By Amy Barradell, University Hospitals of Leicester NHS Trust

If I were to say to you, Long-Covid, what would that mean to you?

A sub-set of people that contracted Coronavirus Disease 2019 (COVID-19), have continued to experience debilitating symptoms for more than 4 weeks following their acute infection. They commonly report both physical (e.g., breathlessness, fatigue) and psychological (e.g., anxiety, cognitive impairments) symptoms. Those experiencing these symptoms call it ‘Long-COVID’.

In my experience…

Working in a Long-COVID clinic has shown me that people struggle to accept their new symptoms (and the consequences of their symptoms) which puts a road block in the way of their self-management strategies. They focus on what they could do before ‘Long-COVID’ and how their life has changed for the worse since their diagnosis.  This indicates experiential avoidance (i.e., an attempt or desire to suppress unwanted internal experiences, such as emotions, thoughts, memories and bodily sensations) and a tendency for people to focus upon the form of symptoms instead of the function of symptoms (i.e., the body’s indicator to change one’s behaviour). It shows people are not open to these experiences and shy away from living in the present moment.

Furthermore, more than 25% of people who were hospitalised with COVID-19 have ongoing symptoms of depression 6 months after they have been discharged. As depression is linked to activity avoidance (i.e., choosing not to enter into a situation), it shows that people may not be engaging in valued actions.

The role of psychological flexibility in Long-COVID

Psychological flexibility is the mechanism of action for Acceptance and Commitment Therapy (ACT). It involves three pillars of the therapy:  (1) encouraging openness to experience, (2) having awareness of the present moment, and (3) engaging in valued actions. As described above these pillars appear to be imbalanced in people living with Long-COVID and so addressing them is important. ACT can therefore be used to help people change the relationship they have with their distress (i.e., reduce their experiential avoidance), build their acceptance of a new ‘normal’ (i.e., increase their awareness of the present moment) and motivate and empower them to make behavioural changes that are important to them (i.e. engage in valued actions). ACT in Long-COVID is already making progress, participants reported improved wellbeing, still experiencing COVID-related distress, but felt more able to cope with general psychological distress (such as anxiety).

Using ACT in the Long-COVID clinic: Introducing Jo

When I first met with Jo, they were experiencing regular symptom relapses. To maintain anonymity, Jo is a representation of a range of people who I have worked with in the Long-COVID clinic. Their most debilitating symptoms were breathlessness and fatigue which made daily activities very difficult. Jo was afraid of the relapses and made conscious efforts to avoid anything which would aggravate them (i.e., experiential avoidance, avoidance of the present moment). They spent little time on activities that gave them joy and meaning (i.e., avoidance of engaging in valued actions).

In our sessions together, we addressed each of the components of the ACT:

• Cognitive defusion, (i.e., noticing thoughts rather than getting caught up or buying into the thought and letting thoughts come and go rather than holding onto the thought) – to differentiate between thoughts/feelings and actual experiences (they are not necessarily the same!)
• Contact with the present moment – to adopt mindfulness strategies to ground them in their sensory experiences (i.e., present moment awareness).
• Explore values – to identify areas of their life which were most important to them.
• Take committed action – to set behavioural goals which aligned with their values.
• Self as context – to make contact with their ‘observing self’ and see their thoughts from a distance (i.e., a more accurate perspective) without becoming tangled up with them.
• Acceptance – to stop struggling with what is out of their control and re-focus on what is within their control (i.e., their behaviours).

In session two, Jo set herself two behaviour goals aligned to their core values. I used motivational interviewing techniques to support them in developing a SMART goal and if-then plans to foresee any concerns they may have.

Four weeks later they took great pride in telling me they’d met their goals. They’d also embedded several mindfulness activities into their day to day life (i.e., the leaves on a stream exercise, a gratitude diary, and 5 minutes of yoga). They’d experienced increased psychological flexibility (i.e., when a person is psychologically flexible, they will make decisions based on their values and long-standing beliefs rather than the immediate short-term emotions they’re experiencing), reduced symptoms of depression, and elevated confidence in self-managing outside of the sessions.

Recommendations for healthcare professionals supporting people with Long-COVID:

1. Don’t forget the importance of a biopsychosocial assessment – truly understanding the complexity of a person’s Long-COVID symptoms and the consequences of these symptoms is key to identifying patient-centred management strategies. Don’t be afraid to ask questions such as: “What is the symptom you struggle with the most?”; “What is the impact of your breathlessness/fatigue/brain fog… on your life?”; “What thoughts run through your head when you experience breathlessness/fatigue/brain fog”?
2. Consider measuring psychological flexibility – the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT) is a quick and validated measure of self-reported psychological flexibility. You can quickly identify which of the pillars of psychological flexibility need increasing and plan your management strategy accordingly (i.e., if they are avoiding engaging in valued actions explore what their core values are and help them set a SMART goal).
3. Provide/signpost to mindfulness exercises – mindfulness exercises can be extremely powerful in ACT to help people build their pillars of psychological flexibility. Depending on what someone presents with you can offer an appropriate exercise, here are some ideas:
   1. Cognitive defusion – Leaves on a stream
   2. Contact with the present moment – Notice 5 things
   3. Self as context – The Stageshow metaphor
4. Keep up to date with the best practice guidance – As with many health conditions, the Long-COVID evidence-base is constantly evolving so make sure to stay abreast of the literature and clinical practice guidelines. The ACT evidence is growing!
5. Make sure you are looked after too – Working with people who have Long-Covid can be challenging so make sure to have regular supervision or ‘debriefs’ with someone you trust. Not only is this helpful in discussing specific patients but it also helps you to stay psychologically well in your practice.