Table 5 Exemplar of therapy protocol development: stage four (the rest phase)

Stage four: modification of the draft protocol

• We edited the rest phase section to ensure the guidance was concise and increase the use of bullet points

• We deconstructed key features of rest (analogies to physical health, tackling guilt), tips for explaining rest (using metaphors to describe the rationale, experience and nature of rest), techniques for preparing for rest (silent sitting) and warning points (e.g. potential misinterpretations of the meaning of rest) into boxes of different colour to aid ease of use

• We delineated the indicators of progress in a table relating each to a conceptual objective, means of assessment and verbatim examples of patients demonstrating the indicator as identified from a further review of the literature (personal communications: Minami, M)

• We developed a summary sheet for negotiating and engaging in the rest phase (guidelines, purposes and indicators of progress) to provide simplified and accessible key guidance to refer to during a therapy session

• The pre-treatment patient handout was made suitable to be provided to patients’ significant others when embarking on the rest phase, to provide additional support for patients during this phase and thus ease therapists’ concerns in this area

• As well as clarifying the instructions to provide to patients entering the rest phase, we clarified that all patients, regardless of presentation, should engage in as much rest as possible, in order to address confusion around assessing this and stress that, in the event of patients’ reluctance to engage in rest, reiterating the importance of and rationale for rest should be prioritised over missing this phase

• Thus, whilst acknowledging and addressing the challenges of the rest phase for both patients and therapists, we adhered to the literature which deems rest, or at least silent sitting, fundamental to Morita therapy [5, 7, 28]