Treating clients with long COVID

By Lisa R. Rhodes

November 2023

Alicia Dorn, a licensed clinical professional counselor in Maryland, has had clients come to see for help managing the emotional toll that comes with living with long COVID — a condition that the Centers for Disease Control and Prevention (CDC) defines as “a wide range of new, returning, or ongoing health problems that people experience after being infected with the virus that causes COVID-19.” The health issues that can develop from long COVID (such as chronic fatigue, memory difficulties, insomnia, and changes in smell or taste) can last weeks, months or years after the initial diagnosis, and although these symptoms typically occur in people who experienced a severe bout of COVID-19, anyone who has been infected can get long COVID.

As researchers work to discover the causes of long COVID and ways to prevent and treat the condition, counselors like Dorn are helping clients learn to manage the anxiety, depression and grief that results from experiencing this new chronic condition.

“I first help my clients by validating the emotional experience for them. They’re not wrong for feeling out of touch with themselves and angry that things aren’t getting better,” Dorn says. “Although we can’t change the diagnosis or how the symptoms arrived, we [can] focus on what’s within their control and help them find meaning there.”

Facing the unknown

Dakota Lawrence, a licensed professional counselor with a private practice in Tennessee, has been treating clients with long COVID for two years. He says the long-lasting symptoms cause many clients to worry whether they will ever get relief so their lives can return to “normal.”

“They also worry about getting sick again, either with COVID or another virus, further impacting their physical health,” Lawrence continues. And some clients who struggle with depression often express a sense of hopelessness about the future or worry they are a burden to their loved ones, he says.

Although none of Lawrence’s clients with long COVID currently meet the diagnostic criteria for posttraumatic stress disorder, some of them consider the sudden and long-lasting change in their health status to be traumatic.

Dorn says the uncertainty about long COVID can make it difficult for clients to rebuild their lives after they are diagnosed with it. “Clients with long COVID often do not recognize themselves in comparison to who they were before they got COVID,” she explains. “It’s harder sometimes to return to school or work successfully with long COVID because there is not much information out there on it, and many employers and schools don’t know how to best accommodate living with the condition.”

Long COVID in children

Like adults, children and adolescents are susceptible to experiencing long-term health symptoms after they have had COVID-19. The Kennedy Krieger Institute in Baltimore created the Pediatric Post-COVID-19 Rehabilitation Clinic to help children and adolescents who have recovered from COVID-19 but still need additional support for lingering neurological and physical issues related to the illness. The patients at this clinic range in age from 2 to 21 years and often present with abdominal pain, muscle or joint aches, nausea or vomiting, skin rashes, numbness in the extremities and recurrent fevers. They also struggle with anxiety and depression.

Ellen Henning, a psychologist who works as a consultant at the clinic, provides assessments and recommendations for each young person. “We take a functional rehabilitation approach to treatment. We make recommendations to help each patient reach the next level of functioning with the ultimate goal of helping them get ‘back to play,’ which can be school and extracurricular activities,” she explains. “Many times, we are concurrently addressing both physical symptom management and mental health concerns.”

Henning says long COVID affects each person at the clinic differently. “Some patients … are able to continue their typical routine but notice bothersome symptoms throughout the day,” she explains. “Other patients have difficulty attending school or have to stop major life activities, like extracurricular activities or sports, due to the symptoms.”

Young people who are living with ongoing pain, fatigue or other symptoms of discomfort may find commuting between classes or staying up late after school to complete homework assignments to be challenging, Dorn adds.

Grieving changes and losses   

Helping adults and youth deal with grief and loss is also a necessary part of managing the psychological pain of living with long COVID. Henning says patients who have not dealt with a major illness or health issue before getting long COVID feel a loss of typical daily functioning. For example, attending a full day of school can lead to energy “crashes” at the end of the day. Even spending time with friends can be exhausting, she adds.

“I allow space to discuss loss if the patient wishes to, but [I] am also respectful of boundaries if they do not,” Henning says. “By taking a functional rehab approach, we meet the patients where they are currently and help set gradual goals to help [with] increased functioning so [they will ideally] be able to get back to their previous functional level or at least be able to create a routine that is acceptable to the patient, along with strategies for symptom management.”

Lawrence has noticed that some of his clients with long COVID hyper-fixate on losses from the past or uncertainties about the future. He often uses mindfulness-based cognitive therapy to help them develop and implement a regular mindfulness practice. “Mindfulness is wonderful for increasing tolerance of uncertainty, regulating difficult emotions, tolerating difficult physical sensations and coping with anxious or depressive cognitions,” he says. And it’s “incredibly useful in orienting them to the present, which is often less painful or anxiety provoking.”

Dorn often uses acceptance and commitment therapy because it helps clients grieve the changes in their lives that they can’t control. With this approach, counselors can help clients learn skills, such as mindfulness, to regulate their nervous system and ways to treat themselves with compassion so they can learn to move forward.

People with long COVID are reminded daily about how the virus has taken a major toll on their body, and the condition often makes them feel helpless, Dorn notes. “Sometimes they only want a listening ear and someone to believe [their] experience without judgment or questions,” she says.

Clients sometimes struggle with feelings of bitterness or resentment about getting long COVID, Lawrence adds. Clients may feel they “did everything right” during the pandemic; they got vaccinated, practiced social distancing and wore a mask, yet they still got sick. And their experience with COVID is different than most of their peers who quickly recovered from the virus. These clients “struggle with a sense of injustice or unfairness,” Lawrence explains. He uses somatic and mindfulness-based strategies to help these clients to reflect on and manage their emotions. For example, he may ask a client, “Where do you feel that anger, sadness or grief in your body?” or “When you make space for the pain and allow it to be, how does it change?” He says that helping these clients realize that it is OK to feel upset is often the first step to moving past their distress.

No easy answers

Research about long COVID continues to emerge, and mental health professionals are also learning important lessons as they help clients to move forward in their journey with this chronic condition.

“When I first started working with patients with long COVID, I remember it feeling daunting because it was so new. There were no manuals for it,” Henning recalls. “We still have a lot to study and understand better, but anecdotally, we have found that [by] applying information from other populations (e.g., chronic pain, concussion, headache/migraine), we have been able to make great strides with this population.”

Dorn recommends that counselors consult with the client’s physician and any other health care providers to keep abreast of developments in the client’s health. She also says counselors should keep up with the latest research about long COVID. “Be aware of how viruses affect mental and physical health outcomes over time and encourage [clients] to follow up with their doctor if new symptoms arise,” she advises.

Clients may come to therapy asking about treatments and the long-term effects of long COVID — questions for which there are still no clear answers. “COVID is so new to the world. Long COVID is even newer,” Lawrence says. “Counselors must be comfortable sitting in the discomfort of the unknown” while still helping clients to process and accept the present.

Learn more about treating clients who are dealing with chronic health conditions in the November cover story, "Coping with the stress and uncertainty of chronic health conditions."

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.