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Acta Paulista de Enfermagem

On-line version ISSN 1982-0194

Acta paul. enferm. vol.27 no.6 São Paulo Nov./Dec. 2014

https://doi.org/10.1590/1982-0194201400094 

Original Articles

Meaning of aromatherapy massage in mental health

Thiago da Silva Domingos1 

Eliana Mara Braga2 

1Hospital das Clínicas, Faculdade de Medicina de Marília, Marília, SP, Brazil.

2Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, SP, Brazil.


ABSTRACT

Objective

To understand the meaning of the aromatherapy massage intervention in mental health for the patient during psychiatric hospitalization.

Methods

A qualitative study including 22 participants with a diagnosis of personality disorder hospitalized in a psychiatric unit of a general hospital. We used semi-structured interviews with a guiding question for participants, for whom the aromatherapy massage intervention was performed. The content of the interviews was assessed according to content analysis.

Results

Among the study subjects, there was a predominance of females and the majority presented a diagnosis of Emotionally Unstable Personality Disorder. Two categories that emerged were identified from qualitative data: “Identifying the benefits of aromatherapy” and “Enabling self-knowledge.”

Conclusion

The meaning of the aromatherapy massage intervention was represented by improvements in nursing care and treatment during psychiatric hospitalization, while assisting in the reduction of anxiety symptoms and coping with mental illness.

Key words: Nursing research; Nursing care; Nursing; practical; Mental health; Aromatherapy

RESUMO

Objetivo

Compreender o significado da intervenção de massagem com aromaterapia em saúde mental para o usuário durante a internação psiquiátrica.

Métodos

Pesquisa qualitativa que incluiu 22 participantes com diagnóstico de Transtornos de Personalidade internados em unidade psiquiátrica de um hospital geral. Foram realizadas entrevistas semiestruturadas, com uma questão norteadora aos participantes, os quais se submeteram a intervenções de massagem com aromaterapia. O conteúdo das entrevistas foi avaliado segundo a Análise de Conteúdo.

Resultados

Entre os sujeitos de pesquisa, houve predominância do sexo feminino e do diagnóstico de Transtornos de Personalidade Emocionalmente Instável. Dos dados qualitativos, emergiram duas categorias: “identificando os benefícios da aromaterapia” e “possibilitando o autoconhecimento”.

Conclusão

O significado da intervenção de massagem com aromaterapia foi representado por melhorias no cuidado de enfermagem e no tratamento durante a internação psiquiátrica, ao auxiliar na diminuição dos sintomas ansiosos e no enfrentamento do transtorno mental.

Palavras-Chave: Pesquisa em Enfermagem; Cuidados de Enfermagem; Enfermagem prática; Saúde mental; Aromaterapia; Massagem

Introduction

The utilization of complementary and alternative practices in hospitals has gradually increased around the globe and throughout the country.(1-3) Among numerous techniques that integrate those practices, aromatherapy is based on the prescription of essential oils from aromatic plants, along with the therapeutic plan, administered using the dermal or olfactory pathway, in order to promote and assist the treatment of health problems from various medical specialties.(4)

Aromatherapy is considered to be a growing area, with advances in medical specialties such as psychiatry and oncology. It has been shown to constitute a safe and potentially therapeutic resource to decrease symptoms, such as psychomotor agitation and aggression in patients with signs of dementia.(5) A randomized controlled trial with 67 patients with dementia did not show a statistically significant difference associated to the use or nonuse of aromatherapy massage, however, improvements related to the aggression status were shown.(6) In another similar study, no significant results were found comparing the use of the essential oil, Melissa officinalis, donepezil or placebo.(7) The use of this practice for cancer patients showed an improvement in depressive and anxious symptoms.(8) The use of a self-governing aromatic inhaler reduced symptoms such as nausea and anxiety, enhancing relaxation of cancer patients.(9) In a group of women in the postpartum period at risk for developing postpartum depression, a significant decrease in levels of anxiety and depression was demonstrated, by using essential oils of Lavandula angustifolia and Rose otto at a concentration of 2%.(10)

In this context, to provide aromatherapy as a working tool for use with the patient during psychiatric hospitalization helps with the identification of new ways to qualify the care provided by nurses in the area of psychiatry and mental health, in addition to strengthening the implementation and application of complementary and alternative health practices in the country, and to advance the development of knowledge that supports safe and effective practices. Given the above, the objective of this study was to understand the meaning of the aromatherapy massage intervention for the user with personality disorders during psychiatric hospitalization.

Methods

This was field research, using a descriptive, exploratory, and qualitative approach that included the meanings that users attached to aromatherapy during psychiatric hospitalization. A semi-structured interview was used as an instrument for data collection, with the guiding question: “How did you feel about your participation in the aromatherapy massage during hospitalization?”. The interviews were recorded and subsequently fully transcribed.

The results were analyzed according to content analysis, with the intention of understanding the obtained data and its immediate meanings. This means that overcoming uncertainty, and the possibility of an enriched in-depth reading of the investigated phenomenon were proposed. In this analytical procedure, the following steps were taken: (1) pre-analysis, (2) coding, (3) categorization and (4) inference.(11)

Participating in the study were 22 patients in a psychiatric care unit in a general hospital in the state of São Paulo (SP), in treatment between May and October of 2013, with the medical diagnosis of Personality Disorders and Adult Behavior, according to the International Classification of Diseases (ICD 10), 18 years old or older.(12) The selection of this population occurred by considering the prevalence rate in the unit, the impact that this condition caused on the health team, and the perception of the need to diversify nursing care that was offered in this unit.

We considered as exclusion criteria: hypersensitivity to essential oils, pregnancy or signs suggestive of pregnancy, continued use of antiarrhythmic medications, and cognitive impairment.

The intervention consisted of eight meetings that took place during the psychiatric hospitalization. In the first meeting, the initial contact between the researcher and the research subject was made. This meeting occurred no later than one day after admission to the unit, when the research was presented, and the signing of the consent form was explained. The aromatic solution was also applied in the patients’ antecubital fossa, and signs of irritation or allergy were observed during the following 24 hours (sensitivity test). From the second to the seventh meeting, sessions previously scheduled with users on alternate days occurred with aromatherapy massage and measurement of cardiac and respiratory frequencies. In the eighth meeting, which occurred a day after the last session of aromatic massage, a semi-structured interview with the study subject was performed.

The aromatherapy intervention was characterized by the application of essential oils in six sessions of massage on the muscles of the trapezius and the posterior thorax, lasting 20 minutes, three times a week, on alternate days for two weeks for a total of six sessions conducted in the patient’s room with him/her in the sitting position.

As for the application of the massage, the technique selected was the effleurage, or stroking, which is the application of light and continuous movements on the surface, performed with the entire palmar surface by applying movements in several directions. This is an established method in the aromatherapy literature since its inception, which promotes increased skin absorption of the essential oils and does not stimulate acupuncture points.(4)

The essential oils chosen were lavender (Lavandula angustifolia) and geranium (Pelargonium graveolens), since they present, chemically, a high concentration of ester of 40 to 55% and 15%, respectively. Thus, these oils have a soothing and calming action, being both indicated for anxiogenic situations. We used a 0.5% concentration of each essential oil that was diluted in a neutral gel application during massage.(4,13)

The development of this study met national and international standards of ethics in research involving human beings.

Results

Among the 22 subjects who participated in the survey, 18 were female (81.81%). The mean age of the sample was 34.6 years, with a minimum age of 18 years and a maximum age of 60 years. All patients resided in the same city in which the hospital was located, and had previously used anxiolytic drugs. In relation to psychiatric diagnoses, Emotionally Unstable Personality Disorder predominated in 18 of the study subjects (81.81%); two presented Histrionic Personality Disorder (9.01%), one had Antisocial Personality Disorder (4.54%) and one had Dependent Personality Disorder (4.54%).

The categories of data were prepared using the subject as the unit of record, which, in turn, was portrayed in context units, allowing the anchoring of their meanings. After the development of the qualitative analysis corpus, two categories arose: (i) identifying the benefits of aromatherapy and (ii) enabling self- knowledge.

Category 1 - Identifying the benefits of aromatherapy

In this category, the data that converged to identify the benefits of aromatherapy were presented among the diversity of themes identified by the research subjects.

Subcategory 1.1 - Favoring psychological and physical well-being

The subjects assigned to aromatherapy the function of promoting psychological and physical well- being during the hospitalization period, assisting them in adapting to the environment and reducing some characteristic symptoms of anxiety, such as fixed ideas related to personal problems, anxiety and the state of permanent alert. Collaborating with this experience, the aroma generated by the volatilization of the essential oils was actively perceived by subjects who assigned to it a factor of reassurance and safety.

In relation to physical symptoms, such as decreased psychomotor agitation, tremors of the extremities, palpitations and physical fatigue, which often feature a sudden onset and expose patients to experiences previously suffered and decontextualized during hospitalization. The reduction in symptoms during hospitalization offered a better development of integration, openness and a greater willingness of the patients to participate in activities that were offered to them.

Subcategory 1.2 - Improving sleep pattern

Research subjects reported irregularities in sleep patterns prior to hospitalization, including experiencing this in their homes, where they used to take medications for insomnia. Of the 22 study subjects, 20 reported improvement in sleep pattern (91%), with sleep becoming invigorating or by decreasing the difficulty of initiating sleep. This result was attributed to the application of aromatherapy, given the almost immediate improvement of the sleep pattern, as was noted by the research subjects on the evening after the intervention.

Subcategory 1.3-Emphasizing the therapist-patient commitment

The intervention was explained in detail and scheduled with research subjects. This aspect confirmed the therapist-patient commitment, and was found to be positive, according to the discourses of research subjects. Furthermore, they reported the expectation generated by the scheduling of the sessions and the security they felt from the explanations that were offered on the intervention (essential oils used and the body part that would be massaged).

Subcategory 1.4- Comparing drug therapy and aromatherapy

The research subjects compared, surprisingly, the agility they realized from the effects attributed to aromatherapy with the allopathic treatment they used, even before admission. They also exposed the importance of the availability of aromatherapy after discharge as an alternative to the use of inadvertent drugs if anxiety symptoms appeared suddenly.

Category 2 - Enabling self knowledge

The aromatherapy sessions favored the reflection of the research subjects about themselves and the events that led to psychiatric hospitalization. Whereas the psychological functioning of these patients caused pain in their intrapersonal and interpersonal relationships, activities that promote self knowledge favor their ability to address the recognition and control of symptoms, such as impulsivity and self- centeredness. Two subcategories composed this phenomenon.

Subcategory 2.1 - Promoting a time for self-reflection

The statements elucidate that the aromatherapy sessions served to provide a moment during psychiatric hospitalization in which the subjects could reflect on their actions and behaviors. The subjects illustrated that their daily routines limited these moments to reflect about who they are, about their feelings, their behaviors and their relationships. This reflection led to their awareness of how behaviors, emotional incontinence and impulsivity exposed their interpersonal relationships, creating suffering for themselves and those with whom they lived.

Subcategory 2.2 - Assisting in controlling symptoms

The research subjects were able to identify some symptoms related to personality disorders and observed their decrease: less impulsivity and irritability were the most cited. The reflection promoted by aromatherapy, as explained in the previous subcategory, allowed the research subjects to conceive of their symptoms as traits of their personality, taking responsibility for them. The mobilization of the family and the need for attention during visiting hours were symptoms addressed by research subjects and, according to the subjects, were controlled from the moment they became aware of their psychodynamic functioning.

Discussion

One must consider that the use of aromatherapy in healthcare and its configuration as a nursing care modality are emerging themes in the scientific literature, reflecting the lack of research that address these issues. Thus, we limit the discussion of the results of this research to specific theoretical frameworks of aromatherapy and complementary and alternative health practices. Another limitation of this research was the relationship between therapist and patient as a phenomenon that may have influenced the results, constituting a placebo effect, which is inherent in complementary practices. The results of this research, however, assist in addressing this limitation to be represented in a sub-analysis. Concomitant drug treatment performed during hospitalization represents a bias, as the relief of symptoms may have occurred due to the use of anxiolytics. It is noteworthy that all participants were already using this type of medication and still reported episodes of anxiety before and during hospitalization.

Regarding the study population, the prevalence of women and the diagnosis of Emotionally Unstable Personality Disorder are still questionable factors in the epidemiology of mental disorders. There is no consensus evidence that females have higher prevalence of this subtype of diagnosis. The young age of the population met epidemiological data that considers a negative relationship between the diagnosis of personality disorder and age.(14)

The benefits of aromatherapy were evident from the moment subjects experienced a decrease in anxiety, physical and psychological symptoms, and improved sleep patterns. These results have been suggested previously in studies of clinical design without, however, directly focusing on the users’ perception of such improvements.(13,15,16) These results are attributed to the use of essential oils of lavender and geranium and their respective chemical constitutions, although incomplete knowledge remains about their mechanisms of action. The lavender essential oil is beneficial and indicated for the treatment of irritability, heightened anxiety and insomnia, whereas geranium, in addition to these indications, is associated with hormone action and is related to the promotion of vitality and willingness.(4,14,17)

Complementary and alternative health practices offer the potential for technical care diversification in the Brazilian National Health System (known as SUS), as important tools in promoting autonomy over treatment and increasing the user’s share of responsibility about his or her health. Moreover, it is an alternative care practice to the use of a medical drug, discouraging the phenomenon of social medicalization.(18-20) These aspects are evident in the perception of the research subjects, when one observes that the improvements promoted by aromatherapy were experienced immediately, and when one compares them with the medications that had been taken previously.

The commitment established by the therapist during the intervention, represented by the establishment of dates and the fulfillment of the aromatherapy sessions, highlights the importance of positive recovery of the therapist figure, through the bond and commitment with the user. These factors are inherent to complementary and alternative health practices and represent some of the reasons why users seek out and use complementary treatments.(13,19,21) Still, the therapist-patient relationship is a procedure of great importance to patients with personality disorders, since the therapeutic contract is an indispensable care tool.(22,23) It is observed that psychiatric admissions in general hospitals is a place that fosters the establishment of this bond, because of the low turnover of professionals, thus offering follow-up throughout the patients’ hospitalization and the performance of the nurse as a therapist for patient care in techniques of complementary and alternative health practices. It is noteworthy that in the current mental health policy, psychiatric admissions to general hospitals is a substitutive alternative to crisis management, when other psychosocial care services such as mental health services and primary health care (PHC), were not sufficient for the user’s care.(24)

The intervention provided an opportunity to promote self-awareness, a result that makes it an enriching tool for nursing actions for patients with mental disorders in the psychiatric unit environment in general hospitals, which must focus on providing the users with the ability to recognize themselves in their actions.(22) The recognition of oneself in the psychodynamics of personality disorders was a result pointed out by the subjects, who observed that they were responsible for their symptoms, in particular, for impulsivity. This concept of autonomy and recognition of oneself are affinities based on the knowledge both in alternative and complementary health practices and in the therapeutic interpersonal relationship.(25,26)

Conclusion

Intervention with aromatherapy in psychiatric hospitalization in general hospitals has brought about improvements in many spheres, such as the decrease of anxiety symptoms and the possibility of coping with the mental disorder, and they were accessed through the perception that the user assigned to nursing care and treatment.

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Received: July 26, 2014; Accepted: August 11, 2014

Corresponding author: Thiago da Silva Domingos. Monte Carmelo street, 800, Marília, SP, Brazil. Zip Code: 17519-030. thiagosd7@hotmail.com

Conflicts of interest: none to declare.

Collaborations: Domingos TS and Braga EM state that they contributed to study design, result analysis and article writing. Domingos TS performed the intervention and data collection.

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