Holistic aromatherapy usually combines essential oils with body massage (see Chapters 16 and 17), and this application remains the main form of aromatherapy as taught and practiced worldwide, with at least 6000 aromatherapists practicing in the United Kingdom alone (Walker et al, 2002). Characteristics of this form of aromatherapy include the following:

• Low doses (0.5% to 2%) of essential oils are blended into lipophilic bases such as vegetable oil or lotion and applied to the body with massage.

• The concept of the “individual prescription” with client participation in essential oil selection is regarded as an important part of the therapy process.

• Essential oils are usually blended together (between two and four essential oils), and the fragrance of the overall combination is a main consideration.

• More than one aromatherapy session is usually necessary, with between four and six sessions being the norm.

• A holistic approach is taken with thorough consultation and focus on balance to the body-mind.

• Self-care and home use of essential oils between therapy sessions is usually actively promoted.

• The main risks to the client relate to the methods of administration used; thus dermatitis (irritant, photocontact, or allergic) along with mucous membrane irritation are the key hazards.

The Holistic Aromatherapist

A profile of the average aromatherapist was compiled from a U.K.-based survey conducted in 2001 (Osborn et al). Obviously these trends are not necessarily representative of all countries where aromatherapy is practiced, but in the author’s opinion they do reflect an international profile of holistic-style aromatherapists. Key profile points include the following:

• Most holistic aromatherapists are women.

• Most are middle aged.

• Most are from the middle to upper income bracket.

• Most also practice other complementary therapies, including reflexology, massage, Indian head massage, and energy therapies such as reiki.

• Most are in private practice, although aromatherapy might not be their main source of income.

• Most are working from home or providing domiciliary visits.

• Many also volunteer their aromatherapy services in the community (in rehabilitation centers, hospice settings, residential facilities).

• They liaise with and actively refer to other health care professionals.

Aromatic Medicine or Medical Aromatherapy

As can be seen in Figure 23-1, aromatic medicine, or medical aromatherapy, has its origins in phytotherapy and largely arises, is taught, and is practiced in European countries such as Germany and France where only those who are licensed medical professionals are legally permitted to practice. This more intensive and often internal use of essential oils is now being increasingly taught and practiced in other countries such as the United Kingdom where there may be greater freedom to practice by nonlicensed medical professionals such as herbalists, traditional Chinese medicine practitioners, and practitioners of aromatic medicine (these are usually qualified aromatherapists who have pursued supplementary training in this discipline). This style of aromatherapy is characterized by the following:

• Essential oils are prescribed to treat a range of predominantly physical disorders (e.g., infection, pain, inflammation, specific pathologies).

• Administration methods include topical, oral, sublingual, rectal, vaginal, and inhalational.

• Dosages vary widely according to requirements but are generally higher or more intensive than those employed in holistic aromatherapy.

• Essential oils and other active agents such as herbal tinctures might be used in combination, and they are usually administered by the patient himself or herself rather than by the practitioner.

• It is usually the pharmacological activity of the essential oils that determines their selection rather than aroma or psychophysiological effects.

• The overall formulation takes into account the chemistry of each active ingredient along with the pathologies concerned as the main considerations.

• Selection of essential oils is usually made by the practitioner with little patient participation.

• Risks to the client are mainly related to the administration methods employed, and thus dermatitis, mucous membrane irritation, and toxicity and drug–essential oil interactions are all possible.

The Medical Aromatherapist

A profile of the medical aromatherapist has not yet been determined, but because of the more allopathic approach, it is hardly surprising that trends resemble those among orthodox practitioners, especially in terms of gender. Having worked closely with medical aromatherapists over a number of years, the author has the following observations.

• There is a larger representation of male practitioners than among holistic aromatherapists.

• Practitioners combine essential oil prescriptions with other orthodox care methods for diagnosis and treatment.

• They are more likely to combine prescriptions with alternative forms of medicine such as homeopathy, acupuncture, and herbal medicine.

• They are more likely to be in private practice than employed in a national health service.

• They are less likely to practice other therapies that involve direct care delivery such as massage.

Clinical Aromatherapy

When essential oils are integrated into medical environments to address particular patient challenges alongside mainstream care, the practice is often termed clinical aromatherapy. It effectively represents a merging of both holistic and medical styles that are adapted to individual needs. While most interventions in medical environments still tend toward use of the lower-dose and external and inhalational methods, as in holistic aromatherapy, there is an increasing trend toward and acceptance of using more intensive interventions where necessary for particular clinical challenges, such as pain management, malodor control, wound care, oral care, and treatment of infection. This style of aromatherapy is characterized by the following:

• A holistic approach, especially with regard to well-being and anxiety reduction, remains a key feature of the clinical aromatherapist’s role.

• Interventions are often brief and specifically focussed (e.g., anxiety management, relief of nausea, oral care, wound care, pain relief).

• Most interventions involve topical (including buccal) application or inhalation. Ingestion or rectal administration is less frequent.

• Clinical aromatherapy is usually delivered by a trained practitioner as part of regular health care provision.

• Involvement of the caregiver or the patient’s immediate family is often a key element in care provision.

• There is active liaison with other health professionals.

The Clinical Aromatherapist

The development of essential oil use in the clinical environment was and remains largely nurse driven, although in many settings it is not a prerequisite that the practitioner be medically qualified (e.g., nurse, midwife); indeed, many aromatherapists working in hospitals and hospice settings are not nurses. They are often qualified therapists who have a good understanding of pathology and experience in their specialist area. For example, before working in the cancer care or hospice setting, aromatherapists often pursue supplementary training to prepare them specifically for this field. A range of specialist texts and articles exist for clinical aromatherapy integration (Buckle, 2003a, 2000b; Dunning, 2007; Price et al, 2007; Smith et al, 2008; Tiran, 2000).

As yet there has been no survey of clinical aromatherapists, but based on the author’s experience in working and training in this style, a typical profile becomes apparent:

• Most clinical aromatherapists are women.

• Many but not all have current or prior medical training in disciplines such as nursing, midwifery, physiotherapy, and occupational therapy.

• Many are able to use essential oils within their full or part-time employment as part of their role (e.g. nurse-aromatherapists or midwife-aromatherapists).

• Others are employed as aromatherapists in a specialized health sector such as midwifery, cancer care or geriatric care.

• Many have education to a higher level (e.g., university).

• More aromatherapy research is conducted by or supported by clinical aromatherapists than by either holistic or medical aromatherapists.

• They are more likely to critically evaluate their work, conduct research and document their findings in professional publications.

Aesthetic Aromatherapy

Aesthetic aromatherapy has its origins in the Anglo-Saxon holistic style of aromatherapy in which pioneers of the art and science of aromatherapy such as Marguerite Maury explored the cosmetic benefits of essential oils combined with the whole aromatherapy experience, including massage. Today, work in the research and development departments of many leading cosmetic companies has led to the inclusion of essential oils in cosmetic products as active agents, and research exists to confirm the role of essential oils in skin care. Because of financial rivalry, results of cosmetic research conducted by leading companies are not widely diffused in the professional literature. What has been published confirms the valuable role of essential oils in dermatology (Denda et al, 2000; Hosoi et al, 2000; Monges et al, 1994; Mori et al, 2002), and one specialist aromatherapy text now exists for this field (Bensouilah et al, 2006).

Although the main styles of aromatherapy have been detailed earlier, there can be significant variations and, depending on the country in which each method has evolved, differences in technique and application. For example, while in the United Kingdom aromatherapy training and practice almost invariably include massage, in the United States (due to massage licensing laws, which can vary among states) often holistic aromatherapists are not massage practitioners, working instead with custom blends of essential oils that are then promoted for use in self-care. In addition, the various aromatherapy styles show significant interdependence, with holistic care usually at the core of all the styles (Figure 23-2).

Figure 23-2 Interdependence of styles of aromatherapy.

It is also apparent from the earlier discussion that the main styles of aromatherapy may have different training requirements; however, the reality is that, although training provision is well structured for holistic aromatherapy, with minimum standards already established in a number of countries, training in clinical and medical styles is less well recognized and standards are not consistent internationally. For example, in France, training in the medical aromatherapy style that is aimed at medical professionals is extremely variable in duration and content. A recent bold move in Australia is the establishment of national training standards and competencies for aromatic medicine as separate from aromatherapy (available through http://www.NTIS.gov.au); it is the first such move in the world, and it is anticipated that other countries will respond in a similar fashion in the future.

THERAPEUTIC POTENTIAL

There is a wealth of research to support the therapeutic value of essential oils, and in recent years this evidence has become increasingly disseminated and accessible in professional publications. The immense psychophysiological potential of essential oils is due to two or three factors.

1. Essential oils are fragrant substances. Thus they are able to impact the body-mind via the olfactory sense, with all its deep-seated limbic and higher brain connections that influence, among other things, emotions, memory, desire, basic drive, and hormonal response. The olfactory neurons travel directly to the frontal portions of the brain. For these reasons, inhalation of essential oil fragrance is considered a key aspect of an aromatherapy treatment.

The capacity of fragrant substances to influence emotions and behavior has led to the field of Aroma-Chology as defined by the Sense of Smell Institute (formerly the Olfactory Research Fund; http://www.senseofsmell.org) in 1989. This field is dedicated to the study of measurable effects of the interrelationships between psychology and fragrance technology and is not restricted to essential oils and naturally derived aromatics. However, there is a significant overlap between Aroma-Chology and aromatherapy, with aromatherapists going a step further to seek physiological benefits of essential oils, either indirectly via the olfactory sense or more directly through their absorption and pharmacological activity. A recent systematic review addressing the psychophysiological effects (on mood, cognition, behavior, performance, physiology) of fragrant substances (Herz, 2009) confirms that they can significantly impact the body-mind via inhalation.

Aromatherapists use these confirmed mood-enhancing benefits of fragrance to reduce stress and thereby improve general health and well-being. However, these effects are largely influenced by context, expectation, prior experience of the aroma, its concentration when presented, and perception of the fragrance as pleasant or unpleasant. Indeed, it may be possible that psychological effects can override the potential physiological properties of an essential oil (Moss et al, 2006; Robbins et al, 2007). This may explain the inconsistencies that are sometimes found when attempts are made to measure the effects of individual essential oils on the body-mind (Neale et al, 2008). There is nevertheless supportive evidence for the positive and measurable effects of aromatherapy in relieving stress and anxiety and promoting well-being over a range of administration methods and evaluation tools (Atsumi et al, 2007; Cooke et al, 2000; Morris, 2008; Saeki, 2000).

2. Essential oils are pharmacologically active. Their chemical components are secondary metabolites produced by the plant predominantly for defensive purposes, and they are thus biologically active substances. Because of their lipophilic nature and small molecular size, many components of essential oils are able to penetrate the body irrespective of their route of administration and exert a pharmacological impact either locally (in the tissues surrounding their application site) or systemically (via the bloodstream). For these reasons, essential oils are often administered via different routes according to the needs of the individual. The capacity of essential oil components to enter the bloodstream via different routes has been studied, at least for inhalation (Buchbauer et al, 1991; Jager et al, 1996; Stimpfl et al, 1995) and topical administration (Fewell et al, 2007; Fuchs et al, 1997; Jager et al, 1992), and pharmacological effects are confirmed via ingestion for a range of pathologies (Goerg et al, 2003; Juergens et al, 2003; Kerhl et al, 2004). Because of the increased physical and metabolic barriers at the skin interface (stratum corneum, especially) compared with other routes of administration, this route is likely to result in extremely low (but nonnegligible) amounts of active components’ reaching the bloodstream.

Assuming therefore that some essential oil components are able to enter the tissues locally and/or enter the bloodstream, there are a number of pharmacological possibilities. The main actions are listed in Table 23-1.

TABLE 23-1 Main Pharmacological Actions of Essential Oils

Action	Research studies (not exhaustive)
Analgesic	Yip et al, 2008 (ginger and orange) Le Faou et al, 2005 Greenway et al, 2003 (geranium)
Antibacterial	Cermelli et al, 2008 Enshaieh et al, 2007 Dryden et al, 2004
Antifungal	Sokovi´c et al, 2008 Khosravi et al, 2008 Jirovetz et al, 2007
Antiinflammatory	Chao et al, 2008 (cinnamaldehyde) Lee et al, 2007 Ghazanfari et al, 2006
Antioxidant	Singh et al, 2008 Chung et al, 2007 Zhang et al, 2006
Antiparasitic	Navarro et al, 2008 Scanni et al, 2006 Oladimeji et al, 2005
Antispasmodic	Goornemann et al, 2008 Grigoleit et al, 2005 Jahromi et al, 2003
Antiviral	Schnitzler et al, 2008 Schnitzler et al, 2007 Giraud-Robert, 2005
Carminative	Alexandrovich et al, 2003 Goerg et al, 2003
Cicatrisant	Amanlou et al, 2007 Orafidiya et al, 2005 Orafidiya et al, 2003
Deodorizing	Warnke et al, 2006 Mercier et al, 2005 Sherry et al, 2003
Immune stimulating	Nam et al, 2008 Serafino et al, 2008 Mikhaeil et al, 2003
Mucolytic and expectorant	Fenu et al, 2008 Kehrl et al, 2004 Mattys et al, 2000
Rubefacient	Xu et al, 2006 Hong et al, 1991 Green et al, 1989
Sedative	Moss et al, 2006 Lim et al, 2005 Koo et al, 2003