Steady Ground: A Therapist Guide to a Stepped, Measurement-Led Psychological Protocol for Long COVID

Long COVID · Practice-informed · Practice-informed

A stepped, measurement-led protocol for adults living with Long COVID, built from five recent studies and an evidence update, and delivered alongside medical care. It targets distress, illness-threat appraisals, sleep and values-led living inside the limits set by the medical team, and it never prescribes activity increases. Eight individual sessions and an optional booster run from a CBT-informed shared map through a two-part model of the body and the alarm, nose-low-slow breathing, a sleep and wind-down diary with no sleep restriction and loosening symptom-watching, then compassion-focused work before ACT values work. The evidence is early: a pilot trial and mixed pooled analyses support psychological care for distress and fatigue, while two randomised trials, one of a group programme and one of a tailored individual programme, found no advantage over their comparison. No trial has tested this bundle, so the overall rating is practice-based, the lowest tier present, and each approach is rated honestly for this population. It is the broader of two Long COVID protocols: a section helps the clinician choose between it and The Energy Envelope, the specialist companion for post-exertional worsening, or run both in sequence.

Underlying mechanism: Stepped, Measurement-Led Psychological Protocol for Long COVID: CBT-Informed Formulation, Breathwork, Sleep Wind-Down, CFT and ACT

What it helps with

  • Giving clinicians an honest map of a young field, with each approach rated and each extrapolation named, rather than a promise.
  • Working on distress, illness-threat appraisals, low mood and sleep that sit on top of the illness, without treating symptoms as imagined.
  • Individual formulation and a spread of outcome measures, so that function and not only symptom totals can be followed.
  • Settling the body with a gentle breathing skill that is first-line and low risk, with a resonance step that is optional and later.
  • Living well inside limits: small, energy-sized actions with rest planned in, and a set-back plan for flares and low patches.
  • Choosing between this protocol and The Energy Envelope with a screening question and a decision table, and sequencing both without repeating content.

How clinicians use it

  • Confirm medical assessment first, screen for red flags and ask about post-exertional worsening. Say clearly that nothing here asks the client to push through.
  • Take baseline measures at Session 1 and repeat them at Session 8 and the booster. Note the dominant symptom profile and baseline severity to decide where to spend sessions.
  • Run the eight sessions in order, and keep the CFT session (6) before the ACT session (7) by design. The order is clinical judgement and has not been tested.
  • Teach nose-low-slow breathing first and offer resonance breathing, about 4 seconds in and 6 out, only later and only as an option.
  • Use no sleep restriction. Treat any session as complete once its main aim is met, and repeat the previous session if a week is lost to a flare.
  • Use the Section 2 decision table at Session 1: with no delayed worsening after exertion start here, with an unstable boom-bust pattern start with The Energy Envelope.

Clinical Implementation Guide

  1. Confirm medical assessment, screen for red flags and post-exertional worsening, and use the decision table to choose between this protocol and The Energy Envelope.
  2. Keep the compassion-focused session (6) before the ACT values session (7), and never prescribe activity increases.
  3. Repeat the same measures at Session 8 and the booster, and say honestly if nothing has moved.

What the worksheet looks like

Therapist Guide: Steady Ground — worked example
SessionFocusWorksheet(s)
1Assessment and shared map: screen for safety and post-exertional symptoms, take baseline measures, build a formulationW1
2Two parts: the body and the alarmW2
3Settling the body with nose-low-slow breathingW3
4Sleep and wind-down, with no sleep restrictionW4
5Loosening the grip of symptom-watching, with optional resonance breathingW2, W3
6A kind coach for a hard illness (CFT), before the ACT session on purposeW5
7Values inside my limits (ACT)W6
8Review and set-back plan: repeat measures and plan for flaresW1 to W6
BoosterFour to six weeks later: repeat measures and troubleshoot (optional)Any

Clinical cautions

This protocol is not graded exercise and must never be used to push a client into increasing activity. Do not start without a medical assessment, and refer urgently for chest pain, fainting, new neurological signs, severe breathlessness at rest or any sign of an acute medical problem. Never use breath holds, forced breathing or deep over-breathing, and take extra care with asthma, COPD, dysautonomia, panic or a trauma history in which attention to breathing is distressing. No sleep restriction, bed-time curfews or lie-in bans. Screen for suicidal thoughts at the start and when scores rise. Do not promise recovery, reduced fatigue or improved heart rate variability. This tool does not diagnose any condition and is not a substitute for individual face-to-face therapy or for emergency crisis support. Professional judgement and supervision apply throughout.

References

  1. A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36. https://doi.org/10.1159/000365764.
  2. Aboagye, N. Y., Baker, M. R., Baker, K., & Del Din, S. (2026). Bidirectional associations between autonomic function, sleep quality, and daily fatigue and energy symptoms in long COVID: Longitudinal digital health study. JMIR Cardio, 10, e99630. https://doi.org/10.2196/99630.
  3. Cabello Fernandez, C., Didone, V., Lesoinne, A., Slama, H., Fery, P., Rousseau, A.-F., Moutschen, M., Dupuis, G., Delrue, G., Demoulin, V., Goin, J., Della Libera, C., Collette, F., & Willems, S. (2025). Cognitive and affective psychoeducation for Long COVID: A randomized controlled trial. Brain Communications, 7(6), fcaf447. https://doi.org/10.1093/braincomms/fcaf447.
  4. Carvalho, N., Kalfas, M., Jolley, C., Rafferty, G. F., Pearson, O., Emsley, R., Metcalfe, A. J., Barrett, B., Brewin, D., Felton, L., Khan, T., Hart, N., Duncan, E. L., Nicholson, T., Witard, O. C., Evans, R. A., Beckwith, C., & Chalder, T. (2026). Randomised controlled trial assessing the efficacy of balance acceptance and commitment therapy (ACT) for post-COVID syndrome: A study protocol. BMJ Open, 16(8), e122602. https://doi.org/10.1136/bmjopen-2026-122602. Trial protocol only, no results yet.
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  7. Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41. https://doi.org/10.1111/bjc.12043.
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  9. Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. https://doi.org/10.3389/fpsyg.2014.00756.
  10. Minjoz, S., Jeanne, R., Pellissier, S., & Hot, P. (2026). Psychophysiological effects of heart rate variability biofeedback versus sham biofeedback: A randomized controlled trial. Biological Psychology, 206, 109254. https://doi.org/10.1016/j.biopsycho.2026.109254.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. Sumińska, S., Rynkiewicz, A., & Szulczewski, M. (2026). Resonance frequency versus fixed 0.1 Hz breathing in HRV biofeedback: A four-week randomized comparison. Scientific Reports, 16(1), 22630. https://doi.org/10.1038/s41598-026-53333-6.
  18. Thomas, B., Pattinson, R., Cunningham, G., Bundy, C., & Davies, J. L. (2026). Somatosensory processing in long COVID fatigue and its relations with physiological and psychological factors. Experimental Physiology. Advance online publication. https://doi.org/10.1113/EP093600.
  19. Wilson, M., Michalsen, H., Anke, A., Pedersen, S. G., Espinasse, M., Langeland, N., Cox, R. J., Aukrust, P., Dahl, T. B., Sandvig, A., & Wilhelmsen, M. (2026). Effectiveness of tailored individual follow-up vs. standard one-day group course on health-related quality of life in patients with post COVID-19 condition: A randomized controlled trial. Frontiers in Rehabilitation Sciences, 7, 1927300. https://doi.org/10.3389/fresc.2026.1927300.

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 1.1, approved 21 October 2026, revised as the evidence develops.

Suggested citation (APA 7th edition): Pomfret, R. (2026). Steady Ground: A stepped, measurement-led psychological protocol for adults with Long COVID (Version 1.1) [Therapist guide and worksheets]. Third Wave Therapy Tools. https://thirdwavetherapytools.com/

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