Visual vs auditory bilateral stimulation in EMDR
Bilateral stimulation is the “dual attention” part of EMDR. While the client holds a memory in mind, they also attend to a stimulus that alternates left and right. Eye movements were the original form, and auditory tones and tactile taps came later. This guide compares the options and explains when to use which.
The three main types
- Visual (eye movements): the client follows a moving target with their eyes, usually horizontally. This is the form Francine Shapiro originally described.
- Auditory: alternating sounds in the left and right ear, through headphones.
- Tactile: alternating taps on the hands or knees. The taps can come from the therapist, from the client (the “butterfly hug”) or from handheld vibrating pulsers.
What the research says
The leading explanation for how bilateral stimulation works is the working memory account. Holding a memory in mind and doing a demanding task at the same time compete for limited working memory. As a result, the memory feels less vivid and less emotional when it is recalled later.
In a well-known lab study, van den Hout and colleagues (2011) found that eye movements taxed working memory more than beeps did, and reduced the vividness of memories more. A meta-analysis by Lee and Cuijpers (2013) also found that eye movements add to the effect of EMDR.
In practice, this means:
- Eye movements are a sensible default. They have the most research behind them.
- Auditory and tactile stimulation are widely used alternatives, but there is less evidence that they are equally effective.
- The right load differs between people. If the task is too easy, it may do little. If it is too demanding, the client can't hold on to the memory.
Side by side
| Visual | Auditory | Tactile | |
|---|---|---|---|
| Good for | Default choice; most research | Clients with eye strain, a small screen, or who prefer eyes closed | In-person work; self-soothing (butterfly hug) |
| Online | Works well on a laptop or larger screen | Works very well with headphones | Only if the client taps themselves |
| Watch out for | Eye fatigue, dry eyes, contact lenses, vision problems | Without headphones, both ears hear both sides | Hard to control the pace remotely |
When to switch or combine
- Eye strain or headaches, or the client can't follow the target smoothly: switch to sound.
- Processing gets stuck (the client keeps looping on the same image or feeling): change the direction, speed or type of stimulation. This is a standard intervention in EMDR practice.
- Combining visual and auditory: some therapists use both at once, for example to keep a client more present. There is little research comparing combinations, so treat it as a clinical choice and check SUD to see what works.
Speed and pattern
- Speed: reprocessing (desensitisation) usually uses faster sets. Resource work, such as installing a calm place, uses slower, shorter sets.
- Pattern: horizontal is the standard. Vertical, diagonal or figure-8 movements are useful variations, especially when processing stalls.
Setting it up in Remote EMDR
- Visual: choose speed, pattern (left-right, up-down, figure 8 or random), ball size, colour and background.
- Auditory: turn on sound and pick one of eight sounds: beep, soft tone, tap, wood block, chime, water drop, soft drum or swoosh. The sound pans left and right in sync with the ball. Ask your client to use headphones. You can also play the sound on your own screen; wear headphones so it doesn't leak into your video call.