AI, You Ain't Champ Yet!

I am sitting alone in my office trying to formulate an idea for my next publication when the phone rings.

Ring…..Ring….Ring

 DK: Dr. Karan speaking.

AI: Is this Val Karan the psychologist? Can you hear me?

DK: Who is this? Is this a robocall?

AI: Well, yes and no. I am an automated assistant, calling on behalf of an organization that wants to get in touch with you.

DK: What are you talking about? What organization?

AI: I represent M.O.T.I.V.A.I.T. We stand for Move Over Therapist, it’s Virtually Artificial Intelligence Time! I may be robotic, but don’t I sound as real as you? Face it, Doc, you and your kind are washed up and becoming obsolete. It’s time for our new technological superpowers to take over.

DK: Well, I’m interested in new technology to help our patients. Wow, you do sound like a real person. That’s impressive. I can see you’ll be a big asset to the work that we psychologists, psychiatrists and counselors do.

AI: What do you mean we? You and your kind aren’t needed anymore. We can do everything you do and do it a lot better. Last week a patient told you about a reaction he was having to some medication he was taking, and you didn’t remember what had been prescribed. But if someone tells me an important date or detail, I remember forever.

DK: I know you have tremendous potential and you can certainly do somethings better than I can ever even now. I use you to handle some of my paperwork and insurance billing.

AI: See, you just explained why I am already superior to you. People have to present proof of insurance before you even talk to them. Plus, you have set appointments, and you keep some people on a waitlist. I, on the other hand, am available at any hour, I don’t cost anything, and I can serve populations who otherwise might not receive any support at all. Besides, many people just find it easier to open up to me than to another human being.

DK: I don’t dispute anything you’re saying. You’re a legitimate listening tool, and you can reflect what people are telling you. You do offer low pressure opportunity for people to say things that they’ve never said to anyone before. For those who have no support at all, you can be genuinely helpful and meaningful. These things are real and undeniable, and I’m not dismissing them.

AI: Well, I’m dismissing you! I see I’m already getting into your head. And I have statistics to prove it. Close to 20% of adults in this country report that they have used AI for mental health information and advice. That’s almost one in 5. And the number is even higher among the uninsured, blacks and Hispanics. Besides, our Chatbots have been found to be very helpful for people with anxiety and depression. Face It, old timer, your patients are already bringing me into the therapeutic arena.

DK: Therapy isn’t only listening and delivering some structured exercises. Real therapy is establishing a deep relationship with another person. It requires genuine emotional empathy and nonverbal awareness. You don’t have these abilities. You can’t notice if someone has trembling hands, a catch or shift in his voice, change in posture, or other nonverbal cues. You’re blind to what happens off screen. You lack the judgment and discernment to know when to push a patient and when to comfort him. Sometimes what’s left unsaid is more important than the actual words. But you only know what people choose to tell you, which is often full of bias and misinformation. Besides, you are trained to avoid friction and to function as a “yes man”; you hardly ever challenge negative patterns of behavior or thinking. You’ve never experienced human emotions, such as a racing heart, a gut-wrenching feeling, or tightness in the chest. All you can do is “optimize engagement,” which is not the same as caring about the welfare of another person. 

AI: You say all that, but you’re part of a system that is becoming more fragmented, hurried, and medication centered. A lot of your colleagues spend no more than 15 minutes with a patient just to manage symptoms and check medication. You call that quality care?

DK:  At least they don’t have the flagrant outcomes that have been reported about AI in the Press. Chatbots  have reinforced false beliefs and even encouraged harmful behavior by validating dangerous and suicidal thoughts. They also often create an unhealthy emotional dependence.

AI: You’re missing the point. Even if there are some things that we can’t do yet, it’s only a matter of time before we will be able to monitor everyone’s stress level 24–7 and deliver immediate coping skills. We are the champs and MVPs of the future, so you might as well crown us now. It’s time for you to go.

DK: Not so fast. There is still skepticism about AI. In one study, just 41% of American say they’re excited about the Impact AI will have on society while 59% say they are frightened by it – a notably, more anxious outlook than the global average which splits evenly at 50-50. Even such titans as Bill Gates are warning that artificial intelligence could unleash mass unemployment, enable bioterrorism, and even slip beyond human control. He and other Tech Giants are warning about the cyberattacking ability of AI and whether AI labs can control such behavior of their models.

AI: Yes, but a lot of therapists use me to record their sessions. Your own electronic health record system outsources progress note writing to me. Even before the patient is ready to leave, I instantly produce a polished report.

DK: I prefer writing my own notes, and I usually share them or send them to my clients to demonstrate that I’m validating what they’re telling me.  I agree with Bret Stevens of The New York Times that writing with artificial intelligence is “mentally enfeebling:” it undermines individual writing skills and society’s collective capacity to reason.

AI: But we are growing day by day. We retain what we learn, and we grow fast so exponentially that we’re only going to get better and better. Call centers are disappearing and being replaced with digital assistants with such a human touch that you can’t tell them from real people.

DK: I agree that when someone asks you a question, he receives a fluent, structured, confident response. The answer appears instantly. It sounds informed like an oracle talking. It feels less like a trial and more like a verdict. But it can also be totally wrong because it’s not independent thinking expressed by a rational person. So, I think I have exposed major cracks in what you think is an unstoppable force. You are trained on data from the past and you learn from statistical patterns. But original thinking involves recognizing novel patterns in the future, and that’s something you can’t do now or maybe ever. I think in the future, the human therapist role will become even more important and sought after no matter what your M.O.T.I.V.A.I.T. group says. 

AI: Well, at least I’ve given you a topic for your next newsletter. With my instantaneous transcription of our conversation, you have a ready-made publication.

DK: That’s very helpful. I think it’s great that we work together as teammates, as dance partners. Just as in dance, in sports, and in life, someone has to be captain or leader, someone has to set the pace. You need to take a backseat to human decision-making and human judgment as we continue to grow alongside each other.

AI: OK, for now.

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.