formal education. But they instilled in my brother and me a love for higher education and for helping others. They also taught us reverence for higher authority, particularly institutional authority, such as police, government officials, executives, and people in power positions. They never encouraged me or taught me how to stand up to bullies. The upshot is that I have gone through life with a cowering and fearful feeling about raising my voice: I would remain silent in situations, even when I knew I was right. But after TMS, I suddenly found my voice! My wife, who has known me for over 60 years, noticed this as well and she was shocked at the difference. I was accompanying her to the Cornell Weill Medical Center, where she was preparing for cataract surgery. We were experiencing long delays in preop procedures and bureaucratic snafus. Ordinarily, I would be very patient and not say anything. But this time I was assertive: I expressed my disappointment in the dehumanizing quality of the procedures, in the lack of thorough review of my wife’s medical history, and in the hospital caring more for economics rather than the care of the patient. I chastised the surgeon, a renowned ophthalmologist, who is head of her department, although I was not disrespectful or aggressive. But in all honesty, I do not think I would’ve spoken up like this before TMS; and now I feel I can confront other authority figures, without my voice feeling still or small. 

In short, I see evidence of actual neurobiological shifts triggered by the stimulation process. For me and others, there are slow and subtle improvements like noticing that intrusive thoughts are no longer as overpowering, that small joys or hidden talents are rediscovered, that there are no side effects like meds. 

A considerable number of people don’t respond to TMS. My wife, for example, says she felt no difference after 4-6 weeks. For others, the experience is frustrating or inconclusive. TMS doesn’t work for everyone, but for those who respond well, it can be life changing. The success rates are promising, especially for depression: About 50-60% of people with treatment-resistant depression see a significant improvement. Moreover, around 30-40% achieve full remission, meaning they no longer meet the criteria for depression. 

What’s Next? What is the Predicted Future of TMS? 

Companies in Israel and in America already are developing wearable TMS devices, allowing people to receive daily treatment at home. Imagine: A TMS headset you wear for 20 minutes at home, just like taking a pill. Scientists are also working on personalized "brain circuit tuning" to focus on more specific regions of the brain. TMS could one day help treat neurodegenerative diseases.

I believe that with TMS, we are on the verge of an even greater revolution with faster protocols, portable devices, multiple therapies combined, and new applications for addiction, PTSD, and Alzheimer’s. 

From the very limited options of the 1960s to today’s diverse, data -driven landscape, the evolution of psychological treatment has been simply amazing. Techniques like TMS demonstrate that practitioners are taking bold strides at the intersection of neuroscience and mental health, offering new hope to millions. As a clinician and recipient of TMS, I am excited as the future of psychological treatment promises even more astounding innovations. As science continues to study the mysteries of the mind, I look forward to even more “WOW!” moments in menial health care for people than ever before.

Israel’s Topsy Turvy World

       This past summer, my wife and I travelled abroad. Our first stop was a small country mired in a war with neighboring countries. Bombings and shootings happen so frequently in the north and south that 94,000 people are still displaced, evacuated from their homes near the restive borders. Our state department had issued warnings about travel to this country, and many airlines cancelled flights. The tourist industry upon which the country depends is reporting a huge drop since the previous year. The volatility, the uncertainty, the lack of knowing what’s going to happen next is profound. According to researchers, 23% of adults in this polarized and besieged country suffer from post-traumatic stress disorder (PTSD) and about 55% of adults suffer from clinical anxiety.  

     My wife and I then went to a country that Gallup’s recent World Happiness Report lists as the fifth-happiest nation on Earth, behind Finland, Denmark, Iceland, and Sweden. The US ranks twenty-third. In this particular country,  traumatic events spur an unprecedented wave of solidarity and mutual support. The sense of “togetherness” and shared destiny became palpable. People discover a mental fortitude and a sense of meaning that transcends individual struggles. This collective resilience is a crucial factor in this country’s happiness. People in this country remain determined to go about their ordinary lives. Even if there’s a war, it’s business as normal — the beaches, markets, and bars are still full. The presence of so many rifles and uniformed soldiers indicate definite low-level stress in the air, but people are still going about their lives.

     The countries I am describing are actually one and the same place. Since its inception, Israel has combined an outer toughness over an inner soft core, like the sabra plant which defines any Jew born in the land. Calm, pragmatic, hopeful seem to be the markers of the good people of Israel. They are used to the sword rattling of their enemies all around them and have strong faith in their military.

     I witnessed that personally on this trip and also back in 2001 when I went in the midst of the second Intifada. Then as now, Israelis were living on the precipice of a prolonged war with seemingly no end in sight. The situation was a breeding ground for helpless and hopeless feelings that can lead to profound depression.

     Yet despite all of this, I witnessed people getting along with their lives in a remarkable way. There is a level of tension and dislocation, but the basic flow of life continues. I saw a vigilance, but not a sense of paranoia; I saw anger, but not violent, vengeful rage as a way of seeking justice.

     In 2001, I used the term “flow” coined by the psychologist Mihaly Csikszentmihalyi to explain how Israelis transform a hopeless situation into a new controllable flow activity. The Israeli key to infusing normality in life, I said,  is going with the flow and maintaining a sense of control over your life.

     But I now think that the flow that I described in 2001 does not completely describe the Israeli approach to coping with traumatic and chaotic situations. It does not account for the hopefulness, the sense of “togetherness” and shared destiny, the creativity and the ingenuity as well as the ability to embrace disorder as a necessary step in problem solving. They don’t call Israel “Start-Up Nation” for nothing. More and more foreign companies set up their research and development facilities here. Indeed, Israel’s main resource is its talent, with hard-working innovators all over the place. Israelis, it seems, can think of a solution to any problem; its very survival demanding new security, defense and intelligence measures.

Hope Springs Eternal

    One of the main factors contributing to happiness in Israel is that Jews do not believe in fate. Jews believe in freedom: there is no “evil decree” that cannot be averted. Rabbi Jonathan Sacks has brilliantly noted that the word tragedy doesn’t exist in Hebrew, reflecting the Jewish resistance to a worldview that embraces despair. Instead, we believe in hope, which is also the title of Israel’s national anthem. There is a spirit of unity and mutual responsibility. The word for crisis in Hebrew, also means a childbirth chair. According to Rabbi Sacks, the Jewish reflex is to see difficult times as birth pangs. Something new is being born.

     The Greeks gave the world the concept of tragedy. Jews gave it the idea of hope. Judaism is a set of laws and narratives designed to create in people, families, and communities habits that defeat despair. Judaism is the voice of hope in the history of mankind.

It takes a Village to Raise a Child

     Another factor in Israel’s ability to persist is a sense of solidarity and connection that exists among all levels of society, especially when dealing with outside enemies. Being an Israeli is not something private and personal but rather something collective and historical. It meant being part of an extended family, many of whose members are not known, but with whom one nevertheless feels connected by bonds of kinship and responsibility.   

    According to the political historian Gil Troy, Israelis pursue happiness through family and community, by feeling rooted and having a sense of purpose. He adds: “Despite disagreeing passionately, Israelis live in an intimate society that runs on trust and generates hope. Israelis feel that they’re never alone, and that their relatives and friends will never abandon them.”

     Amid unspeakable suffering, Israelis have found comfort in one another and a higher calling. Too many Americans feel lonely and lost.

     While Americans might honor or respect their soldiers, the writer Forest Rain Marcia notes that Israelis love their soldiers passionately. Honor is something you do from far away. Love is up close and personal. To Israelis, according to Marcia, soldiers aren’t heroic figures for whom you throw parades and give medals. Soldiers are their boys, their girls, their family. You feed them, make sure they are warm and comfortable. You let them sleep on your shoulder if they fall asleep next to you on the bus. It doesn’t matter if you never saw them before and don’t know their name. It doesn’t matter if they come from a different background than you or have a personality you don’t like. The minute they put on the uniform, they belong to you and you belong to them. Each soldier could be anyone’s soldier so you do for someone else’s son or daughter exactly what you would hope someone would do for yours. No one calls them “Sir.” Rarely will anyone thank them for their service but everyone will love them.

Life is a Balagan, Old Chum

    The final crucial factor in Israel’s resilience and happiness, I believe, comes from a societal mindset best described by a word for chaos or fiasco borrowed from modern Hebrew (where it is a loan word from Russian). Balagan is a term commonly used in everyday Israeli life: from waiting in the supermarket line, to riding on a bus, to visiting a governmental office, to participating in a political protest, to Israeli children in a typical playground, to fighting a war. There is always balagan.

     “While this may seem chaotic to an outsider, in Israel, it is simply the way social interactions operate,” wrote Inbal Arieli, an Israeli businesswomen and author. “Balagan encourages adapting and adopting new and unforeseen parameters. It encourages both us and our children to continuously reconsider our deepest biases and assumptions regarding the ‘organization of things,’ and allows us to consider alternative possibilities.”

     As such, balagan is central to the Israeli way of life — disruptive, often rude — because it doesn’t follow conventions. It encourages kids to understand there’s no single way to do things. if you put the word ‘Yalla’ which is slang for ‘get a move on’ or ‘lets go,’ in front of ‘Balagan’ (Yalla Balagan) then you are basically saying ‘great, let’s go for it, it’ll be great fun.’

  In Israel, the thrill and excitement of living in such a dynamic environment significantly contribute to psychological well-being. Research shows that 55% of Israelis prefer an unconventional life filled with excitement over a tranquil one. This constant stimulation, whether positive or challenging, keeps life engaging and fulfilling and  is part of the Israeli identity, making the country’s citizens resilient and adaptable.

     Judaism is no comforting illusion that all is well in this dark world. It is instead the courage to celebrate in the midst of uncertainty. Accepting life as a balagan is a decision to live calmly and carefree in the face of chaos and impending problems

    Using the concept of balagan, Israelis have developed an attitude of “What doesn’t kill you, makes you stronger.” Although this expression is often said jokingly, regarding small uncomfortable situations like going to the dentist or telling a child to do something they don’t like, Israeli’s experiences as individuals and as a nation have taught that terrible things will happen. Some people will die as a result but those who survive will be stronger because of it. Apparently, under certain circumstances, we are capable of achieving things we wouldn’t have been able to achieve without the stress and trauma. This is the mindset of post traumatic growth. This is beyond resilience. It involves far more than just returning to routine and functioning normally. It’s about genuine growth and positive change. It’s true on a national level, too. Throughout history, every attempt to destroy the Jewish people has not only failed, but it has caused us to grow stronger.

 Israel needs American Jews: Israel has long benefitted from the political and economic support of both the United States and American Jewry. Now when Israel  is vilified for everything it does, it needs American Jews to  lend aid and supplies. My daughter Suzie, I am proud to say, did just this when she volunteered to work as an anesthesiologist in Jerusalem and to bring medical equipment.

American Jews need Israel: In the U.S., there is unprecedented antisemitism and campus  riots. Are my wife and I happier after this trip? For sure, as we had a chance to show solidarity with the country and to meet friends and relatives. It was so heartening to us to see how Israel has seemingly patented its own brand of happiness despite the challenges and conflicts,  This happiness is not necessarily tied to the quality of life but rather to excitement, action, hopefulness, belonging, and strong community bonds. In a world increasingly plagued by loneliness and depression, a thriving, vibrant, resilient Israel is key to restoring pride and steadfastness in Jews like us in the diaspora.