The usefulness of a rehabilitation programme for people with stress-related disorders - A case from a rehabilitation center in Estonia.

Psychotherapy

Psychotherapy interventions are applied to people with stress to have positive qualities, strength, empowerment, energy, self-control, and self-motivation to function adequately and gain energy to overcome problems of people with stress (Schrank et al., 2014, 95-103). There is strong evidence that psychotherapy is effective for self-motivation; therefore, motivation constructs people’s strength and encouragement, improving their courage to accomplish tasks (Widodo, 2015). According to Mangkunegara (2013), motivation influences arousing, directing, and balancing behavior in any environment. A previous study has revealed that when individuals have not completed a psychotherapy well-being program (Hüning et al., 2020), it results in more deterioration of stress disorder (Lamers et al., 2015, 553–560). Therefore, to prevent relapse and improve the full recovery from stress, it is necessary to increase psychotherapy well-being interventions (Fava et al., 2017, 801–808). Muzio, (2004), mentioned that well-being therapy is essential to creating a situation in which mastering life acts in connection to a worthwhile working life. Another term for the psychotherapy well-being program is self-mastery or self-control, which is useful for relieving stress that has been confirmed in various qualitative studies about the usefulness of this program (Åhrberg et al., 2010, 167-77). According to Karlson et al. (2010), a psychotherapy rehabilitation program is a useful method for self-control. However, no one has scrutinized how it affects self-mastery or self-control in individual life. Fava et al. 2017, stated that a more recent study showed that on behalf of common mental disorders, psychotherapy well-being is more effective in improving well-being and reducing stress symptoms than Treatment as Usual (TAU). However, many health practitioners and psychiatric doctors prescribe only anti-depressive medication to relieve stress rather than referring to the psychotherapy rehabilitation program because ignoring or thinking about psychological rehabilitation programs is not a useful method of intervention for relieving people with stress (Salomonsson et al., 2018, 1954-1965). However, psychotherapy rehabilitation is paramount and acts from assessment to patient recovery and further follow-up to home rehabilitation, whereas other interventions provide symptomatic management of patient care. According to Stevens-Watkins et al. (2014), psychological resilience is another intervention in a psychotherapy program that describes the ability to cope mentally or emotionally with a crisis or to return to pre-status instantly. A resilience psychotherapy program is defined as the ability to adapt and apply to obtain better outcomes for employees, people, and family stressors for people with stress (Muzzio, 2004). Rehabilitation counselors act as role models by providing an assessment of resilience and, therefore, establishing a resilience training plan for employees for home-living people and other cases that have stress symptoms with respect to providing robust support (Kosciulek, 2011, 8-12). Another important point of resilience training is allowing people to share their feelings and exchange their ideas, concepts, and skills with others in a positive way, where they can enjoy their lives purposefully (Leahy, Chan & Saunders, 2002, 68-81). The author noted that the previous coherence study, 2015, applied psychotherapy, cognitive-behavioral therapy, and other programs resulted in low effects on people with stress, because of the low methodological quality of research where treatment criteria were based on medications and a small number of participants who took part in this research as a selection method (Ruotsalainen et al., 2015). However, according to Yunus (2014), psychotherapy, and cognitive-based therapy were most frequently used in many rehabilitation programs, and people with stress have obtained significant results from this program in addition to other programs that showed the most promising results on reducing stress. However, given the lack of previous literature, it is urgent to investigate from the primary data how psychotherapy therapeutic programs contribute to relieving stress in people’s lives.

Cognitive-based programs

Cognitive-based programs are utilized to improve individual thoughts and behaviors and make positive changes to individual lives. Cognitive-based programs are most frequently used in the rehabilitation of patients with stress. Generally, cognitive impairments occur in the areas of attention, concentration, working memory, and episodic memory. Therefore, cognitive-based rehabilitation programs play a major role in reducing stress impairments, although the program has not been empirically investigated before (Glise et al., 2012, 18). Cognitive rehabilitation programs are the most frequently used rehabilitation programs for stressed patients because they reduce stress by improving patient attention, concentration, and cognitive function. Cognitive rehabilitation programs focus on stress prevention when applying cognitive behavioral therapy (CBT), various types of behavioral training, and convulsion therapy. Deligkaris argues that during the past decade, cognitive rehabilitation programs applied in patients with stress-related impairment have shown that the condition is associated with de facto cognitive impairment that improves concentration, attention, and memory impairment (Deligkaris et al., 2014, 107-123). This statement indicates that cognitive rehabilitation programs applied in patients with stress are associated with de facto cognitive impairment that improves concentration, attention, and memory impairment in patients. Cognitive rehabilitation impairment programs have been utilized in practice for invigorating concentration, attention, and stress-related conditions that have been associated with de facto behavior for the past decade. De facto means, which exists in reality, regardless of whether they are officially recognized by laws or other formal norms. It is commonly used to refer to what occurs in practice. Cognitive rehabilitation training programs are used for cognitively challenging tasks, especially in neuroplasticity, which means the ability to adapt to any situation through structural organization and simultaneous change behavior (Lindenberger, Wenger, & Lövden, 2017, 261-262). Therefore, it is approached in two ways: strategic and process-based training. Strategic training focuses on teaching strategies, for example, computer-based training that performs specific tasks, whereas process-based training mainly concentrates on executive function and working memory (Ball et al., 2002, 2271-2281).

Occupational therapy

Occupational therapy is a therapeutic program that focuses on refining a patient’s ability to perform activities of daily living. It facilitates the learning of skills and functions essential for adaptation to the environment and for promoting and maintaining health. The Occupational Therapy Journal defines it as a scientifically based program that provides interventions for mental disabilities and impairments that help a person lifelong through the therapeutic use of various activities, social activities, and cognitive changes (Occupational Therapy Journal, 2017, 24). This statement indicates that occupational therapy provides interventions for various disabilities and impairments in people with mental health problems by preparing various therapeutic activities. Occupational therapy is a rehabilitation-based program that enhances a patient’s recovery and creates a balance in daily working: for example, occupational therapy assists in accomplishing daily tasks routinely and meeting deadlines. Occupational therapy aims to promote individual self-esteem, encourage functional activities, and promote independence. Despite the usefulness of occupational therapy in a mental health care setting, there has not been enough systematic review in various research or journals about the program’s influence to gain energy and motivation to get involved with surroundings (Lopez, 2011).

Physiotherapy

Physiotherapy is a scientific-based program that provides assessments and interventions to restore maximum function and improve mobility and well-being. It also prevents risk, injury, and illness through various rehabilitation programs. According to Klaperski. S. et al. (2013), Physiotherapy provides well-documented health benefits and is the remedy for many stress-related illnesses. Physical activity contributes to decreased physiological reactions to psychosocial stress. These statements indicate that performing physiotherapy aerobic exercise reduces cortisol levels and increases the activity of the hypothalamus-pituitary-adrenal gland, which reduces blood pressure and stress. Accordingly, group-based training programs are useful for obtaining more motivational support for teamwork in each workforce to improve cognitive function, including attention and concentration, and increase adaptability and self-esteem (Hötting et al., 2012, 332-346). Physiotherapy has also been shown to improve coping ability in various adverse environments and to enhance self-control, which can alleviate stress from challenging situations (Kirschbaum, C.& Hellhammer, D. H. 2000).

Research design

The qualitative study design is being conducted in this research because people with stress require evidence-based recommendations to fulfil their future needs, which is only possible in the qualitative study design (Hoefsmit et al., 2012, 462-477). Reviews many inconsistent results revealed between quantitative on behalf of usefulness on stress, therefore, quantitative research design is not likely to discover an in-depth understanding of people’s knowledge and skills regarding stress which may affect the success of interventions (Briand et al., 2008, 207-217 & Pearson et al., 2005, 207-215). Given that, the author selected a qualitative study design that discovers the historical background related to people’s problems and supports them through various rehabilitation programs (Corbière et al., 2016, 511-519). This study aimed to determine the usefulness of rehabilitation programs for individuals with stress-related disorders. The research question is how useful is the rehabilitation program for people with stress-related disorders? A convenient sampling method was selected in this research, which is an easily accessible and convenient way to collect samples with allocated time and resources. Semi-structured interview questions were formulated in which participants expressed their feelings and conversed their histories in their own words. Open-ended and closed-ended questions were devised for this study. The questionnaire included 12 questions, and 10 participants were selected throughout the interview process. The researcher formulated an interpretive research design to obtain in-depth information and explore insights into the data, whereas positivism mainly focuses on quantitative research design (Thanh & Thanh, 2015). According to Willis (2007), the interpretive approach is more subjective, therefore, the goal of interpretivism is to create value subjectively. Thomas (2003), stated that qualitative approaches are always supported by interpretivists because the interpretive paradigm portrays a world in which reality is socially constructed, complex, and ever-changing. Based on the above characteristics, a qualitative study with an interpretivism design was conducted in this study, which investigated the usefulness of rehabilitation programs for people with stress. Therefore, it is useful to know how rehabilitation programs act on people’s stress to improve their daily activity plans, self-motivation, attention, coping ability, self-control, etc. (Koerner, 2011, 45-67).

Sampling

The author selected convenience sampling was used to gather data that were easily accessible and available within the allocated time and resources. These samples are intended to be generalized to the population and the future. According to Leiner (2014), the main objective of this sampling is to obtain information from participants who are accessible and homogeneous. In another way, this sampling method was affordable, the subjects were ready and available, and the criteria were suitable for conducting this research. The sample was collected from the healthcare industry to provide significant outcomes and results to complete this study efficiently. To avoid biases, the author did not take any representative, therefore, the author met the participant in person for the entire interview process. As a qualitative study method, only 10 participants were selected after obtaining their consent and approval to participate in this study. The participants aged between 25 and 55 years old. This age range was chosen because of a better understanding of the services of the rehabilitation program. Before conducting the interviews, the author arranged meetings with the management in each organization to obtain consent before meeting clients. After obtaining consent from every participant, the author started conducting interviews in person according to the questionnaire. The author provided the participants with an idea of the research topic, the aim of the study, and the inclusion and exclusion criteria.

Inclusion criteria

Exclusion criteria

Setting

The recruitment period was from January to March 2020. The author chose various rehabilitation centers, however, the interviewees were from the Marienthali Clinic, Aarika, and Elil Rehabilitation Centre, depending on the participant’s availability and selection criteria. I selected samples from these organizations to generalize the usefulness of the rehabilitation program. The author justified the reason for choosing this rehabilitation center in light of getting participants easily and conveniently within a short period rather than selecting any other healthcare organization. Moreover, these organizations were invited to execute therapeutic centers, where all multidisciplinary teams, including doctors, nurses, psychologists, and social workers, carried out various rehabilitation programs on a day-to-day basis. In addition, the services were conducted from the patient assessment to discharge to further follow-up where the author had an opportunity to obtain in-depth knowledge of participants’ history and their experience in this field. On the other hand, the author excluded other rehabilitation centers because they were not well-structured and documented in the individual participants’ records. Furthermore, the selected participants met the inclusion and exclusion criteria of this study.

Aarika Ou

The organization was inaugurated in 2008 to provide psychiatric services, especially for stressed clients. The Aarika board of the directorate has introduced various rehabilitation services, such as psychotherapy, psychiatric clinical, special education, occupational rehabilitation, physiotherapy, and specialist care education, since 2008. Most clients were referred by the government’s unemployed health services and social welfare department, therefore, very few patients were referred by general practitioners or psychiatric doctors for rehabilitation programs in this organization. However, this organization has a reputation and maintains a protocol in which patients’ records are well-documented, updated, and available from the first admission until their discharge, along with rich confidential systems. Furthermore, the participants’ data were captured easily and conveniently from the systems and paper files for further analysis.

Marienthali clinic

The organization has been serving various treatment programs for patients since 2017. The clinic consisted of a psychiatric doctor’s department, psychology adults and children, nurses, physiotherapy, occupational therapy, and social rehabilitation. The organization provides services on an outdoor basis, which means that patients receive their care plans and then go home. The clinic’s doctors did not refer clients to any of the rehabilitation services, although the patients benefited from the rehabilitation programs. According to the participants’ viewpoint, most of the patients did not refer to rehabilitation services. The author selected this organization owing to the confronted loads of patients receiving services who have a variety of conditions and have very intriguing histories about their past service. The environment of this clinic was calm and quiet, and the clients could express their emotions and feelings in their own words safely and effectively.

ELIL Rehabilitation Center

The Estonian Association of People with Mobility Disabilities introduced ELIL in 1989. In the past, they had various awareness programs based on education and teaching facilities to ensure accessibility for all sectors of people who have mental health issues and are physically disabled. However, many services had already been shut down because of the change in Estonian administrative policy and procedures. Primarily, the servicing systems of the organization were based on occupational rehabilitation, which includes physiotherapy, psychology, occupational therapy, special education, etc. The author selected this organization because, to begin with, it is a rehabilitation center. Moreover, clients would not have been referred to receive rehabilitation programs in the first instance unless they had taken medication from psychiatric doctors. even though it was recommended earlier by the Social Welfare Department. Furthermore, participants were very enthusiastic about conducting face-to-face interviews to share their experiences in this research.

Data collection

Data collection methods were devised in this study while selecting the qualitative form of the research approach. Data collection methods were segregated into two types of sources, secondary and primary. Primary data were collected from the participants’ comments. Secondary data were from reliable sources, such as existing literature, including journal articles, books, academic papers, and scholarships. The secondary sources were recaptured from the EBSCO discovery service and EBSCO academic database, Google Scholar, Taylor and Francis, Emerald Insight, and the Journal of Rehabilitation Medicine. The questionnaire also highlighted the usefulness of primary and secondary data. The authors reviewed more than 80 journal articles to identify the most relevant data for this research. Academic papers that had been published in recent years were also reviewed for the analysis of these research findings. At the same time, the author enclosed some journal articles that were not so recent but gave some significant, concrete ideas and relevant to compare that were being kept in this prospective research. Many articles and sources were rejected due to poor methodology, very old-fashioned publications, etc. Convenience sampling methods were used in this study. Semi-structured interviews were selected because they proved to be versatile and allowed both individual and group interviews (DiCicco-Bloom & Crabtree, 2006, 314-321). According to Gill et al. (2008), the semi-structured format is the most frequently used interview technique in qualitative research studies and a healthcare context, given that the author decided, a semi-structured format to obtain in-depth data. Semi-structured interviews are convenient for collecting rich descriptions of this topic. With semi-structured questions, participants had the freedom to explain their feelings in their own words. All data were collected by the researcher using a physical method to avoid bias. As mentioned earlier, 10 participants were selected from the rehabilitation center. Some of them were allocated to ongoing rehabilitation programs, and a few were waiting to finish their rehabilitation program. The interview was conducted in English and hired interpreters to translate difficult English words to make a simple form in the Estonian language. Face-to-face interviews were conducted because this may provide a higher response rate than any other data-collection method. During the interviews, key points were noted without interrupting the flow of interviews. A voice memo was used to record the conversations and discussions with the participants. Simultaneously, a pen and paper were used to write the notes. The questionnaire was designed to conduct interviews with selected participants. The interviews were recorded after permission was obtained from the participants. The interviews continued until the saturation point was reached. The data collection was carried out over time, therefore, semi-structured, convenient sampling, and questionnaires including open and close-ended questions were used in this research.

Sample question and questionnaire

The sample questions were formatted as open and closed-ended in English and Estonian to gain more confidence about the facts, situations, and circumstances of their problems. The author formulated some generalized questions to get inside the participants’ views to discover any specific ideas or concepts from the participants’ statements to justify this research aim. In the case of difficult Estonian languages, translators were hired to harness simple languages. According to Estonia Language Facts and Stats (2019), only 50% of the population in Estonia can read and make a sentence in English, whereas a high percentage of the population has a good command of the Estonian language. The same questions were asked to all participants with an equal timeframe to collect the primary data. It was observed that most participants could speak and understand the English language but sometimes needed to explain difficult English words. The interview duration was 40-50 minutes. The questionnaire included 12 questions covering the most important points that the researcher wanted to carry out in this research. Open-ended questions were formulated, whereas by providing open-ended questions, participants had an opportunity to talk and tell stories about real facts or incidents; therefore, those stories or facts create a good context that makes qualitative research more reliable and valuable. The author encompassed close-ended questions, such as the LIKERT Scale, multiple choice questions, and yes/no questions to participants understand and provide the right answer within a short time. For Instance, physiotherapy/occupational therapy/psychotherapy/cognitive therapy, and good/very good questions. The questionnaire was described as follows.

Questionnaire: (Hossain M, 2024)

Data analysis

After taking the entire interview, the voice memos and notes were transcribed fully to make a final note. The data then progressed to the data analysis phase for examination, interpretation, and management. In the initial phase of the analysis, data were collected from the participants and organized according to the questions for analysis, consolidated, and further analysed. The transcript was read several times to get inside the data and determine the participants’ comments for discovering recurring codes that stand out. Primarily, all transcribed interviews were formatted into a code. All codes were verified thoroughly to ensure that they were different from one another. The Author used a code to provide a clear description. The purpose of coding is also to safeguard the confidentiality of the participants’ personal information, except for their willingness to disclose. Therefore, whatever the participants stated was reflected in the codes. All interviews were coded and levelled line by line to ensure that they were close to the participants’ words. Extract codes within the participants’ interviews were compared to each other to determine similarities, differences, closeness, and completeness from every individual opinion, therefore, they were formulated. After categorization, all categories were combined for further exploration. Once the code was transformed into a category, the findings were formulated, based on the category. To enhance credibility, the author devised a comparison of the study findings with the primary and secondary data to verify consistency with previous research and journals or articles to ensure the authenticity and generalizability of the research findings. Three essential aspects occurred in the data analysis process: data organization. summarization and categorization together contribute to the second known method used for data reduction. It helped to find patterns and themes in the data for easy identification and linking. The third and last parts of the data analysis were both top-down and bottom-up. Data analysis is as important as data collection methods because poor data analysis does not carry out good research findings and reduces the image of overall research.

Quality services

The author formulated this category in the first place to understand if a rehabilitation program does not provide quality service, then how it generates a useful factor for people with stress. The rehabilitation program offered quality services with effective interventions for patients. The majority of participants had a positive opinion about the treatment procedure of the rehabilitation program, which means that it is an intensive care plan and provides good quality services. In other words, when a rehabilitation program provides quality services, there is no doubt that the rehabilitation program itself is a good treatment procedure as well. Participants specifically mentioned psychotherapy and physiotherapy programs, which have influenced the care of relieving stress and have many useful roles in providing good quality services. However, cognitive-based therapy (CBT) and occupational therapy have many other useful roles in relieving stress. The findings of this study revealed that the rehabilitation program is a good treatment procedure that provides quality services in the context of Estonia. The author brought a segment from the literature review for comparison that the rehabilitation programs do care for individuals to get back their previous life, and enhance physical, mental, cognitive, functional, and well-being. This particular context highlights the need for a rehabilitation program for all purposes and offers quality services for individual daily life. However, one participant gave one negative response. The rehabilitation program is useful and conveys a good treatment procedure, but people are not completely satisfied with the rehabilitation program because they do not get around a skilled service provider, albeit meeting their demands. Eventually, it is explored that the findings of this research study have positively reflected in terms of the usefulness of rehabilitation programs for people with stress disorder.

Self-motivation

Self-motivation is a psychotherapeutic intervention procedure for rehabilitation programs. After gathering participants’ statements, it was revealed that the client is optimistic about the future when the rehabilitation program heals their stress and encourages them to learn new objects because they do not want to adapt to any transformation in their lives. People are satisfied with the rehabilitation program because they enjoy it every day and feel that they are in their comfort zone. In addition, they found that rehabilitation was a useful treatment method in light of utilizing a client-centered approach, which is rare in any other interventions. On the other hand, another participant commented that people’s motivation for rehabilitation services was positive and enquired about receiving more rehabilitation sessions. This statement reflects that motivation is a characteristic of positivism but still does not live up to their satisfaction level because they want more rehabilitation programs.

Daily activities plan

The daily activities plan is a treatment procedure for occupational therapy, as well as a physiotherapy rehabilitation program. According to the participants’ view, the rehabilitation program executed a daily living activities plan in various phases of life. Hötting et al. (2012), indicated that physiotherapy constructs everyday daily routine activities, creates strategic plans, and analyses everyday life schedules. Rehabilitation acts as a guideline for how people manage their time at home and in the workplace effectively and successfully during their stressful lives. Nevertheless, (Spencer et al., 2017) in a previous literature review explained that occupational therapy is an evidence-based practice of rehabilitation programs but is not useful in terms of people with stress-related disorders. In contrast to this statement, the opposite opinion emerged in primary data. Therefore, without the usefulness of occupational therapy programs, how do people manage their tasks effectively and in a timely manner? Occupational therapy redesigns daily activities to improve individual skills. This category is designed for stressful clients in various environments in Estonia, who are in homes or workplaces. Therefore, it is necessary to have a good activity plan for workers to mitigate substantial days off from the workplace, hence, if this can be prevented, organisational productivity will be enriched. One of the indispensable statements was delivered by one participant regarding the contribution of the rehabilitation program. As such, it provides the right direction for various activities, but the rest of us have to do it ourselves. This does not help if we do not contribute. This statement indicates that the rehabilitation program itself cannot provide the right direction unless other health professionals are involved. This statement is consistent with the research problem. As such, if a patient is not referred to receive rehabilitation by other medical services, then the rehabilitation program itself is not able to make the referral, and it requires collective efforts. Conversely, one distinctive comment came from another participant not see any major change in her condition because of not carried out exercise regularly. This means that if someone does not carry out home exercises regularly, she or he is not able to see any changes in his condition, but we cannot say that the rehabilitation program is not useful.

Self-control

Self-control or self-mystery is a psychotherapy well-being therapeutic rehabilitation program. After analysing the participant’s comments, it was found that the rehabilitation program was useful for the self-control of individuals during various activities. The psychotherapy rehabilitation program helps people learn more about how to control themselves. The Author brought up a comparison study of rehabilitation programs and hospital services. By receiving rehabilitation services, people think that they are not isolated, can control their emotions, and are fully connected with interim service providers and service users. In contrast, hospital services are based on medication, where there is no management of how to control emotions, no connections from service providers to service users, or even no motivational support from the services. Accordingly, a rehabilitation program ensures that every individual can enjoy their day-to-day life efficiently with positive control, whereas hospital-based services are not able to provide any of them. Self-control or Self-mystery is a salient factor in relieving stress, which is highly demanding in terms of various psychological factors (Åhrberg et al., 2010, 167-77), and imposed well-being therapy is a more effective intervention in reducing symptoms than Treatment as Usual (TAU) (Fava et al., 2017, 801–808). However, according to Ruotsalainen et al. (2015), previous studies indicated that psychotherapy has low effects on people’s stress due to the low methodological quality of research, and a small number of participants recovered compared to the administered Treatment as Usual (TAU) procedure. However, this research found that a psychotherapy rehabilitation program is a useful method of intervention for the self-control of every individual during various activities and encourages people empowerment, which is not possible with any hospital-based intervention or even Treatment as Usual (TAU).

Recovery

Many participants stated that a rehabilitation program was a substantial tool for recovery from the initial phase to the recovery stage. Thus, the participant could complete the tasks in an effective time frame through the rehabilitation program. A rehabilitation program provides various interventions that help patients recover early, as it is a scientific-based therapeutic program that assists in being more accurate. Accordingly, a medium-progressed client receiving a rehabilitation program can still hope to recover even though her rehabilitation program has not yet finished. This means that rehabilitation is a useful and recovery-oriented treatment method in which clients benefit from the initial assessment to further follow-up procedures. When all clients have positive comments regarding the recovery of the rehabilitation process, there is no denying that the rehabilitation program is a useful method to relieve stress. The author found that there were no negative comments from any of the participants about the recovery sections. Conversely, the literature review stated, that many health practitioners, including psychiatric doctors, prescribe only anti-depressive medication to relieve stress rather than referring to the psychotherapy rehabilitation program because ignoring or thinking of psychological rehabilitation programs is not useful for relieving stress. In summary, a rehabilitation program is a useful method of treatment, if the symptoms remain mild further progress is possible.

Attention and concentration

Attention and concentration are a cognitive-based interventions and physiotherapy methods used in rehabilitation programs. A greater number of participants perceived that rehabilitation programs focused on individual tasks and enhanced physical, mental, and cognitive functions. Previous studies have shown that cognitive interventions have insignificant effects on reducing stress symptoms compared to Treatment as Usual (TAU) (Perski et al., 2017, 551-561). However, concerning the practical observation of primary data on clients’ opinions, positive results were ascertained from the participants’ comments. However, one negative perception emerges from one individual, the rehabilitation program creates more attention on tasks but not a major change in her stress condition. This statement does not imply that the rehabilitation program is not useful, as the client has obtained significant results with attention to tasks but has not progressed adequately on stress due to probably not attending regularly or revealed that progress in delay depends on person to person. Cognitive-based rehabilitation programs are the most effective intervention for stress disorders. On the other hand, another participant commented, that she had not seen significant change through the rehabilitation program at home, but when she was at work, was told by her friends that her attention to activities had refined and, in the end, she realized why the rehabilitation program was required for people under stress conditions. Moreover, according to the last client’s perception of no comments about the rehabilitation program, either it brings positive or negative changes in relieving stress. This is due to some conceptual overlapping interventions interrelated with Treatment as Usual (TAU) and cognitive rehabilitation programs, such as executive function, memory training, and attention and processing speed (Cohen, J. D, 2017) where sometimes the outcome would not appear when all interventions were applied together.

Coping skills

Coping skills are rehabilitation interventions in psychotherapy and physiotherapy programs. According to one participant’s impression, the rehabilitation program enhanced coping skills to get closer to the family members. Another participant’s perception was that as soon as she started the rehabilitation program, she managed to adapt to new things, new ways to exercise, new ways to see various situations and overcome stress symptoms. According to Stevens-Watkins et al. (2014) in the previous article from the literature review, psychological resilience is an intervention of psychotherapy that describes the ability to cope mentally or emotionally with a crisis or to return to pre-status instantly. The resilience psychotherapy program is defined as the ability to adapt and apply to obtain better outcomes for employees, people, and family stressors for people with stress (Muzzio, T, 2004). Another important point of resilience is allowing people to share their feelings and exchange their ideas, concepts, and skills with others in a positive way, where they can enjoy their lives purposefully (Leahy, Chan & Saunders, 2002, 68-81). Moreover, according to Gerber et al. (2012), a higher level of physical ability indicates higher resilience and lower stress when applying various settings of physical activity programs. On the other hand, one participant’s conception was that the rehabilitation program does not affect her significantly, sometimes the effectiveness depends on the environment and social circumstances, and then again, she stated that she had only completed a few sessions, not even completing a total of the rehabilitation program. This means that the participants did not disagree about the usefulness of the rehabilitation program regarding coping ability. However, there are some disputed opinions in the literature review due to limited laboratory findings, little-known knowledge about the efficacy of rehabilitation programs, and low methodological research. As a result, the actual outcome of rehabilitation programs was not visible. Eventually, it was devised from primary data rehabilitation programs as a useful intervention method to enhance coping skills.

Medicine based treatment

The purpose of collecting additional data in a qualitative study was to maintain the standards of the research findings. The author formulated this additional category to identify and analyse participants’ perceptions of how Treatment as Usual, especially medication, contributes to individual clients in everyday life. Accordingly, the author devised concrete outcomes from primary data findings; however, secondary data have various opinions about Treatment as Usual (TAU) regarding relieving stress. According to the participants’ impressions, medication is not a useful intervention method that has various side effects compared to the rehabilitation program. Accordingly, participants also raised comments about the hospital and free health services where patients did not receive appropriate treatment facilities and the treatment was based only on medication. Practitioners did not deal with actual patient problems, not even referring to appropriate rehabilitation services, unless they produced any significant outcomes from the medication process and, in many cases, services overlapped by the practitioners in some cases. However, few clients receive rehabilitation services by chance when they have long queues for medical services. In other cases, the patient was referred to a green forest as a traditional method of intervention, which is not even a structural method of treatment while maintaining some rules or regulations. This is due to ignoring rehabilitation programs as an effective method of intervention or prioritizing pharmacological practice. Other participants commented when patients recovered from rehabilitation programs, they never came across receiving any further hospital services or even taking medication. On the other hand, one participant’s perceptions about the management systems of ‘Parnu’ Hospital were very impressive but did not refer patients to rehabilitation services. Grossi and Santell (2009), Brouwers et al. (2009) and Heiden et al. (2007), De vente et al. (2008), stated in a previous study that no or only marginal differences between various rehabilitation strategies and Treatment as Usual (TAU). However, it explored from the primary date that Treatment as Usual (TAU), especially medicine, can only change the symptoms; therefore, patients are not motivated by medicine due to not contributing individuals changing their life and dividing activities plans or assisting in adjusting various environments and even creating a balanced life in society.

Limitations

The lack of understanding and knowledge of the participants about the usefulness of rehabilitation programs during the interview could have affected the quality of the responses. Due to inadequate rehabilitation centers in Estonia, clients have to be discharged before completing the full program; consequently, short interventions may have little or no effect on rehabilitation programs. In other words, as an author, it can be suggested to generate a larger sample size in future research, where articles will be formulated with adequate comparison along with an appropriate design and tool. Due to limited time and resources, a large sample selection would not have been taken where there was feasibility to get more ideas and concepts, the way to make research more reliable, valuable, and more scientific. Some participants could not speak English, therefore, the translation from Estonian to English and vice versa may have missed some context from the full interpretation.

Ethics and consent

Ethical approval name: The Ethics Committee of Estonian Entrepreneurship University of Applied Sciences (EUAS).

and the date - 06/05/2020.

The approval committee: Estonian Entrepreneurship University of Applied Sciences - regulation no 2.5.1-344.

The approval number: 350

Participants were informed verbally and with written consent according to their level of understanding of the aims of the research. They received a clear conception of the research study guidelines and provided informed consent in writing that their presence depended on their willingness, to participate as attendees. Participants were aware that their information might be published, but their names, ages, and addresses would not be published by any means of this research. Their data will be kept in a safe and secure place, and there is no chance of breaking confidentiality and anonymity. The notes, transcripts, and voice recorders were not shared or discussed with others. The Author provided consent from the organization manager where the interview took place and assured clients that the subjects of this study were completely voluntary and could deny any questions or withdraw at any time during the interview process. After obtaining consent from the clients, the author interviewed them.