Long COVID Therapy Pathway: Choosing Between Steady Ground and The Energy Envelope

Long COVID · Practice-informed · Practice-informed

Two protocols in this library are written for adults with Long COVID, and they answer different questions. Steady Ground asks what psychological therapy can add for distress, worry about symptoms, low mood, poor sleep and loss of valued activity, without ever prescribing activity. The Energy Envelope asks how a client spends their energy, especially when exertion is followed by a delayed worsening. This page helps a clinician choose, and shows how to use both without repeating content. About a quarter of adults with post-COVID condition report post-exertional malaise (pooled prevalence 25%, 95% CI 17% to 36%, low certainty), so a pacing protocol suits a subgroup and not everyone. Pacing rests on one uncontrolled cohort of 31 people and studies with a high risk of bias, with no randomised trial in Long COVID, and trials of psychological therapy are early and mixed. Neither protocol is a treatment for Long COVID.

Underlying mechanism: Stratified Psychological Care Pathway for Post-COVID-19 Condition: Presentation-Led Choice Between a Distress and Appraisal Protocol and a Pacing Protocol

What it helps with

  • Choosing a starting point from one screening question instead of guessing.
  • Avoiding a pacing protocol for the majority of clients who do not have post-exertional worsening.
  • Putting energy first for clients whose boom-bust pattern would undermine every other skill.
  • Using both protocols in a defined order, skipping the sessions that repeat.
  • Keeping the worksheets from the two toolkits apart when a client holds both.

How clinicians use it

  • At the first session of either protocol, ask: does exertion of any kind, including thinking and emotion, bring a worsening a day or two later?
  • If there is no delayed worsening and distress, worry about symptoms, low mood or poor sleep dominate, start Steady Ground alone.
  • If there is delayed worsening with an unstable boom-bust pattern, start The Energy Envelope.
  • If there is delayed worsening and marked distress or threat appraisals, complete The Energy Envelope first, then run Steady Ground sessions 1, 2, 5 and 8 with the Energy Envelope flare plan as the set-back plan.
  • If you are not sure, or the medical team is already setting pacing parameters, start Steady Ground. It screens at Session 1 and never asks the client to do more. Add The Energy Envelope if boom-bust emerges.
  • Take the Steady Ground measure set before the first phase and again at the start and end of the second, and label worksheets by toolkit (EE W3, SG W3). The sequence is a practice suggestion and has not been tested.

Clinical Implementation Guide

  1. Ask the screening question at the first session.
  2. Start where the presentation points, and review after a few sessions.
  3. Use the sequence for both protocols and skip the repeated sessions.

What the worksheet looks like

Long COVID Therapy Pathway: Steady Ground or The Energy Envelope? — worked example
PresentationWhere to startWhy
Distress or poor sleep, no delayed worseningSteady GroundBroad psychological protocol; never prescribes activity
Delayed worsening and boom-bustThe Energy EnvelopeStabilise energy before other skills
Delayed worsening and marked distressThe Energy Envelope, then Steady Ground sessions 1, 2, 5 and 8Avoid repeating breathing, sleep, compassion and values work
UnsureSteady GroundScreens at Session 1 and adds no activity demands

Clinical cautions

Not a diagnostic or risk-assessment tool. Both protocols assume that the client has been medically assessed and stays under medical care. Refer urgently for chest pain, fainting, new neurological signs or severe breathlessness at rest. Never use either protocol to increase a client's activity against their symptoms. Screen for low mood, hopelessness and suicidal thoughts and follow local risk procedures. Do not promise recovery, reduced fatigue or changes in heart rate variability. This page does not 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

  1. Godfrey, B., Shardha, J., Witton, S., Bodey, R., Tarrant, R., Greenwood, D. C., & Sivan, M. (2025). A personalised pacing and active rest rehabilitation programme for post-exertional symptom exacerbation and health status in Long COVID (PACELOC): A prospective cohort study. Journal of Clinical Medicine, 14(1), 97. https://doi.org/10.3390/jcm14010097.
  2. National Institute for Health and Care Excellence. (2020). COVID-19 rapid guideline: Managing the long-term effects of COVID-19 (NICE guideline NG188). Updated 2024. https://www.nice.org.uk/guidance/ng188.
  3. National Institute for Health and Care Excellence. (2021). Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: Diagnosis and management (NICE guideline NG206). https://www.nice.org.uk/guidance/ng206.
  4. Negm, A., Stolz, M., & Krauth, C. (2026). Effectiveness of physical, psychological, and alternative interventions for post-COVID-19 condition: A systematic review. Journal of Rehabilitation Medicine, 58, jrm46279. https://doi.org/10.2340/jrm.v58.46279.
  5. Pouliopoulou, D. V., Hawthorne, M., MacDermid, J. C., Billias, N., Miller, E., Quinn, K., Décary, S., Razak, F. A., Cheung, A., Galiatsatos, P., Pereira, T. V., & Bobos, P. (2025). Prevalence and impact of postexertional malaise on recovery in adults with post-COVID-19 condition: A systematic review with meta-analysis. Archives of Physical Medicine and Rehabilitation, 106(8), 1267-1278. https://doi.org/10.1016/j.apmr.2025.01.471.
  6. Rometsch, C., Colditz, K., Elgner, M., Allwang, C., Zipfel, S., Junne, F., & Binneböse, M. (2026). Efficacy of a psychotherapeutic group intervention for patients with post-COVID-19 condition: A randomized controlled trial (PsyLoCo study). BMC Psychology, 14(1), 1088. https://doi.org/10.1186/s40359-026-05149-2.
  7. Sauer, K. S., Bräscher, A.-K., Germer, S., Huth, D., Kolb, J., Mütze, K., & Witthöft, M. (2026). Cognitive-behavioral therapy for post COVID-19 condition: A pilot randomized controlled trial. Journal of Psychosomatic Research, 210, 112920. https://doi.org/10.1016/j.jpsychores.2026.112920.
  8. Soriano, J. B., Murthy, S., Marshall, J. C., Relan, P., Diaz, J. V., & WHO Clinical Case Definition Working Group on Post-COVID-19 Condition. (2022). A clinical case definition of post-COVID-19 condition by a Delphi consensus. The Lancet Infectious Diseases, 22(4), e102-e107. https://doi.org/10.1016/S1473-3099(21)00703-9.

Copyright and use in research

© 2026 Dr Richard Pomfret and Third Wave Therapy Tools. May be used in research with the author and site cited. Version 1.0, approved 21 October 2026, revised as the evidence develops.

Suggested citation (APA 7th edition): Pomfret, R. (2026). Long COVID therapy pathway: Choosing between Steady Ground and The Energy Envelope (Version 1.0) [Clinical guide]. Third Wave Therapy Tools. https://thirdwavetherapytools.com/resources/long-covid-therapy-pathway

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