What Happens in Your First CBT-I Session? A Complete Walkthrough

Quick Answer: In your first 60-minute CBT-I session with ACT components, you'll review your sleep history and explore what matters most to you. You'll receive a personalized sleep schedule, behavioral guidelines, and introduction to acceptance skills for working with sleep anxiety. You'll leave with concrete homework addressing both sleep behaviors and your relationship with sleep-related thoughts and feelings.

Introduction

If you're scheduled for your first CBT-I (Cognitive Behavioral Therapy for Insomnia) session, you might be wondering what to expect. This approach integrates traditional CBT-I with ACT (Acceptance and Commitment Therapy) components, which means we'll work together on changing your sleep behaviors while also shifting your relationship with sleep itself. This guide walks you through everything that happens in our initial 60-minute session, so you can arrive prepared and confident.

Before Your First Session: What to Prepare

Sleep Diary (1-2 Weeks)

You'll be asked to complete a sleep diary for 7-14 days before the first appointment. This includes:

• What time you got into bed

• Estimated time you fell asleep

• Number of nighttime awakenings

• Wake-up time

• Time out of bed

• Daytime naps

• Caffeine, alcohol, and medication use

CLICK HERE to download the sleep tracker I use.

Pro tip: Accurate data is what matters, making your data look healthier than it is can make treatment ineffective. Be honest about your sleep patterns; this helps create the most effective treatment plan for you.

Questions You'll Want to Answer

Think about these beforehand:

• How long have you had insomnia?

• What do you think triggered it?

• What have you already tried?

• What medications or supplements are you taking?

• Do you have other health conditions?

• How has insomnia affected what matters most to you? (relationships, work, hobbies, health)

The First Session Structure (60 Minutes)

1. Introduction and Goal Setting (5-10 minutes)

We'll start by getting to know each other and establishing what you hope to achieve. Together, we'll:

• Explore what CBT-I with ACT components is (and isn't)

• Outline the typical treatment timeline (4-8 sessions)

• Discuss your goals for treatment

• Address any concerns or misconceptions you have

What makes this approach different: Beyond just improving sleep behaviors, we'll work on changing your relationship with sleep anxiety, nighttime thoughts, and the struggle itself. You'll learn that you can have a full life even while working on your sleep—you don't have to wait until sleep is "fixed" to live according to your values.

2. Comprehensive Sleep and Values Assessment (15-20 minutes)

We'll conduct a detailed assessment to understand your unique sleep situation and what matters to you:

Your Insomnia Pattern:

• When did it start?

• What type: difficulty falling asleep, staying asleep, or early morning awakening?

• How many nights per week?

• What makes it better or worse?

Sleep Behaviors:

• Your current bedtime routine

• What you do when you can't sleep

• Where you sleep (bed, couch, recliner?)

• Your bedroom environment (light, noise, temperature)

The Struggle with Sleep:

• How much mental effort are you putting into trying to sleep?

• What do you do to try to control or force sleep?

• What thoughts show up when you can't sleep?

• How do you feel about those thoughts?

Values Exploration (ACT Component): This is where we talk about what really matters to you:

• How has insomnia affected your relationships, work, health, or personal interests?

• What activities have you stopped doing or avoided because of sleep concerns?

• What would you be doing differently if sleep wasn't a barrier?

• What kind of person do you want to be, regardless of how you slept last night?

Daytime Impact:

• Fatigue levels and how you respond to them

• Mood changes

• Work/life disruption

• Safety concerns (driving drowsy?)

Medical Screening:

• Sleep apnea symptoms (snoring, gasping, witnessed pauses)

• Restless legs syndrome

• Other medical conditions

• Medications that affect sleep

3. Sleep Diary Review and Analysis (10-15 minutes)

Together, we'll analyze your sleep diary and calculate:

Sleep Efficiency: Time asleep ÷ time in bed × 100

• Healthy sleepers: 85-90%+

• With insomnia: often 60-80%

Total Sleep Time: Your actual hours of sleep

Sleep Opportunity: Time you're spending in bed trying to sleep

What This Looks Like: "Looking at your diary, you're spending 9 hours in bed but only sleeping 5.5 hours. Your sleep efficiency is 61%. This tells us we need to consolidate your sleep by initially reducing your time in bed—this might sound counterintuitive, but we'll explore why this works."

We'll also explore:

• How much effort and struggle is happening during those hours in bed?

• What are you trying to control that might not be controllable?

• Are you treating sleep as a problem to be solved every single night?

4. Education: Understanding Your Insomnia Through CBT-I and ACT Lenses (10-12 minutes)

We'll explore both the behavioral and psychological aspects of your insomnia:

The 3-P Model of Your Insomnia:

• Predisposing factors: What made you vulnerable (genetics, tendency toward anxiety)

• Precipitating factors: What triggered it (stress, illness, major life change)

• Perpetuating factors: What keeps it going—THIS is what we'll target together

Perpetuating Behaviors We'll Address (CBT-I):

• Spending too much time in bed

• Irregular sleep schedules

• Compensatory behaviors (napping, sleeping in, excessive caffeine)

Perpetuating Psychological Patterns We'll Address (ACT):

• Struggling with and trying to control thoughts about sleep

• Fusing with unhelpful thoughts ("I'll never sleep well again," "I need 8 hours or I can't function")

• Avoiding life activities because of sleep concerns

• Making sleep the enemy or the center of your life

The Sleep Drive Concept: We'll discuss how sleep pressure (adenosine) builds during wakefulness and how spending too much time in bed actually weakens this natural drive. Think of it like appetite—if you graze all day, you won't be hungry for dinner.

The Paradox of Sleep: Here's a key ACT insight we'll explore: Sleep is something you can't force or control through effort. The harder you try to make sleep happen, the more you activate your arousal system. Together, we'll work on creating the right conditions for sleep while letting go of the struggle to control it.

5. Introduction to Psychological Flexibility with Sleep (5-7 minutes)

We'll introduce the ACT components you'll be working with:

Acceptance:

• Learning to allow uncomfortable thoughts, feelings, and sensations about sleep to be present without fighting them

• Noticing that the struggle with these experiences often causes more suffering than the experiences themselves

Example we might explore: "When you're lying awake at 2 AM, you might notice the thought 'I'm going to be exhausted tomorrow.' Right now, you might try to argue with that thought, push it away, or feel anxious about it. What if instead, you could notice it as just a thought—'I'm having the thought that I'll be exhausted tomorrow'—and let it be there without engaging in a battle with it?"

Defusion:

• Creating distance from unhelpful thoughts about sleep

• Recognizing thoughts as mental events, not facts or commands

Values-Based Living:

• Identifying what matters most to you

• Taking action toward your values even on days when you didn't sleep well

• Not letting poor sleep dictate whether you show up for your life

Committed Action:

• Following your sleep schedule and behavioral guidelines

• Doing meaningful activities during the day regardless of sleep quality

• Practicing acceptance skills when sleep anxiety shows up

6. Your Personalized Sleep Prescription (12-15 minutes)

Based on your sleep diary, we'll create your personalized behavioral treatment plan together:

Your Sleep Window Calculation:

Here's how we'll figure this out:

• Your average total sleep time from diary: 5.5 hours

• Adding 30 minutes = 6 hours sleep window

• Choosing your wake time: 6:30 AM (based on your work schedule)

• This means your bedtime: 12:30 AM

Your Specific Instructions:

• Don't go to bed before 12:30 AM

• Get out of bed at 6:30 AM every day (yes, including weekends)

• No napping during the day

Setting Realistic Expectations with an ACT Perspective: Let's be honest about what to expect:

• You'll feel more tired initially—this is expected and temporary

• Uncomfortable thoughts and feelings will show up: "This isn't working," "I can't do this," "I need more sleep." That's normal. We'll practice noticing these thoughts without letting them derail your plan

• We're building sleep pressure while also building your ability to function and live your values even when you're tired

• Most people feel this gets easier after the first week

• We'll adjust this based on how you respond

7. Stimulus Control Instructions with ACT Framing

You'll receive specific behavioral rules to follow, while acknowledging the discomfort that may arise:

1. Only go to bed when sleepy (physically drowsy, not just tired or fatigued)

2. Use bed only for sleep and sex (no reading, TV, scrolling on your phone)

3. If awake for 15-20 minutes, get out of bed and do something boring in dim light

   • ACT perspective: This isn't punishment. When anxiety or frustration shows up, you're practicing acceptance by getting up rather than lying there struggling

4. Return to bed only when sleepy again

5. Same wake time every day regardless of how you slept the night before

   • ACT perspective: Even if your mind says "You need more sleep," you're committing to this action because it serves your long-term wellbeing

6. No daytime napping

What to Do When You're Out of Bed:

• Do something calm and boring in dim light

• If anxious thoughts show up ("I'll never fall back asleep," "Tomorrow will be terrible"), practice noticing them rather than engaging with them

• You might try: reading something dull, light stretching, listening to quiet music, or doing a brief mindfulness exercise

8. Brief Acceptance Practice (3-5 minutes)

We'll do a short experiential exercise together to introduce the ACT approach:

"Leaves on a Stream" or "Thoughts as Clouds" Exercise: You might be guided through closing your eyes and practicing noticing thoughts about sleep as they arise, visualizing them as leaves floating down a stream or clouds passing in the sky—observing without grabbing onto them or pushing them away.

This gives you a taste of what "acceptance" and "defusion" feel like in practice.

9. Safety Check (2-3 minutes)

We'll make sure the sleep restriction protocol is safe for you:

• Do you drive long distances for work?

• Do you operate heavy machinery?

• Any history of bipolar disorder? (sleep restriction can trigger manic episodes)

• Seizure disorder?

If any safety concerns come up, we'll modify your treatment plan accordingly.

10. Questions, Next Steps, and Homework (5-7 minutes)

Questions Often Asked in First Sessions:

"Will I be even more tired than I already am?" "Yes, initially you will be. This is part of building sleep drive. The ACT piece is learning that you can still do meaningful things even when tired—fatigue doesn't have to stop you from living your life. Most people feel significantly better by week 2-3."

"Can I really not read in bed? That's how I've always fallen asleep." "That association is actually part of the problem. We're retraining your brain to associate bed with rapid sleep onset. You can read before bed—just do it in another room. And when your mind protests this change, that's a perfect opportunity to practice acceptance."

"What if anxious thoughts keep me awake all night?" "That's common, and it's exactly what we'll work on together. Rather than trying to get rid of the thoughts, we'll practice changing your relationship with them. You don't need to win the battle with your thoughts to sleep better."

"What if I can't stay awake until 12:30 AM?" "We might adjust the schedule if needed, but let's try it first. That sleepiness you're feeling is actually working in your favor—it's consolidating your sleep."

Your Homework:

Behavioral:

• Continue your sleep diary with your new sleep window

• Follow the stimulus control rules we discussed

• Note any challenges, questions, or observations

Psychological (ACT):

• Notice what thoughts and feelings show up during the week (especially around sleep and fatigue)

• Practice the "noticing" exercise we did today when sleep anxiety appears

• Identify one value-based action you can take this week, regardless of how well you sleep

• Don't make any other changes—we want to see how these specific interventions work

What Happens Next: We'll meet again in one week (Session 2). We'll review your sleep data and also discuss what you noticed about your thoughts, your struggle with sleep, and how you engaged with your values. Each week, we'll fine-tune both your behavioral plan and your psychological flexibility skills together.

What to Expect After the First Session

Week 1: The Adjustment Period

Physically:

• You'll likely feel more tired during the day

• Falling asleep should become easier

• Your sleep may feel more "solid" even if it's shorter

• You might struggle to stay awake until your prescribed bedtime

Psychologically:

• Your mind will likely protest: "This is too hard," "You need more sleep," "This won't work"

• You may feel anxious or frustrated—this is normal and expected

• You'll have opportunities to practice acceptance and defusion

• You might notice how much energy you've been putting into fighting with your thoughts about sleep

Our Goals

Behavioral: By restricting your sleep opportunity, we're consolidating your fragmented sleep into solid, continuous sleep. Once you're sleeping well consistently during your sleep window (85%+ sleep efficiency), we'll gradually extend it back to a healthier duration.

Psychological: You'll develop a different relationship with sleep anxiety and unhelpful thoughts. Rather than needing to eliminate these experiences before you can sleep well or live well, you'll learn to have them present without them controlling your choices.

When to Reach Out Before Session 2

Please contact us if you experience:

• Excessive daytime sleepiness that affects your safety

• Significant mood changes or increased anxiety that feels unmanageable

• Physical health concerns

• You're completely unable to follow the protocol

• You have questions about the acceptance practices

Otherwise, we'll see you next week and review everything together.

Key Takeaways

✓ This approach combines behavioral sleep interventions with acceptance and psychological flexibility

✓ You'll leave with a personalized sleep schedule AND tools to work with sleep anxiety

✓ You'll start making changes immediately—both behavioral and psychological

✓ The first week is challenging, but you don't have to eliminate discomfort to make progress

✓ This is collaborative: your honest data and willingness to practice new skills help create better outcomes

✓ We're not just fixing sleep—we're helping you live a full life regardless of sleep quality

Final Thoughts

Unlike sleep medication that you passively take, CBT-I with ACT components requires active participation in two ways: making behavioral changes to strengthen your sleep system, and practicing new ways of relating to thoughts, feelings, and the struggle with sleep itself.

The first session sets you up with a clear plan and specific tools. While it may feel counterintuitive to spend less time in bed when you're exhausted, and counterintuitive to stop fighting your thoughts about sleep, this integrated approach has strong scientific support for long-term insomnia relief.

What to bring to your first session: Your completed sleep diary, an open mind, a willingness to try something different, and a curiosity about your own thoughts and behaviors. The skills you'll develop, both behavioral and psychological, can improve not just your sleep but your overall quality of life.

I look forward to working with you and helping you develop a healthier relationship with sleep.

Primary Keywords: first CBT-I session, cognitive behavioral therapy for insomnia, CBT-I with ACT, acceptance and commitment therapy for insomnia, what to expect CBT-I

Secondary Keywords: ACT for sleep anxiety, sleep restriction therapy, insomnia treatment, behavioral sleep medicine, psychological flexibility and sleep, acceptance-based insomnia treatment