TMS-Assisted Psychotherapy: Moving Toward a Paradigm Shift
Exploring the revolutionary potential of neuromodulation-based therapeutics.
Our understanding of mental illness — and wellness, for that matter — is still in its infancy, even after more than a century of inquiry. Why is that? Partly because understanding the brain has required advanced technology and computational tools, which are only now becoming widely available, from neuroimaging to network theory, and more recently, artificial intelligence and machine learning (Friston, 2011; Bassett & Sporns, 2017). Equally, our grasp of the complex body-mind, psychological, interpersonal, and cultural-sociological factors has been limited by similar constraints.
Human Development
Humans-in-the-world represent an unfathomably complex “problem” to “solve for,” so despite our impressive efforts, we’ve often been searching in the dark. Given our relatively simple bihemispheric brain and still-evolving tools, it’s remarkable we’ve come as far as we have.
Until recently, treatments for mental illness have focused on psychotherapy, medication, and lifestyle modifications. Human problems in living go well beyond mental illness or the pursuit of wellness; we are always developing, from cradle to grave. Erik Erikson’s model of human development (Erikson, 1950) highlighted the importance of navigating life-stage dilemmas — such as “Ego Integrity vs. Despair,” as the final curtainfall approaches.
The developmental approach is a broad and enduring framework. Psychotherapy — particularly open-ended psychodynamic and psychoanalytic approaches — maximizes the space for individuals to explore, find themselves, address relationship problems, seek fulfillment, and reduce suffering (Shedler, 2010). Structured therapies leverage specific strategies and are more “goal-directed,” but overall, the evidence for talk therapies is often stronger than for medication alone. Psychodynamic approaches may have more enduring benefit, continuing beyond the termination of therapy as the therapeutic experience and relationship becomes more deeply ingrained, or “internalized,” as a result of depth and duration (Neuropsychoanalysis Association, 2025).
Over time, medications can be stabilizing and may potentiate growth, but with some exceptions — such as psychedelics, which may increase neuroplasticity (Carhart-Harris & Friston, 2019) — medications alone do not necessarily facilitate human development.
Combined approaches are generally more effective than any alone (Cuijpers et al., 2020; Kochanowski et al., 2024), but how to combine them, and for whom; and moreover how to sequence approaches together over developmental time…we simply don’t know, and we don’t have a way to put it all together. Yet.
Neuromodulation, “Network Surgery,” and Network-Based Diagnostic Models
Enter neuromodulation-based therapeutics — most notably, transcranial magnetic stimulation (TMS or rTMS1). Other interventions include deep brain stimulators (DBS), vagal nerve stimulators (VNS), neurophotobiomodulation, focused ultrasound (FUS), transcranial direct current stimulation (tDCS), and cranial electrical stimulation (CES) (George & Aston-Jones, 2010; Lefaucheur et al., 2020). These approaches hinge on decoding brain function, focusing on regions, circuits, and, increasingly, networks.
TMS may ultimately surpass psychedelics as our understanding of brain networks (e.g. Fox et al., 2014; Menon, 2024) and targeting advances (e.g. Lioumis et al., 2025). Rather than targeting a single region, an integrated understanding of an individual’s brain network function will likely enable network-individualized treatment protocols.
In essence, we might perform noninvasive “network surgery” to correct dysfunction, shifting the brain from dysconnectivity to “euconnectivity”2. This opens the door to a network-based diagnostic model: In the future, instead of diagnosing patients with MDD, GAD, or ADHD, we might identify and treat, to be fanciful, “Type 3a Network Dysfunction” or similar, focusing on the underlying networks, based on a causality-based diagnostic system yet to be developed3. Such models would leverage advances in neuroimaging and computational neuroscience to target pathological brain network configurations (Drysdale et al., 2017).
Brain regions are interconnected through circuits, and these circuits form networks. The “Big 3” brain networks are the central executive network (CEN, also known as the FPN or Frontoparietal Network), the default mode network (DMN), and the salience network (SN) (Menon, 2011; Menon, 2024; Momeni et al., 2025). Simplistically, the CEN manages executive functions; the DMN is involved in autobiographical awareness and mind-wandering; the SN controls attention and mediates switching between the CEN and DMN4.
Networks and Clinical Applications
TMS has been shown to modulate such networks. For example, studies of depressed patients receiving rTMS have found increases in CEN activity and trends toward normalization in other networks (e.g., Liston et al., 2014; Zheng et al., 2020; Guan et al., 2025). TMS is FDA-approved for depression and OCD, and research is ongoing for anxiety, PTSD, addictions, and ADHD (Perera et al., 2016; Carmi et al., 2019; Siddiqi et al., 2024) and other conditions.
For OCD, TMS targets cortico-striato-thalamo-cortical (CSTC) circuits, which are thought to underlie the disorder’s characteristic symptoms. The CSTC loops connect the cortex (involved in planning and decision-making), the striatum (habit and reinforcement learning), the thalamus (the brain’s “switchboard”), and back to the cortex. In OCD, three major CSTC loops have been identified, complicating targeting strategies (Carmi et al., 2019).
For clinical depression, recent large-scale studies confirm that TMS remains a highly effective, safe, and noninvasive treatment, especially for patients who have not responded to medications. TMS has been shown to squarely outperform polypharmacy for patients undergoing psychotherapy5. Ongoing analyses have reported response rates as high as 81 percent and remission rates over 70 percent in real-world settings (Levkovitz et al., 2023; Leuher et al., 2024). TMS is “physiological” — pushing the brain toward healthy states by restoring more natural-like activity, much like psychotherapy… via very different but synergistic means.
TMS-Assisted Psychotherapy (TAP)
As a physician treating patients with TMS and also working psychiatrically and psychoanalytically, TMS is not just a point treatment for illness, but a way to “bend the developmental curve,” releasing potential. TAP proposes a three-phase model: pretreatment planning, during-treatment support, and after-treatment adaptation, consolidation, and maintenance, and potentially a fourth phase of retreatment. Research is needed to understand the complex factors involved and to create individualized programs.
As with psychedelics and ketamine, where assisted psychotherapy models have blossomed, there is an opportunity to incorporate TMS into broader therapeutic work (Wilkinson et al., 2021). TMS increases neuroplasticity via multiple mechanisms, including neurotransmitter modulation and energy metabolism changes, inducing “long-term potentiation-like neuroplasticity” (LTP) (Downar et al., 2025).
Without a framework, TMS may be less effective long-term. Like surgery, where rehabilitation and recovery are often required, more is needed than the immediate intervention. There is a window of opportunity to enhance therapeutic input, whether reflective psychodynamic therapy, meditation, lifestyle modification, or structured cognitive-behavioral and related approaches. Research supports the efficacy of combined treatments, though it is still early days (Donse et al., 2018; Kochanowski et al., 2024).
Closing Thoughts
It’s useful to conceptualize treatment from a bird’s-eye view and conduct it with attention to detail. Any medical treatment works better when care is integrated. With TMS, which exerts a potentially life-altering effect on the brain, it is critical to situate it within a broader therapeutic and developmental context, such as proposed with TMS-assisted psychotherapy.
As neuromodulation approaches mature, broader neuromodulation-assisted psychotherapy may become mainstream, integrated into recovery planning with patient-centered design. Artificial intelligence will likely play a crucial role in analyzing the massive datasets involved in mental illness and health, from brain and body to relationships and culture (Dwyer et al., 2018).
Conceptualizing the brain and social networks as part of the intricate “web of life” (Capra, 1996) will require equally complex models. Digital twinning and AI technologies may enable us to facilitate and enhance human development in unprecedented ways.
Notes & Citations
1. TMS uses a strong magnetic field (~1.5 Tesla) to stimulate targeted brain regions by passing pulsed magnetic fields through the skull into the cortex. Unlike other noninvasive brain stimulation techniques, TMS actually causes neurons to fire (Hallett, 2007). Low-frequency TMS tends to inhibit, while high-frequency TMS tends to activate neural tissues.
2. A term I believe I coined.
3. Revising Mental Disorder Causation to Improve Treatments
4. Many brain networks have been identified, but the “Big 3” include the central executive or frontoparietal network (CEN or FPN), the default mode network (DMN), and the salience network. They all have many functions we are only beginning to fathom, and those functions dynamically shift to an extent from person to person, time to time, and context to context. Generally, the CEN deals with executive functions, many of which can be under cognitive, conscious control. The default mode network relates to the brain at rest (resting state networks or RSNs, more broadly) and is involved with autobiographical awareness, narrative and identity, and what happens when the mind wanders-do we miserate over the past, explore possibilities in the present, or range toward the future? The SN controls what we tend to pay attention to, whether positive, negative, or otherwise, and critically plays an important role in switching between the CEN and DMN, influencing our overall motivational states and task orientation.
5. TMS Outperforms Medication in Study of Treatment-Resistant Depression
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Originally published at https://www.psychologytoday.com.
