A 23-year-old male Indian medical student was referred to physical therapy after tearing his right anterior cruciate ligament (ACL) while playing flag football and undergoing subsequent ACL reconstruction surgery. Clinical examination was consistent with status post ACL reconstruction. The patient was treated with standard of care after an ACL reconstruction, including weight bearing as tolerated, gait training, interventions to decrease pain and effusion, cryotherapy, electrostimulation for muscle reeducation, quadriceps and lower extremity strengthening, and neuromuscular training.
Patient was seen for 8 visits over 3.5 weeks. Patient initiated physical therapy in his hometown while on his winter break from medical school. After 8 visits of physical therapy, patient returned to medical school and transferred to a physical therapy clinic more convenient to his medical school campus.
Social swearing, as opposed to annoyance swearing, serves interpersonal functions, such as group bonding and impression management and is seen as positively charged. The PT utilized social swearing during treatment sessions with the goal of motivating the patients and enhancing the social connection with the patients, to improve therapeutic alliance. It is important to note that the social swearing implemented by the PT did not include weaponized use of taboo language to inflict or subject the patients to demeaning emotional insult or harassment.
The PT began to swear during the 3rd physical therapy visit for both patient cases and swore 2-3 times each visit thereafter. Swearing was initiated on the 3rd visit to ensure rapport between the patient, and PT was established, with swearing being utilized to further improve their relationship and therapeutic alliance. Each episode of swearing by the PTs was attempted to be well-timed for the purpose of motivation and solidarity. For example, during case 1, the PT said, "Hell yes bro, that is good s***! Keep up the f***ing good work!", while the patient was performing a challenging exercise. The patient smiled and proceeded to say, "F*** yeah dude, let's f***ing go!" and then continued performing his exercises. An example during case 2, the PTs said, "Dude, if you continue to work your f***ing a** off like this, you will become a f***ing animal!" during a treatment session. The patient started laughing immediately and said, "You're damn right." and continued to work through his exercises.
The Helping Alliance Questionnaire (HAQ), a self-reported outcome measure that is completed by both the patient and the PT, was used to monitor the therapeutic alliance at 2 points during the episodes of care of these patients to help show the evolution of the therapeutic alliance and swearing over time.
An additional swearing survey was developed by the researchers, based on the works of Giffin and Stephens et al., to better understand the context in which swearing occurred. The swearing survey was completed at discharge and included questions about the patients' general opinions of swearing, thoughts on the professionalism and acceptability of swearing in physical therapy, and how swearing effected the patient-PT relationship, and also included questions based on the possible psychological mechanisms by which swearing fulfills positive functions. This swearing survey is presented in Fig. 1. Summaries of the therapeutic alliance and swearing survey outcomes are presented in Tables I and II, respectively.
During the 4th visit, the patient and PT completed the HAQ. At discharge, the patient and PT completed the HAQ again (7th visit). At the 4th visit, the patient scored 94/114 on the HAQ and the PT scored 92/114 (19 = poor therapeutic alliance and 114 = strong therapeutic alliance). At discharge, the patient scored 89/114 on the HAQ, and the PT scored 98/114. These results suggest that the patient's self-reported therapeutic alliance score decreased (94/114 to 89/114) as the PT swore during treatment sessions, while the PT's self-reported therapeutic alliance increased (92/114 to 98/114).
The patient completed the researcher-developed swearing survey at discharge. The patient disagreed with the following statements: "I find swearing offensive," "I only swear around my friends and family," and "PT swearing is unprofessional." The patient agreed with the following statements: "I change or monitor my use of swearing based on the people I am talking to or the people around me" and "PTs should be able to swear around their patients." The patient swears more than 4 times per day and believed that the PT swearing did not affect their relationship or his motivation. When asked "How did you feel the first time a swear word was used in your therapy?" the patient responded, "It didn't bother me at all. I am used to it."
Based on the possible psychological mechanisms by which swearing fulfils positive functions, the most noted effect on this patient was that the PT swearing was funny or humorous. All other mechanisms were scored at 50% or less agreement from the patient. Specific swearing survey results are listing in Table II.
Similar to case 1, the patient and PT completed the HAQ during the 4th visit and again at discharge (8th visit). At the 4th visit, the patient scored 110/114 on the HAQ, and the PT scored 100/114 (19 = poor therapeutic alliance and 114 = strong therapeutic alliance). At discharge, the patient scored 113/114 on the HAQ, and the PT scored 110/114, suggesting that both the patient's and PT's self-reported therapeutic alliance scores increased (patient 110/114 to 113/114; PT 100/114 to 110/114) as the PT swore during treatment sessions.
At discharge, the patient strongly disagreed with "I find swearing offensive" and "PT swearing is unprofessional" and agreed with "I only swear around my friends and family" and "PTs should be able to swear around their patient." Patient neither agreed nor disagreed with "I change or monitor my use of swearing based on the people I am talking to or the people around me." The patient reported swearing more than 4 times per day and believed that the PT swearing helped their relationship and increased his motivation. When asked "How did you feel the first time a swear word was used in your therapy?" the patient responded, "Increased the mood in they gym."
The patient fully agreed that the PT swearing made him feel a positive emotion, was funny or humorous, distracted him from thinking about other things, felt like a new or different experience, and made him feel more confident. The patient did not agree at all that the PT swearing made him feel a negative emotion.