Some patients ask if they can listen to a podcast or read a book, or journal, or do some form of meditation with a narrator during their Spravato® session. I can understand that. These are all things we tend to do to help ourselves feel anchored, directed, active, and/or purposeful.
This is why I tell patients no. It's not an arbitrary answer. This is because of a key concept in neuroscience: the default mode network.
What Is the Default Mode Network?
The DMN is the brain network that activates when you're not engaged with the world. It activates during self-referential thinking, which is reminiscing about the past, worrying, rumination, and self-narration. In simple terms, the DMN is the brain's self-centered thought process.
The self-critic. The storyteller who cannot stop playing back what happened last Tuesday and anxiously preparing for what is to come next month.
In patients who have treatment resistant depression, which is the population Spravato® is intended for, the DMN is often very active and in a constant feedback loop. The self-critic is constantly telling the same sad story and reinforcing a pattern of self-sabotage, while the narrator plays the same old songs of self-defeat on repeat and digging deeper ruts in the path of self-defeat. It is not a character flaw; it is a pattern that distinguishes some individuals. It is one of the things that Spravato® is intended to address.
How Spravato® Quiets the DMN
Esketamine — the active ingredient in Spravato® — temporarily disrupts the default mode network and muscle of self-referential thinking. It pries habitual grip on self-referential thinking. This neuroplastic state allows for constructive neuroplastic changes in the brain.
This is the reason why many patients experience a sense of distance from their self-referential thoughts, a feeling of openness, or a sense of observing their life from outside their self-narrative. There is considerable research corroborating the reason for this. Research on ketamine and psilocybin has found that the therapeutic effect correlates to the degree of disruption of the DMN during the session. The more self-referential thinking is disrupted, the more there is to fill the empty space.
This is not a side effect; it is the mechanism.
"The more the medicine can quiet that self-referential loop, the more room there is for something new."
Why Language Re-Engages the DMN
Journaling, podcasts, audiobooks, and other spoken word/audio content during a session are problematic and counterproductive for the reason that language activates the default mode network. Words, especially with meaning and narrative, create an instructional task and activate the brain's language-processing regions. These regions are intimately connected and activated by the DMN. Processing language necessarily brings the individual back to the self-referential mode of thinking, which Spravato® was intended to help quiet.
Journaling is more direct. Writing about yourself calls for you to compose your narrative, reflect on your thoughts, and word the inner states. These are DMN activities. You are basically asking the medicine to open a door and simultaneously shutting it.
The same problem occurs with guided meditations with narrations. Even with calming content, during verbal instructions, the DMN and the language network stay engaged. The voice becomes an anchor to the ordinary mind, at the moment the medicine is pushing you to let go of it.
What About Lyrics in Music?
The same case is valid with music that has lyrics. Lyrics are language. In the background of your normal mind, the medicine is not saying bring your normal mind back. While listening to the accompanying words in the background of your mind, the language network is activated, and the DMN is pulled back online.
This is why music with lyrics is not suggested with music assisted psychedelic therapy, even if the therapy has an aesthetic preference. It is more about neuroscience. Instrumental music can carry emotional weight, create a sense of journey, while supporting the therapeutic process.
There is a meaningful difference between music that moves you, and music that talks to you. This is the case during a Spravato session.
The Integration Window Is Different
It is worth being precise about timing. The issue of language really occurs during the active session, or the time the medicine works and the DMN is most disrupted.
Once the session is complete and during the integration period, language returns. Journaling after a session helps capture insights and process what came up. It can also help engage the first steps of making sense of what was session related, weaving it into everyday life. Personally, I have found post-session journaling to be well received by therapists and clinicians.
Language after the session helps with the integration process. During the session, language is in opposition with the medicine.
What to Use Instead
The alternative to language is not silence. The alternative is non-verbal sound that supports the therapeutic arc without language.
Music that is emotionally expressive and has structure, as well as a harmonic openness and sensitive and controlled dynamics, is able to guide the session experience without the medicine being disrupted by a causal/self referential cognitive network.
During the early stages of a session, when the medicine has not fully taken effect, less emotionally expressive, more calm and droning, music works well. More emotional music can be used during the later stages of a session.
The goal of the music is to help the medicine. Non-verbal music does that. Language helps very little with that.
The Session Is Not the Time to Process
There is a common cultural belief that elements of the experience during an altered state should be engaged to capture insights or work through problems or to make meaning of an experience. Although I know where this belief comes from, I also think that it fails to appreciate the context of Spravato®.
During a session, processing is not the objective, leaving space to allow most certainly is. If you're looking for your medicine to work, step back from your analytical, narrative and self-referential self. The presence of language, in any form, keeps this self seated.
Give your medicine the silence it deserves in order to do its work. You can speak your piece after.