33:04 Lena: Alright Miles, let's get practical here. If someone's listening to this and thinking, "Okay, this is all fascinating, but how do I actually figure out which approach might be right for me or someone I care about?"—what would you tell them?
33:19 Miles: That's the question everyone's been waiting for, right? Let me break this down into some concrete steps people can actually use. First, start with a honest self-assessment of what's really going on. Are you struggling more with how you think about things, or with your ability to think clearly at all?
33:36 Lena: Can you give us some specific examples of what that might look like?
33:40 Miles: Sure. CBT territory might be things like: "I keep assuming people don't like me," or "I catastrophize every small problem," or "I avoid social situations because I'm convinced I'll embarrass myself." These are thinking pattern issues where your brain's hardware is fine, but the software needs debugging.
33:59 Lena: And CRT territory would be different?
28:36 Miles: Right. CRT signs might be: "I can't hold instructions in my head long enough to follow them," or "I get overwhelmed trying to filter out background noise," or "I start tasks but can't seem to organize the steps to finish them." These are more about the basic cognitive machinery not running smoothly.
34:20 Lena: But what if someone has both? That seems like it would be pretty common.
34:24 Miles: You're absolutely right, and that's where it gets tricky. If you're dealing with both cognitive impairments and negative thought patterns, you might need to think about sequencing. The research suggests that if cognitive problems are severe enough to interfere with daily functioning, addressing those first with CRT might make subsequent CBT more effective.
34:43 Lena: So there's a strategic element to this—which domino do you tip first?
4:00 Miles: Exactly. And here's a practical question people can ask themselves: Have you tried therapy before, and if so, how did it go? If you've done CBT-type approaches and found yourself struggling to remember techniques or getting overwhelmed by the cognitive demands, that might suggest underlying cognitive issues worth addressing.
35:07 Lena: That's really helpful. What about finding the right provider? Not every therapist is going to be trained in both approaches.
35:14 Miles: Great point. For CBT, you want to look for someone specifically trained in cognitive-behavioral therapy with experience in your particular issue—depression, anxiety, trauma, whatever it is. Check their credentials, ask about their training, look for people who mention CBT explicitly in their practice descriptions.
35:33 Lena: And for CRT?
35:34 Miles: CRT is trickier because it's less widely available. You might need to look at neuropsychology practices, rehabilitation hospitals, or specialized programs for conditions like schizophrenia or ADHD. Some occupational therapists also do cognitive rehabilitation work.
35:51 Lena: What questions should someone ask a potential therapist to figure out if they're a good fit?
35:56 Miles: For CBT, ask about their approach to homework, thought records, behavioral experiments. A good CBT therapist should be able to explain how they'll help you identify and challenge problematic thinking patterns. For CRT, ask about cognitive assessment, what specific skills they target, how they measure progress.
36:15 Lena: And what about red flags—things that might suggest someone isn't a good fit?
36:20 Miles: For CBT, be wary of therapists who just want to talk about your childhood without connecting it to current thinking patterns, or who seem to avoid giving you concrete tools and techniques. For CRT, be cautious of providers who promise quick fixes or who can't explain the specific cognitive skills they're targeting.
36:40 Lena: What about cost and insurance? We touched on this earlier, but it seems like a real barrier for many people.
36:46 Miles: Unfortunately, it is. CBT is much more likely to be covered by insurance, especially if you're seeing a licensed psychologist or clinical social worker. CRT coverage varies a lot—it might be covered for certain conditions like brain injury or schizophrenia, but not for others.
37:03 Lena: Are there more affordable options for people who can't access traditional therapy?
2:23 Miles: Absolutely. For CBT, there are some excellent self-help books, online programs, and apps that can be surprisingly effective. The research on computerized CBT is actually quite good for depression and anxiety. For CRT, there are brain training apps and online programs, though the evidence for these is more mixed.
37:28 Lena: What should people's expectations be in terms of timeline and commitment?
37:32 Miles: CBT typically involves weekly sessions for 12-20 weeks, with noticeable improvements often starting within the first month. You'll need to do homework between sessions—practicing techniques, keeping thought records, doing behavioral experiments. CRT is a longer commitment—often several months of multiple sessions per week, plus daily practice. Improvements tend to be more gradual.
37:55 Lena: And what if someone tries one approach and it's not working?
37:59 Miles: That's actually really important to address. If CBT isn't working after a reasonable trial—say, 8-10 sessions with a skilled therapist—it might be worth exploring whether there are underlying cognitive issues that need to be addressed first. Similarly, if CRT isn't producing functional improvements after several months, it might be time to reconsider the approach.
38:20 Lena: So flexibility and willingness to adjust course is important?
2:23 Miles: Absolutely. The best treatment outcomes often come from providers who are willing to adapt their approach based on how someone is responding. Mental health treatment shouldn't be rigid—it should evolve as we learn more about what works for each individual person.
38:38 Lena: Any final practical advice for our listeners who might be trying to navigate this decision?
38:44 Miles: Trust your instincts about what resonates with you, but also be open to expert guidance. A good mental health provider should be able to help you understand which approach might be most beneficial based on your specific situation. And remember, seeking help is a sign of strength, not weakness—whether that's CBT, CRT, or something else entirely.