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As a faculty member in a physical therapist education program, I was introduced to the positive effects of swearing in 2019 when a student sent me a manuscript by Stephens et al,¹ “Effect of Swearing on Strength and Power Performance,” discovering that swearing can enhance physical performance. I received this article somewhat humorously, as the student was jokingly suggesting that swearing deserves attention in the physical therapy setting. Although my attention was drawn to this manuscript amusingly, it had a profound impact on my research direction, raising more questions than it answered. A quick literature search to explore this newfound curiosity revealed that swearing is associated with not only improvements in physical performance, but a decrease in pain perception,^2–6 heightened humor,⁷ conveying credibility,⁸ enhancing solidarity and rapport building,^7,9–11 and improvements in memory and recall.^12,13

It became evident that swearing is associated with positive physiological, psychological, and social effects that other forms of language could not replicate. For example, swearing has been found to increase pain threshold,^3–5 increase pain tolerance,^2–6 and even decrease social pain⁶ or the feeling of suffering brought on when social connections are lost or threatened. It was originally proposed that the mechanism by which swearing produces these hypoalgesic effects is an increase in sympathetic activation.^2,3 However, other studies have found a lack of sympathetic activation even when swearing produced a decrease in pain perception.^4,5 Although swearing possesses a unique power, it is currently unknown from where swearing gets its power. It has been hypothesized that positive associations between swearing and physiological, psychological, and social effects are mediated by emotion, humor, distraction, aggression, state disinhibition, psychological flow, risky behavior, self-confidence, and sympathetic activation.^2–5,14,15 It is plausible that there is a combination of mechanisms behind swearing’s power, or that the mechanisms differ depending on the contexts of the situation. My research subsequently shifted toward understanding when, how, and if swearing could be strategically employed to enhance patient outcomes.

There is little discussion or research on the possibility that swearing may actually be considered professional and patient-centered when used in the appropriate context: with the right patient, at the right time, and for the right reason. In workplace settings, the use of the word “fuck” has been correlated with improved solidarity among co-workers.⁹ In the classroom, professor swearing is rated as appropriate when it is directed at course content to emphasize a concept.¹⁶ The context of every patient-physical therapist interaction is unique, and the appropriateness and effectiveness of certain behaviors will vary from clinic to clinic and from physical therapist to physical therapist.

The prevailing belief is that swearing by a physical therapist is inherently negative; however, swearing may be useful and perceived as appropriate given particular contextual factors. Anecdotally, physical therapists use swearing in certain situations. One example is presented below as a case vignette, describing how swearing was used by a physical therapist with the intention of portraying professionalism and patient-centeredness.

‘Phoebe’ is an independent, confident, and athletic Caucasian woman. At the age of 25, she had never experienced a significant injury or illness and was renowned for her dedication to fitness; it was an integral part of her identity. However, her life took a dramatic turn over the course of 6 months. Phoebe began to battle an issue that was not only growing increasingly severe but also remarkably difficult to talk about. It was an issue that made her feel vulnerable, exposed, and overwhelmed with fear and embarrassment. For months, she had been silently contending with stress incontinence.

Initially, Phoebe’s stress incontinence had been relatively mild, and she was able to manage it by making modifications to her exercise routine and relying on pads. Unfortunately, it worsened to a point where it became unpredictable and far more severe, limiting her ability to work out. This strain on her identity was particularly profound. After years of daily visits to the gym, Phoebe found herself missing entire weeks of exercise, and her stress incontinence showed no signs of improvement.

Summoning the courage to seek help, Phoebe consulted a 33-year-old Caucasian male physical therapist whose clinic is next to her gym and has a reputation for treating athletes and fitness enthusiasts. During this consultation, she confidently shared her unfiltered history of stress incontinence, her goal of returning to her fitness pursuits, and her overarching desire to reclaim her sense of self. After listening and processing Phoebe’s narrative, the physical therapist said “This must be fucking tough for you.” The physical therapist observed an initial silent pause and expressionless body language from Phoebe, which he interpreted as being shocked by his use of an expletive. The physical therapist then described a quick transformation from Phoebe observed by her warm smile, open posture, and relaxed demeanor, which was interpreted as being acknowledged, heard, and understood.  Encouraged by this positive response, the physical therapist occasionally utilized swearing as a tool to sustain this rapport and social connectedness throughout the episode of physical therapy care.

While her name and specific details have been altered here, Phoebe’s case is based on real events. Phoebe experienced a successful episode of physical therapy, achieving clinical outcomes that aligned with the expected prognosis of her health condition. Notably, Phoebe had a 100% arrival rate and routinely arrived early to her physical therapy appointments. Although it was challenging for the physical therapist to convey these changes qualitatively, there was a discernible positive shift observed in how Phoebe interacted with her physical therapist immediately after he swore. This prompts the question: If swearing is inherently negative, why were there no apparent adverse consequences? Furthermore, why did the physical therapist perceive an enhanced social connection with the patient after swearing, potentially influencing Phoebe’s arrival rate and the positive shift in interactions? In the absence of empirical evidence, this case serves as a catalyst for reflection on the strategic use of swearing by a physical therapist.

A candid reflection of the case described above reveals that Phoebe’s clinical outcomes aligned with the prognosis of her health condition, suggesting that swearing did not significantly impact the outcomes. However, it’s worth noting that the physical therapist involved in this case considered the use of swearing to be both indicated and professional. This reflective narrative has its limitations. Primarily, this reflection is subjective and is influenced by the authors’ perspectives, leading to potential biases in interpretation and reporting. Consequently, this case cannot be generalized to broader clinical scenarios. Despite these limitations, this reflection aims to present a clinical approach that does not yet have a body of evidence to guide decision making, and to offer a ‘proof of concept’ for an approach with potential efficacy.

Phoebe presented to physical therapy with strong emotions, including a disconnection from her identity. The physical therapist faced the challenge of demonstrating genuine empathy toward the emotional state of the patient. Swearing, by definition, involves using emotionally-charged language that may be taboo in a particular culture.⁷ In this context, the swearing used by the physical therapist served as a tool to convey their understanding of the patient’s emotional experience and to build a therapeutic alliance based on the shared comprehension of the patient’s feelings and goals.

Swearing is generally viewed by many as unprofessional. The American Physical Therapy Association’s Code of Ethics emphasizes the importance of respecting the inherent dignity and rights of all individuals and maintaining integrity in relationships with patients.¹⁷ This Code highlights physical therapists’ fundamental duty to empower, educate, and support their patients.¹⁷ However, no ethical code can comprehensively address every situation. For instance, the appropriateness of specific language used by a physical therapist may be perceived differently by different patients, potentially having either a positive or negative impact. It’s crucial to recognize that the words used by physical therapists have the potential to affect social, psychological, and biological factors,¹⁸ either strengthening or weakening the therapeutic alliance,¹⁹ and causing either healing or harm.^18,20

In Phoebe’s case, swearing served as a strategy to adopt a patient-centered approach. Patient-centered care involves tailoring care to a specific patient’s values and preferences, with the ultimate goal of empowering the patient.²¹ For strategic swearing to be effective, physical therapists must carefully consider the context in which it occurs. Although Phoebe’s specific attitude toward swearing was not explicitly explored by the physical therapist, it was the contextual understanding of her emotional state that prompted the physical therapist to swear, thereby demonstrating a shared empathy for her strong desire to reclaim her identity. It is worth noting that disciplinary actions have been taken against medical providers for their use of swearing, but most of these instances involve swearing out of frustration or anger, rather than a means to foster positive social connections.^22,23 Recent evidence has suggested that ‘clout’ words, or words used to evoke a sense of importance or impact, are perceived by patients as patient-centered.²⁴ The swearing utilized by the physical therapist may be considered a form of clout language and, therefore, a strategy for patient-centeredness.

The authority to swear may be related to the power dynamics within the patient-provider hierarchical structure.²⁵ Although the physical therapist in this case did not feel entitled to swear, citing its lesser appropriateness in formal environments,²⁶ it is important to acknowledge the existing hierarchy between patients and providers. This hierarchy, often associated with power imbalances, makes it more likely for a doctor to swear at a nurse than a nurse to swear at a doctor.²⁵ Additionally, certain cues from Phoebe, such as smiling after the physical therapist swore, may suggest that the she was ‘dancing to the physical therapist’s tune’—feeling forced to accept the swearing due to the power dynamics of the physical therapist-patient relationship. The physical therapist found that the emotional nature of the case, coupled with the intention of strengthening the social connection, justified and exemplified the professionalism of strategic swearing.

This article delineates a case in which a physical therapist employs swearing as a strategy for patient-centered communication. However, what about the swearing behaviors exhibited by patients? Patients who demonstrate behavior considered inappropriate by providers, such as using foul language, are often unfairly labeled as “difficult.”²⁷ A proposed solution to managing such “difficult” patients involves allowing them to vent, or swear, uninterrupted in a private setting, as swearing is believed to have cathartic effects.^27,28 Patient swearing may have utility in a physical therapy setting, beyond its cathartic potential. A recent case report details the formal integration of patient swearing into a physical therapy plan of care. In this case, the patient opted for the swearing strategy of vocally repeating “fuck” during the most painful and challenging interventions, aiming to improve physical performance and decrease pain.²⁹ However, the outcomes of swearing, whether by a patient or a physical therapist, are highly dependent on the context in which they occur. The next section will explore some contextual factors that may influence the effects of swearing.

Swearing has been a part of human language since its inception³⁰ and is prevalent in society, with evidence suggesting 58% of the population swears “sometimes” or “often;”⁷ more than 70% of adults report frequently or occasionally hearing individuals swear in public;³¹ and 57% of workers swear in the workplace.³² This suggests that swearing is prevalent in public discourse and a common part of everyday speech, even in more formal settings. However, the utility of swearing in physical therapy remains under-explored.

The challenge of interpreting and applying the evidence around swearing is that the majority of research on swearing tends to be categorical and conducted in non-naturalistic settings, while overlooking context. However, it’s crucial to recognize that the context in which swearing takes place ultimately determines whether it has a positive or negative impact. The limitations of non-naturalistic research and the significance of contextual factors in determining the outcomes of swearing have been described by Stapleton,³³ and are underscored by research from Rassin and van der Heijden.⁸ When simply asked whether using a swear word is a sign of credibility, deceit, or neither, people tend to view swearing as an indicator of deceit. However, in the context of testimonies provided by crime suspects and victims, testimonies containing swear words were perceived as more credible than those without.⁸ This demonstrates the crucial role that context plays in the perception of swearing. The physical therapist in this case swore as a means to convey empathy and acknowledge the patient’s hardships. Emphasizing feelings is a common motive for swearing; therefore, swearing may be a strategy to express the understanding of strong emotions.^34,35

The outcomes of a physical therapist swearing may be influenced by other contextual factors such as age, gender, and race of both the patient and physical therapist. Notably, the patient in this case (Phoebe) belonged to Generation Z, while the physical therapist was a Millennial. These different generational backgrounds shape their expectations, and given the potential for swearing to cause offense, it could be seen as risky behavior. Younger generations tend to be more inclined to participate in risk-taking compared to older ones.³⁶ Consequently, swearing by young adult physical therapists in the presence of young adult patients may be perceived differently than when used by or in the presence of older generations. Moreover, gender differences in the use of swear words indicate that males tend to use stronger language than females. Research has shown that males use the word “fuck” and its derivatives nearly twice as frequently as females.³⁷ This discrepancy may affect how swearing is perceived.^26,37 It has also been found that females may need to exhibit a higher degree of professionalism compared to males to be considered credible in certain situations.³⁸ Race is a less studied social variable within the swearing research.⁷ Caucasians, in particular, tend to swear in a wider range of social situations than other racial groups, and they typically face less severe judgement for their language.⁷ This suggests that the racial identity of a physical therapist who swears may have implications on the outcome.

The utility of strategic swearing in healthcare settings is underrepresented in the literature.³⁹ In mental health settings, Giffin¹¹ surveyed 50 patients who had experienced swearing from their therapist, which included social workers, counsellors, and psychologists. Surprisingly, 80% of patients reported that their therapist’s use of swear words had a positive effect on their therapeutic relationship, and over 88% of patients described an explicitly positive experience with their therapist swearing. These findings may be attributed to the informal, natural, and humanistic environment created by swearing, which allows the patient and provider to be more authentic.³⁰ Swearing has also been shown to help build rapport⁴⁰ and manifest solidarity.⁴¹ Interestingly, none of the surveyed patients by Giffin¹¹ felt that their therapist’s swearing had a detrimental impact on their therapeutic relationship. These results are consistent with a recent case series in physical therapy that showed swearing by a physical therapist was not perceived as unprofessional and did not offend the patients.⁴²

While this reflection revolved around exploring the potential positive effects of swearing, it is essential to clarify that we are not advocating the idea that swearing is universally beneficial, nor are we suggesting that every physical therapist should incorporate swearing in their practice. Instead, we recommend a prudent, mindful, and context-sensitive approach to swearing, or to refrain from swearing completely. Until we gain a comprehensive understanding of the mechanisms through which swearing serves positive functions, can effectively mitigate the risks of potentially offending someone with swearing, and gain a deep appreciation for which contextual factors are significant, it remains premature to justify the strategic use of swearing within a clinical setting. Further research is required to enhance our understanding of how swearing may be used to promote professionalism, patient-centered care, and the therapeutic alliance. Empirical evidence is a requisite to guide physical therapists on when, how, and if swearing can be used to enhance patient outcomes. Once such evidence becomes available, swearing may indeed emerge as a strategy to help meet our professional vision of “improving the human experience.”⁴³

NBW was responsible for concept development, design, and supervision. NBW, AM, GT, and RS were responsible for data collection and reflection, drafting and editing, and approving manuscript prior to submitting.

We extend our deepest gratitude to Ashley Kappel, whose invaluable contribution transcends conventional acknowledgments. Ashley provided an initial example of patient-centered strategic swearing that not only served as the guiding genesis behind this manuscript but also sparked our interest in exploring the depths of what professionalism truly means.

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