Logopedics Phoniatrics Vocology

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Verbal Instruction Model (VIM) in voice therapy

Ann-Christine Ohlsson

To cite this article: Ann-Christine Ohlsson (2016) Verbal Instruction Model (VIM) in voice therapy,
Logopedics Phoniatrics Vocology, 41:1, 41-46, DOI: 10.3109/14015439.2014.949303

To link to this article: https://doi.org/10.3109/14015439.2014.949303

Published online: 08 Aug 2014.

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Verbal Instruction Model (VIM) in voice therapy

Ann-Christine Ohlsson

Occupational and Environmental Medicine, Institute of Medicine, University of Gothenburg, SE-405 30 Gothenburg,
Sweden

Abstract
The stumbling-block in voice therapy is the patient’s generalization of the new voice behavior in everyday life. Traditionally
voice therapy is based on demonstration, i.e. during the therapy session the speech therapist uses her own voice and body
to demonstrate for the patient how to produce voice in different training tasks. During the last decade a new voice therapy
strategy, the Verbal Instruction Model (VIM), has been developed by the author. In VIM the speech therapist uses verbal
instructions instead of demonstration when conveying the training tasks to the patient. Our clinical experience has shown
that VIM seems to help getting over the stumbling-block of generalization. However, evidence for VIM voice therapy out-
come remains to be scientifically studied and confirmed. The purpose of this paper is to describe VIM voice therapy and
to discuss therapy strategies in the light of motor learning principles.

Key words: Motor learning, therapy strategies, transfer-to-speech, Verbal Instruction Model (VIM), voice therapy

Introduction
Voice therapy in speech clinics implies that the speech
therapist helps the patient to change vocal behavior
to achieve an improved voice function and thereby
quality of life. The goal is to provide the patient with
long-term sustainable strategies to manage her/his
voice in relation to the demands of everyday life. Our
theory is that the training effects shown in the therapy
room will be generalized into the patient’s everyday
life. However, speech therapists find this generaliza-
tion aspect to be the great stumbling-block in voice
therapy. How come that transfer-to-speech in every-
day life of the ‘new’ vocal behavior is a problem? Voice
is one aspect of the individual’s motor behavior, in
the same way as e.g. a person’s way of walking, use
of gestures, etc. The difficulty of generalization of the
‘new’ voice behavior is likely to be explained by the
fact that voice function is an integrated part of the
patient’s communicative behavior. Thus, the patient
has to substitute an old voice behavior with a new
but keeping his ‘old’ personal everyday communica-
tion style. In this process the patient has to rely on
intrinsic and implicit relearning from voice therapy.
During communication, the patient also has to be
aware of and use techniques to replace the old voice
behavior with the new behavior.
Some decades ago voice patients in Sweden could
receive voice rehabilitation during much longer peri-
ods than is common today; it was not uncommon
with about 20 voice therapy sessions. Under those
circumstances it was possible for the patient to suc-
ceed with the generalization process during the treat-
ment period. Nowadays the situation is different.
During the past 50 years of clinical voice therapy in
Sweden, changes have been made in the health soci-
ety and economics which demand fewer therapy ses-
sions and with fast treatment results. The patient
must learn strategies for generalizing his voice from
the therapy to everyday communication more or less
on his own. At the same time database reviews on
voice intervention show improved voice performance
in comparisons with no treatment (1,2). However,
most treatment studies present short-term results;
long-term results including the generalization pro-
cess of relearning are less common. Also, the authors
point out that few of the reviewed studies meet the
highest standards of evidence and that many issues
on effects of voice therapy are still to be answered.

Correspondence: Ann-Christine Ohlsson, Klareborgsgatan 34A, SE-414 67 Gothenburg, Sweden. E-mail: ann-christine.ohlsson@medfak.gu.se

(Received 30 May 2014; accepted 11 July 2014)

ISSN 1401-5439 print/ISSN 1651-2022 online © 2014 Informa UK, Ltd.
DOI: 10.3109/14015439.2014.949303
42 A.-C. Ohlsson
What strategies do speech therapists use today to
further patients’ ability to apply the new voice behav-
ior in everyday life? How tenable is the new voice
behavior in the long run?.
A typical voice treatment program includes voice
hygiene, breathing, relaxation, vocal exercises, and
transfer-to-speech (4,5). In performing voice therapy
a speech therapist can choose between different
approaches or strategies. However, the choice of voice
therapy method is still based mainly on personal
experience and practice in the area, and therefore the
levels of evidence for the choice of treatment are low.
There are only a few studies comparing voice therapy
methods, and, for example, results have indicated
that a combination of indirect and direct treatment
will give short-term results (6–8). Studies describing
the process in voice treatment are rare, and voice
therapy strategies and their theoretical framework
need to be investigated as pointed out by Verdolini
and Lee (10), who discuss how motor learning prin-
ciples can be applied in speech therapy.
The starting-point for this presentation is to
describe a voice therapy strategy, called the Verbal
Instruction Method (VIM), in the light of motor
learning principles. VIM voice therapy was developed
in Sweden during the last decade in order to meet
the demands of faster treatment results. From clini-
cal experience VIM seems to break through the
stumbling-block of generalization, but research stud-
ies for evidence has not yet been performed.
Methods
Traditionally, the core of voice therapy in Sweden
is based on demonstration, i.e. in the therapy ses-
sion the speech therapist demonstrates with her own
voice and body how the patient is supposed to pro-
duce voice in using different exercise tasks. The
patient gets feedback on his voice performance dur-
ing the task. (In this paper, in order to simplify the
text, the patient will be referred to as ‘he’ and the
speech therapist as ‘she’.) In contrast, the core in
VIM therapy is based on verbal guiding. Instead of
demonstrating the voice task the therapist verbalizes
it to the patient and asks questions while the patient
investigates different options to perform the task.
The main point is to give room for the patient to
make his own discoveries at his own pace while
‘playing’ with the voice task, sensing small differ-
ences among performance options. The speech
therapist gives only very little feedback. Feedback
to the patient is merely given by himself, and the
speech therapist supports his discoveries either they
are correct or incorrect in terms of voice quality. In
addition, the patient is frequently asked to imitate
his own productions in order to catch the core dif-
ference in terms of sense and movement between
two different productions manners. The speech
therapist may also imitate the patient to add to the
feedback needed. It goes without saying that the
social climate in the therapy room has to be confid-
ing and playful. Thus, the significant overt differ-
ences between VIM and traditional voice therapy
are, firstly, the strategies the speech therapist uses,
i.e. verbal instructions versus demonstrating, and,
secondly, the issues for augmented feedback, in
terms of the patient’s searching and discoveries
versus voice quality.
Description of VIM strategy
The starting-point in VIM therapy is the same as in
‘traditional’ voice therapy in terms of therapy con-
tent and type of exercise tasks, material, and con-
versations. The only difference is how the speech
therapist presents the training tasks and what she
supports in the patient’s performance. In the follow-
ing, selected therapy issues will exemplify how the
speech therapist communicates training tasks to a
patient in traditional voice therapy in comparison
to how the same tasks are presented in VIM voice
therapy. It is implied that the following five exam-
ples only focus on the technical core pattern of
therapy strategies, leaving all other parameters of
communication in the therapy room behind. Also,
the choices of task examples are arbitrary, i.e. the
same training issues could equally well have been
exemplified with other exercise content than the
presented. Focus is on how the exercise content is
processed between the therapist and the patient. It
is necessary to keep examples brief. The tasks can
be presented in any order.
1. Breathing exercise for abdominal activity. Exam-
ple: In traditional voice therapy the speech ther-
apist demonstrates the sound, e.g. /ss/, and asks
the patient to repeat it. The patient imitates the
sound and gets feedback on how well he per-
forms the task. In VIM voice therapy, the speech
therapist asks the patient to perform the sound,
e.g. /ss/, but without demonstrating it. After hav-
ing produced the sound, the patient is asked to
vary the sound’s duration and intensity. During
the patient’s productions, the speech therapist
asks questions like ‘From where in your body do
you start this sound?’, ‘Where is your impulse
to this sound now?’, ‘Do you feel the strong
muscles in your abdomen?’, ‘Let go and rest
between the sounds!’, ‘Where in your body do
you let go and rest?’ The questions are only
meant to help the patient in his explorations and
are not meant to be answered by the patient.
Thus, in VIM the patient is focused on himself
 Verbal Instruction Model (VIM) in voice therapy  43
while varying and ‘playing’ with the sound. He
is exploring different options, and is supported
in this research by the speech therapist.
2. Exercise for co-ordinating breathing and phona-
tion: voicing the /ss/-sound. Example: In tradi-
tional voice therapy the speech therapist
demonstrates /zz/ and asks the patient to repeat
the sound. The patient imitates the sound and
gets feedback during the process on how well he
performs the sound. In VIM voice therapy the
speech therapist asks the patient to perform the
/ss/-sound together with voice. The patient tries
to find out how to produce the voiced /ss/ and
gets positive feedback for searching. After a
while the speech therapist proposes various
options like: ‘Put your hand gently on your
breast-bone or on your neck, can you feel vibra-
tion under your hand?’, ‘Stop the /ss/-sound and
instead make any voiced sound so that you feel
vibration under your hand on your breast-bone!’,
‘Do you feel the strong muscles in your abdo-
men when you do that voiced sound?’, ‘Now
make the /ss/-sound at the same time as you do a
voiced sound!’, ‘Vary between performing /ss/
voiceless and voiced and use one of your hands
to feel the contractions from your abdomen mus-
cles, and the other hand to feel the vibrations from
your voice organ!’, ‘Do you feel any difference in
your body between the two sounds? If so, where?’
In VIM, the patient’s repeated restarts of /ss-zz/
phonation help in finding out the relation between
his breathing and voicing. In that way, in VIM the
patient’s own explorations are supported. In con-
trast, in traditional therapy, only the ‘correct’
breathing and phonation is supported.
3. Exercise for resonance in syllables. Example: In
traditional voice therapy the speech therapist
demonstrates how to produce a syllable, e.g.
/ba/, with sonority and asks the patient to per-
form it. The patient imitates the sound and gets
feedback on how well he performs it during the
therapy process. In VIM voice therapy the speech
therapist asks the patient to produce the syllable
with good resonance. The speech therapist pro-
poses different options, e.g. ‘Taste the initial
sound’, ‘Hold it, let it resist the pressure from
the abdominal muscles, and then let go’, ‘Do
you feel difference now?’, ‘Where do you feel the
difference?’, ‘Do you hear the difference between
/ba/ with good resonance and not so good reso-
nance?’, ‘Vary between a production with a good
resonance and not good resonance’; ‘How do
you succeed?’; ‘Say a word beginning with this
syllable’, ‘Vary between making it sonorous and
less sonorous’, ‘Do you feel the difference? If
you do, where do you feel it?’, ‘Do you hear the
difference?’ In that way the patient learns to dif-
ferentiate between how to use a production with
more or less sonority. He is allowed to discover
differences at his own pace without imitating an
ideal pattern.
4. Exercise to affect certain aberrations in voice
quality in everyday speech like hyper- and hypo-
function or creakiness. Example: In traditional
voice therapy the speech therapist demonstrates
how to perform voice without hyper- or hypo-
function and without creakiness. The patient
imitates the sounds produced by the speech
therapist, and during the process he gets feed-
back on how well he performs the task. In VIM
therapy the speech therapist asks a patient with
hyper- or hypofunctional or creaky voice if he
can feel or hear his voice quality when perform-
ing a task of spontaneous speech. If so, he is
asked to increase the aberration. If he does not,
the speech therapist imitates the patient’s voice
and asks if he can hear the aberration. During
this process the patient plays with the voice
aberration, and the speech therapist proposes
various options for differentiating between
‘aberration–no aberration’, to increase and min-
imize the aberration, and asks the patient to
evaluate when he succeeds or not. In VIM the
patient is helped in that way to discover small
differences between his productions and the
consequences for his voice quality.
5. Exercise for transfer-to-speech. Example: In tra-
ditional voice therapy the speech therapist and
the patient agree on contracts for the patient’s
use of the new voice behavior in certain every-
day situations. Traditionally, this part occurs late
in the therapy process. In VIM therapy transfer-
to-speech is trained from the start, and the
patient uses the transfer-to-speech-technique
from the beginning outside the therapy room.
Our theory for the earlier start is that the patient
then is helped to remember to practice transfer-to-
speech outside the therapy room while he is still
in his therapy period supported by the speech
therapist. In the therapy room transfer-to-speech
technique is trained during an ordinary conver-
sation between the patient and the speech ther-
apist. The patient is trained to be conscious of
his speech and voice quality and to stop talking
when he uses a non-desired voice quality, as for
example hyperfunction. If he does not discover
when he uses a hyperfunctional voice, the speech
therapist helps him by stopping him the next
time. The speech therapist also proposes options
like ‘Stop as soon as you can after hyperfunction
and imitate it as well as you can; then repeat the
word but this time without hyperfunction’, ‘Stop
44 A.-C. Ohlsson
at the hyperfunction and imitate and then repeat
without hyperfunction’, ‘Stop before the hyper-
function …’, ‘Increase the hyperfunction’, ‘Min-
imize the hyperfunction’, ‘How do you succeed?’
When the patient imitates himself it is very
important that his focus is on making an exact
imitation. Through the therapy period the
patient and the speech therapist agree on con-
tracts for the patient’s home-work on transfer-
to-speech in specific communication situations
in everyday life. Examples of situations for prac-
ticing could be when saying ‘hello’ to the first
person the patient sees after having left the ther-
apy room, or when he says the first word or
utterance every day to someone at his work-
place. Thus, in VIM the training for generaliza-
tion in natural conversation of the new voice
behavior, or certain aspects of it, is started
already from the beginning of voice therapy.
In summary
In VIM voice therapy the speech therapist’s verbal
guiding and questions are determined by the patient’s
activities and discoveries. In traditional therapy the
intentions of the therapist are the same. However, a
difference is that in traditional therapy the patient
imitates the speech therapist and thereby does not
have to find his own solutions. Traditionally, the
patient gets feedback on his voice function, and feed-
back is given often. In VIM the patient is ‘left alone’
to discover aspects of his own behavior, supported
by the speech therapist. Augmented feedback is given
sparingly and in response to the patient’s ability to
discover small differences in his performance as well
as their consequences. The therapy tasks are not
arranged in any chronological order but are pre-
sented to the patient in a mixed and circular fashion.
The same issue is practiced from different angles. For
example, when training soft glottal attacks, or train-
ing to replace creakiness with sonority, or training to
co-ordinate breathing and phonation, the patient is
also training the issue of breath support. The patient
is focused on his own behavior, using his sensory
system in differentiating between options, and sens-
ing and hearing the consequences for voice. The
speech therapist now and then invites the patient to
say how he himself thinks he manages a specific task
and provides the patient instant feedback on whether
she (the speech therapist) agrees or not.
VIM voice therapy and motor learning
The core difference between traditional voice therapy
and VIM therapy is how the speech therapist conveys
and communicates the therapy content or the
practice tasks to the patient. The issues and content
of tasks used for different exercises in therapy are the
same in VIM as in traditional therapy, for example
body postures for breathing, training tools, word lists,
texts. The working hypothesis is that the different
speech therapist strategies have a different impact on
the patient’s learning. Verdolini and Lee (10) make a
difference between performance and motor learning.
Performance supports short-term improvement in
skill, while motor learning supports long-term or per-
manent improvement. According to motor learning
principles as described by Verdolini and Lee (10),
skill acquisition or motor learning demands cognitive
effort, but it is not obviously dependent on conscious
awareness of what is being learnt. The learning is
implicit, ‘by accident’, rather than calculated or intel-
lectual. If needed, the intellectual understanding of
the motor principles and learning process occurs
later on. Three operations are relevant for cognitive
effort: self-generated hypothesis generation and test-
ing, relational processing, and repeated trace activa-
tion from baseline (10). In VIM, for example, the
patient’s attention may be directed towards making
an instant and precise imitation of his own way to use
e.g. vocal hyperfunction for the word he just spoke.
The patient is focused on sensing and performing
differences in small vocal gestures. According to the
definition of cognitive effort in Verdolini and Lee (10)
the patient is implicitly testing self-generated hypoth-
eses during this task. Also, the patient probably
repeatedly starts all over again from baseline, while
searching for a precise imitation of his own hyper-
function. The patient may also, unconsciously, pro-
cess relations between breathing and muscle tensions
in the throat and in other parts of the body while
aiming at a precise imitation of the hyperfunction. In
other words, the task demands cognitive effort from
the patient. According to the motor learning princi-
ples the patient is learning about his own vocal hyper-
function when he is exploring it in this way. In
traditional voice therapy, the therapist demonstrates
with her own voice how to do it, and the patient
imitates the therapist. The patient does not have to
find his own solutions, i.e. he probably does not use
cognitive effort. Following the principles of the motor
learning theory, this kind of instructions helps the
patient to perform, for short-term results, but it does
not help for long-term learning.
In terms of motor learning, variation in practice
issues and random order of practice enhances the
learning but depresses performance. One explana-
tion why variability in tasks and order enhances
acquisition skills more than non-variable practice
stems from ‘schema theory’ referred to by Verdolini
and Lee (10). In schema theory ‘… learners gener-
ate three-dimensional mental “regression plots”

that relate initial performance conditions, motor
program parameters issued, and movement out-
come’. Variation of tasks enriches the regression
plots through the repeated encountering of new
training conditions of the same issue, leading to
repeated relational processing. Cognitive effort is
gained, and consequently learning is facilitated. In
VIM, different practice tasks are mixed without pre-
determined order during a therapy setting. For
example, the patient is asked to pay attention to a
creaky voice quality in conversation and replacing
it with no creakiness, then produce separate sounds
and words paying attention to resonance or breath-
ing support, and so forth. The same basic aspects
of voice behavior (e.g. breathing support and reso-
nance) are investigated by the patient in separate
tasks, in a cyclic fashion, but from different angles.
In contrast, in traditional voice therapy the thera-
pist uses a more step-by-step manner for exercising
tasks, e.g. from single sounds to words to speech to
communication.
In motor learning and skill acquisition, the learn-
er’s sensory feedback and attention are crucial. In
VIM the therapist gives the patient a voice task to
investigate ‘at his own pace’, and the patient’s atten-
tion is directed towards sensing and perceiving his
own bodily and vocal changes, testing different
options while performing the task. His attention is
directed towards his own performance instead of just
imitating the therapist. Augmented feedback is nec-
essary, but ‘less is more’ (10). Learners getting less
frequent augmented feedback have to use more cog-
nitive effort, and this increases true learning for
long-term results. If feedback is given too often there
is a risk that it depresses skill acquisition. The
patient’s attention to his task might be broken and
makes cognitive effort more difficult. In VIM feed-
back is given sparsely, and the speech therapist sel-
dom gives feedback on the patient’s voice function.
Instead the feedback is directed towards the patient’s
capacity to discover aspects of or differences in his
performance, be it ‘right’ or ‘wrong’. The speech
therapist may also ask the patient how he evaluates
his own performance in a certain task. In addition,
for feedback, the therapist may imitate the patient’s
production of a sound. In traditional voice therapy
augmented feedback is given often.
Summarized, the hypothesis is that traditional
voice therapy and VIM voice therapy differ with
respect to motor learning principles. Traditional ther-
apy is supposed to help short-term performance,
while VIM therapy is supposed to help long-term
learning. The main reference for this paper is Verdo-
lini and Lee (10) describing motor learning princi-
ples. They conclude (10): ‘A therapist’s manipulation
to affect a temporary change in performance is in direct
Verbal Instruction Model (VIM) in voice therapy  45
opposition to its impact on learning. Performance may
result in a brief and directly measureable outcome for
a certain activity. Motor learning, on the other hand,
is a process that is not directly observed but is inferred,
leading to relatively long-term stable changes in per-
formance potential following practice or exposure.’
Clinical experiences of VIM voice therapy this far
Experiences from a Swedish network for speech ther-
apists educated in and practicing VIM voice therapy
are that patients take a more active part in their voice
training from VIM as compared to traditional voice
therapy. Furthermore, the general impression among
therapists using VIM is that patients proceed faster
to voice change and that the change is more easily
generalized in patients’ everyday life in comparison
to the change in traditional voice therapy. Possibly a
combination of VIM and traditional voice therapy is
to be recommended. Experiences from clinical work
suggest therapy benefits if starting the therapy pro-
cess with VIM. In addition, VIM voice therapy may
suit some patients and speech therapists better than
traditional voice therapy, and vice versa. Evidence for
VIM voice therapy outcome remains to be scientifi-
cally studied.
Conclusions
A working hypothesis is that VIM voice therapy implies
that the patient is presented with training constraints
that point towards the concept of impli­­cit cognitive
effort within motor learning theory. Furthermore, in
VIM the patient is the ‘agent’; while working on cor-
rect production, he is focused on his own sensations
instead of imitating the speech therapist. An addi-
tional important aspect of long-term outcome may be
that in VIM the consciously trained transfer-to-speech
is integrated early in the process of therapy.
Acknowledgements
The author wishes to acknowledge the colleagues
taking part in VIM voice therapy up till today. Their
participation and discussions constitute the contin-
ued development of VIM.
Declaration of interest:  The author reports no
conflicts of interest.
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