The Standard Stress-Management Toolkit Has a Serious Gap

Review & Opinion. By Matthias Behrends.

That list may be a useful foundation. It should not be mistaken for a complete programme architecture.

Matthias Behrends

TL;DR

• What the workplace evidence says: Individual-level interventions generally produce small-to-moderate effects, with low or very low certainty for almost all assessed outcomes.
• What the evidence does not show: No direct workplace trial of the Baltrusch-taught, Reddemann-informed method was located. The closest controlled trauma-related study was small, bundled and did not establish benefit. Current evidence does not establish superiority over credible active practices.
• Our position: Standard toolkits often omit deliberate practice in accessing personally meaningful supportive emotional resources. Where that capability is a relevant aim, Guided Affective Imagination Techniques should be introduced and evaluated responsibly rather than omitted by habit.
• The practical boundary: Guided Affective Imagery should complement, not replace, organisational action. It requires participant choice, trained delivery, stopping and reorientation procedures, appropriate support and evaluation. It is not a universal prescription.

Breathing, grounding, mindfulness, breaks and peer support can all be useful. A serious programme also asks whether people are learning a structured, safe way to access supportive emotional resources.

When people ask how an organisation protects staff from stress, the answer is often a familiar list: self-care, deep breathing, grounding, mindfulness, scheduled breaks, work-life balance, peer support, team debriefings, supervision, Psychological First Aid and referral when distress persists.

It is a sensible list. Every item can have a place.

The problem begins when the list is treated as a complete programme.

These measures do different jobs:

• Breaks and work-life boundaries can reduce load.
• Breathing and grounding may help regulate arousal and restore orientation.
• Mindfulness may cultivate present-centred awareness.
• Peer support and supervision add relational and professional support.
• Referral connects a person with a more appropriate level of care.

They are not interchangeable, and they do not automatically add up to a complete repertoire for emotional stabilization.

Our position is that the standard toolkit has a serious design gap: it often contains ways to reduce strain or recover in the moment, but no structured method for identifying, accessing and reinforcing supportive inner experience. When that capacity is an appropriate aim, the gap should be closed by responsibly introducing and evaluating Guided Affective Imagination Techniques.

That is an opinion about programme architecture. It is not a claim that the research has already established one universally superior method.

Give the standard toolkit its due

No individual practice can repair chronic understaffing, unsafe conditions, an unmanageable workload, discrimination or harmful leadership. Those are organisational responsibilities. A guided exercise must never become an excuse for leaving structural causes untouched.

The World Health Organization guidelines on mental health at work reflect this wider view. They cover organisational interventions, manager and worker training, individual interventions, return to work and employment. For universal individual stress-management interventions, such as mindfulness-based or cognitive behavioural approaches, the recommendation is conditional and the evidence certainty is low. For workers already experiencing emotional distress, the corresponding recommendation is conditional and the evidence certainty is very low.

That does not make the familiar practices useless. Familiarity should not be confused with a settled evidence hierarchy.

The umbrella review commissioned for the guideline reached the same cautious position. Across 16 meta-analyses, individual-level workplace interventions generally produced small-to-moderate effects, with variation by intervention and population. The certainty of evidence was low or very low for almost all assessed outcomes. The results were promising, but the evidence was modest rather than decisive. (Miguel et al., 2023)

Psychological First Aid (PFA) also deserves precision. The World Health Organization describes it as humane, supportive and practical help for people affected by serious crisis events. It can include listening without pressure, helping with immediate needs, connecting people with information and social support, and protecting them from further harm.

The problem is not that Psychological First Aid is too weak. The problem is expecting a first-response framework to do the work of a structured emotional practice.

The missing design question

Much conventional stress management helps people lower pressure, interrupt escalation or recover enough to continue. That matters. It still leaves a further question:

Other practices may cultivate overlapping functions. The design question is whether this capability is taught deliberately, practised in a recognizable form and evaluated, rather than simply assumed to emerge from the rest of the toolkit.

Emotional Resource Work starts with material that is personally suitable today. This may include a memory, person, place, animal, activity, spiritual reference or symbolic image. The person attends to what is actually present now. No one has to produce a prescribed picture, emotion or intensity.

Guided Affective Imagery is the preferred name for the broader method family. Within Deep Emotional Work, we use Guided Affective Imagination Techniques (GAIT) as a local label for individual practices within it, not as a standardized research category. The Inner Safe Place is one such technique.

This is not simply an instruction to “think positively”. Responsible practice has an observable structure: selecting suitable material, attending to sensory and emotional detail, monitoring present response, pacing the exercise, preserving the right to change or stop, closing the experience and reorienting to the room.

The participant remains in control. They may keep their eyes open, choose a more superficial version, pause, change the image, stop or return to ordinary orientation.

A list of coping suggestions is not the same as practising that sequence.

The Baltrusch and Reddemann lineage

The Academy's approach to Guided Affective Imagery draws on the teaching, mentorship and later supervision Matthias Behrends received from Dr. med. Charlotte Baltrusch (ret.). Her practice and her book Seelenruhe im Sturm der Gefühle are important sources for the resource-oriented work described here.

Some Deep Emotional Work stabilization methods also draw partly on Luise Reddemann's Psychodynamic Imaginative Trauma Therapy, primarily through Baltrusch's teaching. Reddemann's work places compassion, resources and stabilization prominently within trauma-oriented practice.¹

The wider family also overlaps with Katathymes Bilderleben and what developed into Katathym Imaginative Psychotherapy. Deep Emotional Work is not Katathym Imaginative Psychotherapy and does not present the non-clinical group format discussed here as psychotherapy.

Method lineage, procedural expertise and outcome evidence answer different questions.

Start with the broadest located synthesis, not the most encouraging study

No direct workplace trial of the Baltrusch-taught, Reddemann-informed method was located. The nearest evidence therefore comes from different populations and practices. That makes it informative, but its transfer to workplace programmes is uncertain.

The broadest located synthesis for the closest stabilization purpose is not a meta-analysis of Guided Affective Imagery. It is a 2025 scoping review of 31 non-exposure stabilization studies with adult refugees. The interventions, formats, living conditions and results were highly heterogeneous. Most studies had a high overall risk of bias. Eighteen reported post-traumatic stress symptom reductions in at least one comparison or pre-post analysis, nine found no difference between interventions, two found a stabilization approach inferior to the comparison, and two found no pre-post symptom reduction. The authors concluded that a meta-analysis would be needed before effectiveness could be assessed with confidence. The guided-imagery study included in that review did not reduce post-traumatic stress symptoms. Population, setting and outcome transfer to a general staff programme is highly indirect. (Rzepka-Marot et al., 2025)

That review is relevant to stabilization as a broad category. It does not isolate the Inner Safe Place, the Baltrusch-taught procedure or the Deep Emotional Work adaptation.

A 2019 evidence map commissioned by the United States Department of Veterans Affairs identified 12 systematic reviews of generic guided-imagery interventions across 12 health conditions or populations. Definitions varied, findings were mixed outside a few indications and confidence in the evidence was generally low. This confirms that guided imagery is not an evidence-free field. It does not create a coherent evidence base for resource-oriented Guided Affective Imagery, the Inner Safe Place or Deep Emotional Work. (Freeman et al., 2019)

The evidence for the wider psychodynamic imagery family is also weaker than an impressive title can suggest. A frequently cited outcome paper by Sell, Möller and Taubner followed people receiving Guided Imagery Psychotherapy or hypnopsychotherapy in routine outpatient care. It began with 300 participants, had 97 assessed after 30 months, reported improvements across several outcomes and had no control group. It was a naturalistic effectiveness study, not a systematic review or a test of Guided Affective Imagery against another credible intervention. (Sell et al., 2018)

A qualitative study by Bauckhage and Sell interviewed 15 experienced psychodynamic therapists about when they use or avoid Guided Affective Imagery. It offers useful practice hypotheses about contraindications, modification, therapist presence and differential indication. The authors explicitly state that the study cannot establish whether those decisions improve outcomes. (Bauckhage and Sell, 2021)

This is exactly why evidence levels must remain separate. A manual can describe a method. Experienced practitioners can identify plausible safeguards. A naturalistic cohort can show what happened during routine care. None of these designs establishes comparative efficacy for the specific technique or programme under discussion.

What the closest controlled study found

The closest controlled trauma-related study located was a small randomized pilot with refugees living in temporary accommodation. Thirty-two people entered the study and 24 completed all assessments. The four-week intervention combined audio-based mindful breathing, a body scan and the Inner Safe Place. Only a few participants used the exercises regularly.

The study found no statistically significant intervention effect on post-traumatic stress, depression, anxiety, perceived stress or emotional state. (Rzepka et al., 2024)

That is a null or inconclusive result for a small, lightly used, bundled self-practice package. It is not evidence that facilitator-guided imagery works. It is also not a clean test showing that Guided Affective Imagery fails. Breathing, body attention, imagery, delivery format, low use and severe post-migration stress were all entangled.

The honest conclusion is narrower: the closest controlled study does not establish benefit, and it does not answer the comparison this opinion raises.

What the qualitative evidence adds

Earlier open and qualitative studies with refugees show why a simple positive claim would be irresponsible. The 2018 pilot and 2019 qualitative paper concern the same group programme and should not be counted as independent replications.

In a 2018 uncontrolled pilot, distress, anxiety and several immediate emotional ratings improved, but post-traumatic stress and depression did not show the same pattern. Without a control group, the specific contribution of imagery cannot be separated from breathing, body scan, group contact, expectancy or time. (Zehetmair et al., 2018)

In a 2019 qualitative study with 30 participants, people described relaxation and helpfulness, but also concentration difficulties, unwanted memories, tension, pain and difficulty practising without guidance. (Zehetmair et al., 2019)

A separate 2020 audio-practice study enrolled 42 participants at the introductory session. Nineteen attended the nine-day interview and 19 follow-up interviews were completed, with 27 people contributing across those interviews. The Inner Safe Place was often the most appreciated exercise among those assessed. Some participants could not follow the instruction to close their eyes because it felt uncomfortable. Others found it difficult to form an image, reported painful memories during practice, or felt burdened and sad when they returned from an imagined place of safety to an unsafe reality. Overcrowding, noise and lack of privacy impeded practice. (Zehetmair et al., 2020)

These are not minor implementation details. They are part of what the method can become in real life.

There is some direct comparison, but not the comparison we need

One small randomized laboratory study compared 20 minutes of recorded progressive muscle relaxation, deep breathing, generic guided imagery and a control condition in 60 healthy undergraduates. All three active practices increased self-reported relaxation compared with control. Guided imagery and progressive muscle relaxation also showed an immediate physiological relaxation trend. The study did not establish superiority among the active methods, long-term benefit, clinical effect or the value of resource-oriented Guided Affective Imagery. (Toussaint et al., 2021)

A 2026 randomized study compared a personalized virtual-reality safe place with eyes-closed safe-place imagery in 60 adults. Both conditions increased self-reported relaxation, with no significant difference between them. Because both groups first used imagery and there was no non-imagery control, the study informs delivery format more than the basic efficacy of the exercise. (Griessenauer et al., 2026)

These studies are useful. They also expose the central comparative hole.

The reviewed evidence does not tell us whether a Baltrusch-taught, Reddemann-informed Guided Affective Imagination Technique adds more value than equal-time breathing, grounding, progressive muscle relaxation, mindfulness or another credible active practice for a defined population and outcome. It does not tell us which people benefit most, how much facilitation matters, how effects persist, or what the opportunity cost is.

That missing comparison cuts both ways. It prevents a claim of superiority. It also prevents the familiar toolkit from being treated as the proven ceiling.

The comparison that would test the claim

The most informative next study is not another uncontrolled satisfaction survey. It is a matched active-comparator trial.

1. One group would receive a defined standard toolkit plus an equal-time active non-imagery practice, such as grounding or paced breathing.
2. The other would receive the same toolkit plus one exact resource-oriented imagery practice.
3. Time, facilitator contact, expectancy, group structure and follow-up would be matched as closely as possible.
4. The study would measure more than general distress. It would use independently validated outcomes for the proposed capability of accessing supportive emotional resources, alongside immediate regulation, retention, independent use and durability. It would also record unwanted memories, dissociation, worsening, non-completion, stopping, reorientation, facilitator fidelity and cost.

That design could answer the real question: whether the imagery component adds worthwhile benefit, for whom, under which conditions and at what burden. The current evidence does not establish whether adding it improves outcomes enough to justify that burden. Our position is that this question should be tested rather than left invisible.

Why is this method underrepresented?

There is no evidence of one deliberate exclusion, and no conspiracy is required. Our analysis is that several ordinary system forces reinforce one another.

1. The vocabulary is fragmented

Research may be indexed under Guided Affective Imagery, Guided Imagery Psychotherapy, Katathym Imaginative Psychotherapy, Psychodynamic Imaginative Trauma Therapy, safe-place imagery, resource imagery, guided visualization, imagery rescripting or relaxation. These are not interchangeable methods. The fragmented vocabulary makes the evidence harder to find and easier to over-combine.

2. The unit of practice rarely matches the unit of research

Imagery is often embedded inside a psychotherapy, stabilization package, group session or audio bundle. Outcome research then evaluates the package. The contribution of the imagery component remains unknown.

The reverse problem also occurs. A brief laboratory exercise may isolate generic imagery, but its healthy sample, immediate relaxation outcome and recorded delivery may have little resemblance to a supported practice with highly stressed participants.

3. Simple tools are easier to scale and study

A short breathing instruction, checklist or app is easier to standardize, translate, distribute and audit than a practice that depends on participant imagery, facilitator judgment, pacing, stop decisions and reorientation. That makes simpler interventions easier to include in procurement systems, staff programmes and large trials.

This is a plausible implementation explanation, not proof that institutions prefer weak methods.

4. Guided imagery sits across professional boundaries

Light resource-oriented imagery can appear suitable for self-care or non-clinical groups. More open, emotionally evocative imagery belongs closer to psychotherapy and requires greater competence. Programmes may avoid the whole family rather than define where a bounded version can be used safely.

That caution is understandable. The answer is clearer indication and governance, not pretending that every script is harmless.

5. Important practice traditions are not always visible to evidence systems

Important parts of the method history sit in German-language books, training traditions and professional communities. Practice knowledge may remain tacit or travel through teaching and supervision rather than trials, manuals and English-language meta-analyses. That can preserve valuable craft knowledge, but it also limits independent scrutiny and guideline visibility.

6. Guideline systems follow the evidence that can be aggregated

Guidelines usually depend on systematic reviews, comparable interventions and outcomes that can be graded. When a method family has few modern randomized trials, shifting names and multicomponent delivery, it is unlikely to appear as a distinct recommendation.

Absence from a guideline is not evidence of ineffectiveness. It is also not a reason to bypass the evidence problem.

The strongest objection to our position

The strongest objection is straightforward: if direct evidence is weak, comparisons are sparse and the method can evoke unwanted material, perhaps it is underrepresented for good reason.

That objection should change how Guided Affective Imagery is introduced. It should rule out universal prescriptions, casual scripts and claims of proven superiority. It should require trained delivery, participant agency, context-specific suitability, stopping options, reorientation, support and evaluation.

It should not settle the programme-design question in advance.

The standard toolkit also contains conditional recommendations, heterogeneous packages and limited long-term or adverse-effect evidence. The fair response is to compare credible alternatives under equivalent conditions, not to demand perfect evidence from an unfamiliar method while treating the default menu as self-validating.

Closing the gap responsibly

Our conclusion is deliberately stronger than “more research is needed”.

Where a programme claims to build emotional stabilization, it should not stop at load reduction, immediate regulation, social support and referral. It should include, or explicitly evaluate, a structured way to access supportive emotional resources. In our view, Baltrusch-taught and Reddemann-informed Guided Affective Imagery belongs in that design conversation.

This does not mean adding the Inner Safe Place to every workshop. For an unfamiliar group, limited facilitator preparation or uncertain support arrangements, a shorter grounding or resource exercise may be the responsible choice. For some people, imagery may be unsuitable. Clinical needs require appropriately qualified care.

It does mean that omission should become a conscious decision, not an inherited habit.

The money metaphor is an opportunity-cost claim, not an economic finding. No located study shows a financial return from adding Guided Affective Imagery. The potential loss is the time, training and budget spent on a programme that never evaluates whether this proposed capability could have served its participants better.

The kit is not proof that the format is effective. It is an inspectable proposal for moving from a loose recommendation to a teachable, bounded and evaluable implementation.

Breathing, grounding, mindfulness, breaks, peer support, supervision and Psychological First Aid can all keep their place.

That list may be a useful foundation. It should not be mistaken for a complete programme architecture.

Evidence and scope note

This is a focused educational Review & Opinion article, not a systematic review, clinical guideline, diagnosis or treatment recommendation. The search and source checks were extensive but not exhaustive. Guided Affective Imagery is not universally indicated. The exact Deep Emotional Work procedure and the Deep Emotional Stabilization Groups format have not been established as effective or superior to credible alternatives. Clinical decisions require appropriately qualified professionals and context-specific assessment.

Selected sources

1. World Health Organization. Guidelines on Mental Health at Work (2022).
2. Miguel, C., et al. Universal, selective and indicated interventions for supporting mental health at the workplace: An umbrella review of meta-analyses (2023).
3. World Health Organization, War Trauma Foundation, and World Vision International. Psychological First Aid: Guide for Field Workers (2011).
4. Freeman, M., et al. Guided Imagery, Biofeedback, and Hypnosis: A Map of the Evidence (2019).
5. Rzepka-Marot, I., et al. Stabilization interventions in the treatment of traumatized refugees: A scoping review (2025).
6. Rzepka, I., et al. Implementing a stabilizing intervention for traumatized refugees in temporary accommodations in South-West Germany: A randomized controlled pilot trial (2024).
7. Zehetmair, C., et al. Psychotherapeutic group intervention for traumatized male refugees using imaginative stabilization techniques: A pilot study in a German reception center (2018).
8. Zehetmair, C., et al. Stabilizing techniques and guided imagery for traumatized male refugees in a German state registration and reception center: A qualitative study (2019).
9. Zehetmair, C., et al. Self-practice of stabilizing and guided imagery techniques for traumatized refugees via digital audio files: Qualitative study (2020).
10. Toussaint, L., et al. Effectiveness of progressive muscle relaxation, deep breathing, and guided imagery in promoting psychological and physiological states of relaxation (2021).
11. Griessenauer, F., Pfannerstill, F., and Probst, T. AI-generated personalized visualization of the safe place in virtual reality vs traditional safe place imagery: Randomized controlled trial (2026).
12. Sell, C., Möller, H., and Taubner, S. Effectiveness of integrative imagery- and trance-based psychodynamic therapies: Guided imagery psychotherapy and hypnopsychotherapy (2018).
13. Bauckhage, J., and Sell, C. When and for whom do psychodynamic therapists use guided imagery? Explicating practitioners' tacit knowledge (2021).
14. Holmes, E. A., and Mathews, A. Mental imagery in emotion and emotional disorders (2010).
15. Baltrusch, C. Seelenruhe im Sturm der Gefühle (2021). Method-lineage and practice source, not independent outcome evidence.
16. Reddemann, L. Psychodynamisch Imaginative Traumatherapie: PITT, Das Manual. Ein mitgefühls- und ressourcenorientierter Ansatz in der Psychotraumatologie. 11th ed. Klett-Cotta (2021). Method and lineage source, not independent outcome evidence for Deep Emotional Work.

Lineage note

Luise Reddemann is cited here as a method-lineage source. She has not endorsed Deep Emotional Work or its adaptations. ↩︎