Fundamentals of Ethical Decision-Making: Origins of Treatment Room Conflict


Ethical dilemmas lie at the heart of therapeutic conflict and represent some of the most challenging aspects of clinical care.

Conflict and ethical challenges usually occur along a continuum—from minor misunderstandings to more serious abuse and violations—and both the therapist and client may be implicated in treatment room conflicts. 

Learning both how many ethical dilemmas arise, as well as how you can better negotiate this sometimes murky territory, is essential to maintaining the professional standards that are an integral part of your success as a massage therapist. 

The Cost of Conflict 

Ethical dilemmas and treatment room conflict can easily erode trust and destroy the therapeutic alliance. Both therapists and clients may create or be harmed by these circumstances, making considering behaviors separately from responses to conflict very important. When clients cause therapists concern, they create communication challenges and ethical dilemmas. When therapists cause clients concern, the outcomes are much more serious, potentially resulting in violation and breach of trust. 

What makes ethical dilemmas and conflict so disturbing is the dissonance between what should happen, what the therapist fears may happen, and what may actually occur. Usually there are a number of warning signs that appear before a conflict erupts. If therapists ignore the warning signs, then the conflict may seem like a sudden crisis, dramatic and unexpected. If therapists pay close attention to client cues, then the conflict may offer an important opportunity to change or improve the client therapist relationship. If, on the other hand, therapists have no awareness of their personal feelings about an issue, then their decision making processes become hidden by the fog of what is, what should be and what they most fear. 

Three principal responses to conflict heat up clinical disagreements significantly: passivity, passive aggression and aggression. The consequences are different when clients or therapists engage in such responses, but all such circumstances are serious. Remember, too, that responsibility for treatment room communication lies with the therapist. Assessing personal risks and responding appropriately ensures that both clients and therapists remain safe within the massage therapy environment. 

Negotiating Conflict 

Conflict arises when two people disagree over how to get their needs met. 

Learning how to negotiate the rough waters of conflict requires that therapists know their professional obligations “in their bones.” Therapists must observe client behaviors dispassionately, as well as admit honestly how their own behavior contributes to the conflict. Although client and therapist perceptions of a conflict may differ according to the roles they assume in the treatment room, their experiences intertwine and connect. 

When conflict arises, all real treatment progress stops until the problem is resolved. 

Evaluating the origins of treatment room conflicts and ethical dilemmas takes time, yet investing in such reflection is never wasted. In order to find the right response, massage therapists must be willing to speak truth, without offending or taking offense. Experience is a great teacher. Each time conflicts arise and boundaries are reset, therapists become more confident about who they are professionally. Once therapists understand the origins of treatment room conflict, they will likely ask better questions or stop inappropriate behavior before it becomes a problem. 

It’s impossible to consider one part of a conflict without examining other contributing factors. Conflicts occur between therapists and clients over a host of issues—both large and small—so you might sometimes find it difficult to figure out the cause of hurt feelings or frustrations. Most situations, however, fall under one of the following general categories: 

  • Thoughtlessness
  • Expectations or assumption of special status
  • Challenges to professional role and personal beliefs
  • Boundary issues that compromise integrity
  • Manipulation, abuse, and predatory behavior 

Simple thoughtlessness can cause frustration for both clients and therapists. The slights may seem small or unimportant, such as client or therapist tardiness. Tardiness negatively impacts a therapist’s schedule when clients still expect to receive a full session. In order to protect the therapist’s schedule, the client’s behavior must be challenged, regardless of how the client feels about it. On the other hand, when therapists run consistently late, they inconvenience clients who may need to pick up children or attend other appointments. Until both the therapist and the client negotiate a solution to this conundrum, the friction between them will remain. 

Each of these categories seriously challenges therapist ethics. The solutions are not as readily apparent as behaving more politely and thoughtfully. Complex problems demand reflection and careful evaluation about the best course of action. Having a thorough understanding of what is meant by an ehtical dilemma is a great place to start. 

Defining Ethical Dilemmas 

The term ethics relates to the study of moral decision-making. Ethical dilemmas challenge a commonly understood code of conduct. This may be as simple as “do the right thing” or “treat others the way you would like to be treated.” To complicate the situation further, ethical dilemmas also harbor conflicting and hidden values, beliefs and charged emotions. There may be an acknowledged or unacknowledged power differential, and ethical dilemmas that interfere with personal values and beliefs or dispute professional responsibilities can prove challenging to untangle. Without gathering all the information, acknowledging the hidden power differential, or admitting how one contributes to the problem, a therapist making an ethically sound decision may feel inhibited and stuck without knowing why.

In order to appreciate the complexities of ethical dilemmas and treatment room conflicts, it is important to acknowledge each part of the problem, as well as admit the hidden realities that complicate the issue. 

Ethical dilemmas represent considerable challenges to massage therapists because, no matter how misguidedly or inappropriately a client behaves, therapists are always responsible for what occurs in the treatment room. When therapists encounter conflict, an ethical dilemma surfaces between the therapist’s personal reaction and the appropriate professional response. The longer therapists wait to clarify their professional role and boundaries, the more clients will make assumptions about what behaviors are acceptable. 

There are a number of important terms associated with ethics. Reflecting on ways that personal attitudes can color a conflict helps to diffuse the issue. Separating personal beliefs and values from professionally ethical choices clarifies decisions. Judging whether an action is good or bad depends on both personal morals and professional principles. 

At no time do ethical dilemmas cause greater concern than whenclients ask for questionable or illegal favors. If therapists are not scrupulously clear about their unwillingness to perform unlawful or unethical acts, then the normal power differential that exists between the therapist and the client quickly reverses. In an instant, the client appears to hold all the cards, taking charge of the session. 

When therapists are unsure about ethical choices or how to act, they cannot make professional choices easily. The reverse is also true. To solve an ethical dilemma requires knowledge of what is ethically right and appropriate. It also requires that therapists have the courage and time to reflect on the triggers associated with an ethically challenging situation. When therapists have a strong internalized code of ethics, they are able to maintain a clear sense of purpose, professional role, and internal sense of power, no matter what the circumstances. Instead of becoming participants in client boundary violations, these therapists use inappropriate behavior as an opportunity to instruct the client and clarify what is acceptable. 

Fundamentally, therapists must learn how to “practice professionally, independent of personal beliefs.” In order to do so, they must differentiate between personal and professional beliefs and explain how the client’s behavior must change. Regardless of how a client behaves, the answer always lies in choosing the professional role over personal impulses. A professional response, delivered empathically, can usually address whatever issues arise from client behaviors.


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References 

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College of Massage Therapists of Ontario, Communication and Public Health Standard #16, Ref. O. Reg. 544/94 Part VIII Sec. 2. Adopted by Council, Jan. 2006. 

College of Massage Therapists of Ontario, Discipline Decisions. Accessed July 6, 2012, from www.cmto.com/forthe-public/ensuring-professional-conduct/disciplinedecisions 

College of Massage Therapists of Ontario, Zero Tolerance Policy, Pol. #26. Adopted by Council, November 2003. 

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This article is an excerpt from Pamela Fitch’s book "Talking Body, Listening Hands: A Guide to Professionalism."

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