Clinical Observations of Online EMDR: The Imperative for Research on Bilateral Stimulation Techniques

Dear Editor,

In clinical practice, online eye movement desensitization and reprocessing (EMDR) is widely regarded as an efficient and effective treatment option. ¹ An emerging body of literature supports its effectiveness, and its acceptability is growing among clinicians and clients. The transition to online EMDR was sudden because of COVID-19 lockdowns. However, due to the ease and cost-effectiveness of delivering EMDR online, many clinicians have continued to provide EMDR online long after the lockdown restrictions were lifted. ²

Bilateral stimulation (BLS) is a crucial component of EMDR. Studies have shown that providing BLS increases the effectiveness of EMDR, ³ aids in memory recollection, and increases a feeling of relaxation. ⁴ However, the types of BLS provided in online EMDR are diverse and vary significantly across clinicians and clients. The EMDR Europe association suggests using butterfly taps as BLS as they also promote grounding. ⁵ Clinicians use sticky notes on the wall behind the computer or laptop screen, and the client looks from one sticky note to the other. The clinician directs the speed and the duration of the sets of BLS. Knee taps, auditory beeps, and online BLS provided via BLS software or YouTube videos are also popular among clinicians. Several local EMDR associations have provided training and guidelines on providing EMDR online and suggest trying different types of BLS to determine what works best for the client. ⁶

Some clinicians use subscription-based software for online BLS as clients sometimes see ads or do not maximize their screens when free software or YouTube videos are used. These practical and technical issues happen on client screens, which the clinicians can see and know only if the client provides explicit feedback. BLS software tends to be expensive and requires clients to familiarize themselves with the new software. It additionally needs clients to log in from a computer for an optimal experience. Many clients log in to sessions with phones or small tablets, and the BLS offered on the screen does not cover the field of vision. While these variations in treatment are acceptable in clinical practice, in research, inadequate BLS, ads on screens, or switching to tactile BLS or sticky notes during treatment may weaken treatment fidelity. This variation is not merely a technical concern but a contributing variable, as the type of BLS used could impact the therapy’s efficacy. This specific data is not consistently recorded and poses a concern in online EMDR research. Not enough studies have examined the effectiveness of the different types of BLS for online EMDR, and there is little or no homogeneity among clinicians.

In conclusion, while online BLS is effective, there are several challenges posed by client and clinician technology. In online EMDR research, controlling the type, pace, and duration of the administered BLS is crucial. Additionally, it is essential to conduct comparisons of efficacy between various types of BLS as well as to compare clinician-administered versus self-administered BLS. Online EMDR is at a critical juncture where focused research using robust methodologies is essential. Such research would not only contribute to the optimization of online EMDR but also ensure that clients receive the highest standard of care, regardless of the medium of delivery.