Flare-Up Crisis Plan: A DBT-Informed Distress Tolerance Plan for Long COVID Flares
Long COVID · DBT · Emerging
A DBT-informed distress tolerance plan for symptom flares, built while the client is settled rather than mid-flare: a radical acceptance statement, early warning signs, a distress tolerance skills menu (STOP, gentle self-soothe, paced breathing, radical acceptance, adapted opposite action, pros and cons), a pushing-through-versus-pacing-through comparison, and an if-then plan with a support contact list.
Underlying mechanism: DBT Distress Tolerance: A Flare-Response Plan for Post-Exertional Symptom Exacerbation
What it helps with
- Removing the need to make good pacing decisions while at the client's most physiologically depleted.
- Reframing a flare as a physiological response, not a personal failure, through a rehearsed radical acceptance statement.
- Adapting classic DBT distress tolerance skills to genuinely low-exertion versions suitable for a Long COVID flare.
- Giving the client a concrete, pre-written comparison to reread when the urge to push through is strongest.
How clinicians use it
- Build the plan collaboratively with the client while they are feeling settled, never during an active flare.
- Cover each distress tolerance skill in session, checking suitability given the client's specific symptoms.
- Deliberately exclude classic cold-water or ice-based distress tolerance techniques without the client's medical team's sign-off, since some Long COVID symptoms (such as POTS) make sudden temperature change unsuitable.
- Keep the finished plan somewhere the client can genuinely find it in the moment they need it.
Clinical Implementation Guide
- Build the plan in Session 7, only while the client is regulated.
- Rehearse each distress tolerance skill in session, not just describe it.
- Confirm any temperature-based technique with the client's medical team before including it — or leave it out.
What the worksheet looks like
| Skill | How to Use It |
|---|---|
| STOP | Stop, step back, observe what is happening in the body, then choose rather than react |
| Self-soothe, gently | A comfort object, calming sound, soft blanket or scent, kept within reach |
| Paced breathing | Soothing-rhythm breathing, seated and unhurried |
| Radical acceptance | Repeat the acceptance statement without arguing with reality, as many times as needed |
| Opposite action, adapted | A small, gentle, values-aligned act instead of catastrophising or pushing through |
Clinical cautions
Classic cold-water or ice-based distress tolerance techniques are not included without medical sign-off given possible cardiovascular or autonomic symptoms. A flare is a physiological response, not a personal failure — frame the plan that way explicitly. This tool does not diagnose any condition and is not a substitute for individual face-to-face therapy or for emergency crisis support. Anyone in immediate distress should contact their local emergency service or crisis line.
References
- Linehan, M. M. (2014). DBT Skills Training Manual (2nd ed.). Guilford Press.
Part of
The Energy Envelope
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