Strategic swearing in healthcare

I'm an Associate Professor in the Department of Physical Therapy at Samford University. Each year, I train for the department's bench press competition. I'm quite competitive, always looking for an edge. In 2019, a student shared a research article by Psychologist Richard Stephens, titled 'Effect of swearing on strength and power performance' (Stephens et al., 2018), half-jokingly suggesting that swearing might help me win. 

The study revealed that swearing enhanced participants' grip strength during a dynamometer test and power output during a maximal cycling test. This article raised more questions for me than it answered, and I turned to Google. I found another of Stephens' studies (2009): 'Swearing as a response to pain', which demonstrated that swearing increased both pain threshold and tolerance. This resonated with my physical therapy training, where the American Physical Therapy Association's vision is to '…optimize movement to improve the human experience' by calming tissue down, building tissue up, and improving work capacity (Washmuth et al., 2022). If swearing can calm tissue down (improve pain threshold and tolerance), build tissue up (improve strength), and improve work capacity (increase power), could 'strategic swearing' serve as a tool in physical therapy to improve patient outcomes? 

A new world of research opened up for me (Hay et al., 2024; Washmuth et al., 2024), and my friends became aware of it. They began to share examples of their own positive experiences with swearing. Empathy is critical in healthcare, directly improving outcomes and patient satisfaction (Derksen et al., 2013). Therefore, these stories from my friends prompted a deeper question: Can swearing be professional, by fostering empathy and empowerment, strengthening patient-clinician relationships? 

Patient perspectives

A friend described how hearing 'that fucking sucks' after a miscarriage was the most comforting response, validating their emotions in a way traditional conservative language could not. Another friend reported feeling an instant rapport with a mental health therapist who casually said 'fucking hard' during a session, perceiving the therapist as relatable and genuine.

A physical therapist colleague shared a case study in more detail. The patient was an independent, confident, and athletic Caucasian female. At the age of 25, she had never experienced a significant injury or illness and was known for her dedication to fitness; it was an integral part of her identity. However, her life took a dramatic turn as she began to battle an issue that was not only getting more and more severe but also very 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 dealing with stress incontinence. ​

This stress incontinence worsened to a point where it became unpredictable and severe, limiting her ability to work out. This put a strain on her identity. After years of daily visits to the gym, the patient found herself missing entire weeks of exercise, and her stress incontinence showed no signs of improvement. ​

The patient found the courage to seek help, and consulted a 33-year-old Caucasian male physical therapist. During this consultation, she shared her unfiltered history of stress incontinence, her goal of returning to her fitness pursuits, and her desire to reclaim her sense of self. After listening and processing the patient's history, the physical therapist said 'This must be fucking tough for you.' Initially taken aback, the patient's demeanor shifted to one of warmth and openness, signaling that the swearing had validated her experience and strengthening rapport. 

This patient experienced a successful episode of physical therapy, achieving clinical outcomes that aligned with the expected prognosis.​

For me, this case offered a 'proof of concept' worth exploring. To further investigate the role of swearing in healthcare, my colleagues and I surveyed patients who recently completed physical therapy or chiropractic care. Preliminary findings from 46 patients suggest that the prevalence, acceptability, and outcome of swearing are mixed and depend heavily on the context, intent, and established rapport between the clinician and patient. Half of the patients surveyed reported their clinician used swear words during sessions. All patients who experienced swearing reported neutral or positive effects on their motivation, self-confidence, or adherence to care. Most patients who experienced swearing believed swearing improved their experience, while a few patients reported swearing having a negative impact on their experience. Patient age influenced perceptions of swearing's appropriateness. Younger adult patients were more open to swearing, appreciating its alignment with empathy and emotional authenticity. Older adult patients preferred reserved communication, reflecting traditional views of professionalism. Across all ages, swearing delivered in a negative tone was deemed inappropriate. 

Context is key

Swearing is prevalent in society, with evidence suggesting 58 per cent of the population swears 'sometimes' or 'often' (Beers Fägersten, 2012). More than 70 per cent of adults report frequently or occasionally hearing individuals swear in public (Ipsos Public Affairs), and 57 per cent of workers swear in the workplace (Williams and Uebel 2022). So swearing is prevalent in public discourse and a common part of everyday speech, even in more formal settings. However, the utility of swearing in healthcare remains underexplored. 

Swearing, by definition, involves using emotionally charged language that may be taboo in a particular culture (Beers Fägersten, 2012), and is generally viewed by many as unprofessional. 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 (Dyer, 2014; Jovanovski, 2012). No ethical code can comprehensively address every situation. 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. 

Using authentic language, such as swearing in this case, may allow a clinician to demonstrate integrity. Instead of generic and superficial reassurance, swearing may suggest an honest response when someone is experiencing a difficult health condition.​ Swearing may be a tool that a clinician can use to help someone accept and express their own feelings without shame. Swearing may validate someone's experiences and can be seen as a form of support, empowering them to feel understood.

The authority to swear may be related to the power dynamics within the patient-clinician hierarchical structure. 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 (Davies, 2015). Although the physical therapist in the above case interpreted the patient cues after he swore as positive, such as smiling, it may be that the patient 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. 

It's crucial to recognise that the context in which swearing take place ultimately determines whether it has a positive or negative impact. Research has found that 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 suspects and victims, testimonies containing swear words were perceived as more credible than those without (Rassin & van der Heijden, 2005). This demonstrates the crucial role that context plays in the intent, perception, outcome of swearing. The physical therapist in our case swore as a means to convey empathy and acknowledge the patient's hardships. Emphasising feelings is a common motive for swearing; therefore, swearing may be a strategy to express the understanding of strong emotions (Fine & Johnson, 1984; Burns, 2008). 

The outcomes of a clinician swearing are likely influenced by other contextual factors such as age, gender, and race of both the patient and clinician. In the case presented above, the patient belonged to Generation Z, while the physical therapist was a Millennial. 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. With respect to gender, 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 (Guvendir, 2015). This discrepancy may affect how swearing is perceived. 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 (El-Alayli et al., 2018).Caucasians tend to swear in a wider range of social situations than other racial groups, and they typically face less severe judgement for their language (Beers Fägersten, 2012) . This suggests that the racial identity of the clinician who swears may have implications on the outcome. 

Final thoughts

The appropriateness of swearing is a complex issue, as what is acceptable and useful for one patient may be offensive and discouraging to another. Anecdotally, swearing can be a tool for emotional connection and motivation in clinical settings; and research on swearing in mental health settings has found that swearing by a therapist often has a positive effect on the patient-therapist relationship and many patients describe explicitly positive experiences when their therapist swears (Giffin, 2016). 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 (Vingerhoets et al., 2013). 

However, it is perhaps premature to justify and recommend strategic swearing in healthcare without more robust evidence to guide its implementation. Future research should explore how specific patient demographics, contextual factors, clinical settings, and biopsychosocial traits influence the perceptions and outcomes of swearing in healthcare. Once such evidence becomes available, swearing may emerge as a strategy to help clinicians 'improve the human experience'. 

References

Beers Fägersten, K. (2012). Who's swearing now? The social aspects of conversational swearing. Newcastle: Cambridge Scholars Publishing.

Burns, M.C. (2008). Why we swear: the functions of offensive language. Monash Univ Linguist Pap. 6, 61-69.

Davies, M. (2015). Is it OK for doctors to swear at work? BMJ. 350, h383.

Derksen, F., Bensing, J., Lagro-Janssen, A. (2013). Effect of empathy in general practice: A systematic review. Br J Gen Pract. 63, e76-84.

Dyer, C. (2014). Surgeon who shouted and swore at colleagues is suspended. BMJ. 349, g6349. 

El-Alayli, A., Hansen-Brown, A.A., Ceynar, M. (2018). Dancing backwards in high heels: female professors experience more work demands and special favor requests, particularly from academically entitled students. Sex Roles. 79, 136-150.

Fine, M.G., Johnson, F.L. (1984). Female and male motives for using obscenity. J Lang Soc Psychol. 3, 59-74.

Giffin, H.J. (2016). Clients' experiences and perceptions of the therapist's use of swear words and the resulting impact on the therapeutic alliance in the context of the therapeutic relationship. Smith Sch. Available at: https://scholarworks.smith.edu/cgi/viewcontent.cgi?article=2787&context=theses

Guvendir, E. (2015). Why are males inclined to use strong swear words more than females? An evolutionary explanation based on male intergroup aggressiveness. Lang Sci. 50, 133-139.

Hay, C.M., Sills, J.L., Shoemake, J.M. et al. (2024). F@#$ pain! A mini-review of the hypoalgesic effects of swearing. Front Psychol. 15:1416041.

Ipsos Public Affairs (2006). The associated press profanity study. 

Jovanovski, V. (2012). Swearing Polish surgeon who rested his arms on patient during operation and stormed out of theatre is struck off. DailyMail.com. 

Rassin, E,, van der Heijden, S. (2005). Appearing credible? Swearing helps! Psychol Crime Law. 11, 177-182.

Stephens, R., Spierer, D. K., and Katehis, E. (2018). Effect of swearing on strength and power performance. Psychol Sport Exerc. 35, 111–117.

Stephens, R., Atkins, J., and Kingston, A. (2009). Swearing as a response to pain. Neuroreport. 20, 1056–1060.

Washmuth, N.B., McAfee, A.D., Bickel, C.S. (2022). Lifting techniques: Why are we not using evidence to optimize movement? Int J Sport Phys Ther. 17, 104-110.

Washmuth, N.B., Stephens, R., Ballmann, C.G. (2024). Effect of swearing on physical performance: A mini-review. Front Psychol. 15:1445175.

Williams, I.L., and Uebel, M. (2022). On the use of profane language in psychotherapy and counseling: A brief summary of studies over the last six decades. Eur J Psychother Counsel. 23, 404-421.

Vingerhoets, A.J.J.M., Bylsma, L.M., de Vlam, C. (2013). Swearing: a biopsychosocial perspective. Psych Top. 22, 287-304.