Why does the world need rehabilitation? This question seems complex at first glance, but the answer can also be quite simple. When the World Health Organization (WHO) signed the Alma-Ata Declaration in the early 1970s, five pillars of healthcare were defined: prevention, health promotion, treatment, palliation, and rehabilitation.

Treatment often receives the most attention – and rightly so. However, this does not mean that the other pillars are less important. On the contrary: sometimes the necessary solution may lie precisely within them.

Over the past two decades, my work and thoughts have been closely linked to rehabilitation. I have strived to better understand what rehabilitation is and how to organize it more effectively for people. What do we want rehabilitation to achieve? And what should this field offer people? One thing is certain: rehabilitation can be life-saving when treatment has ended, but life needs to continue.

The Invisible Role of Rehabilitation

In Estonia and elsewhere in the world, there is a growing desire to integrate healthcare and social services into a unified system. However, rehabilitation often remains in the background of this discussion, as it is complex to both organize and understand. Despite this, rehabilitation should not be “thrown out with the bathwater” for the sake of simplicity. To prevent this from happening, we need to talk about rehabilitation more and with greater awareness. Hereby, I offer my contribution.

Rehabilitation exists to help people cope better – with their health condition, daily life, and social situation. Its goal is to support an individual’s functioning so that they can manage their life as independently and fully as possible. This may seem like a simple definition, but it actually encompasses a great deal.

Coping is a Complex Phenomenon

A person’s ability to cope with their health condition does not depend solely on medical diagnosis and medication. It depends on their personal characteristics, living environment, and social network. For example, if a person in a wheelchair lives on the fourth floor of a building without an elevator, the environment is a significant obstacle to their independence. Similarly, a person’s state of mind affects recovery – a pessimistic, helpless attitude towards life requires entirely different support than an active and hopeful one. An overly caring loved one can become an obstacle to recovery, just like those who drift away when difficulties arise.

Such factors are not for criticism, but for understanding. Who we are, what our living conditions are, and what the societal support system is like, all affect our ability to recover.

Why Do We Need Rehabilitation?

The goals of rehabilitation are not clearly articulated socially. Currently, services are fragmented and often very system-centric. The emphasis is on service provision, not on what we hope to achieve. We argue over who should pay for which specialist’s services, instead of discussing what those in need truly require. Equally important is the question of what Estonia needs. One possible perspective is that we need functional citizens who, regardless of health issues and/or age, are capable of living: working, learning, enjoying life in its diversity. In more complex cases – when a normal life is not possible, for example, with a very severe coping disorder or a fatal illness – a societal goal could be to reduce the care burden and preserve the vitality of loved ones. Again, so that a normal life – including its societal benefits – is possible. These more complex cases, for clarity, represent the intersection of rehabilitation and palliative care.

It is often assumed that rehabilitation is something offered by a specific specialist. In reality, the collaboration of many different specialists is often necessary: psychologists, peer counselors, physiotherapists, occupational therapists, nurses, doctors, nutritionists, care workers, speech therapists, social workers, etc. It is true that in many cases, not all of them are needed on a person’s path to recovery. However, a flexible readiness to include the necessary specialist at the right moment is essential, as is the opportunity for someone – a social worker, a case manager – to be with the person to help build and maintain the necessary team.

Rehabilitation has many different definitions, but they all share three fundamental commonalities: a team-based approach, person-centeredness, and an orientation towards living life – the ability to function as a human being. For the purpose of mapping the latter, a classification system for functioning has even been created, analogous to the classification of diagnoses.

To live life as fully as possible and take control of one’s own life, three main components are needed: knowledge, skills, and self-efficacy. The latter is often taken for granted – or completely forgotten. Mistakenly so.

Self-Efficacy – The True Measure of Recovery and Coping

Self-efficacy means believing in one’s ability to cope. It is a universal need – we need it in every area of life, but especially when life has unexpectedly changed. When a health condition is different from before, one often has to learn to live under entirely new circumstances.

Unfortunately, self-efficacy is often overlooked in rehabilitation. Sometimes it is thought that if a person lacks motivation, they also lack the right to services. The reality is the opposite: one part of rehabilitation should be to foster motivation and self-confidence. Only when a person does not respond to changes even after targeted support can it be said that they need something else – for example, a support person, supported living services, etc.

Rehabilitation must support a person’s belief that they can manage their own life. Even when their situation is difficult or permanently changed. This is not easy, but it is possible – and necessary. Again, for clarity, “managing one’s own life” is not a dismissive attitude stated condescendingly, but a description of real life. Even in cases where a person’s rehabilitation needs are significant, their time alone accounts for approximately 90% of their time. This part of life should be as active and fulfilling as possible.

What Does Self-Efficacy Consist Of?

Self-efficacy does not arise on its own. Its development requires four important components: personal achievements, social role models, feedback, and the knowledge and ability to perceive one’s physiological body. Awareness of oneself and one’s body means the ability to perceive what a person’s body and mind are telling them. For example, does a person recognize when shortness of breath is a normal sign of exertion and when it’s an alarm bell; does muscle pain encourage them to push harder or force them to stop; do sweaty palms and a racing heart cause them to freeze, or do they have the skill to continue despite them? Feedback must be substantive and honest. “Well done!” is never enough. People need confirmation that their efforts are noticed, understood, and supported. A rehabilitation specialist must be able to provide effective, motivating, and guiding feedback at the right moment.

Social role models are people with similar experiences. Another person who copes creates hope and curiosity: “If they can do it, maybe I can too.” This experience can be consciously shaped – for example, through group discussions, personal stories, or social learning. Personal achievements are the most effective way to foster self-efficacy. The experiences a person achieves through their own effort teach and inspire the most. I learned, I tried, I succeeded. Whether this achievement is invisible to others or seemingly small – for the person themselves, it is always significant. The role of rehabilitation is to create meaningful opportunities to experience success – both big and small.

Person-Centeredness as a Success Factor

Rehabilitation is effective only when it is person-centered. In other words: the most important thing is the individual and their ability to cope in their own circumstances, not their diagnosis or health condition. Otherwise, it is not possible to support someone in restarting their life. Figuratively speaking, if a person doesn’t like skiing, there’s no point in training them in skiing. If they are afraid of dogs, it’s not sensible to show them pictures of dogs. If they don’t like dancing, another activity that resonates with them must be found – be it reading, baking, gardening, or another meaningful activity. The connection of rehabilitation interventions to real life is often the key to success. This does not mean that the diagnosis or the nature of the health condition is not important. It is. But not the most important. More important than that is how it affects a person’s ability to cope and their life.

Rehabilitation does not fit into the universal “healthcare format”: where a specialist has an intervention that cures the patient. It is, from the outset, an art of collaboration and involvement, where traditional roles known from medicine do not work. The more chronic the condition, the greater an expert the person is on their health condition and life issues, and the more valuable a partner they are to rehabilitation specialists. However, this is a shift in mindset, not only for people who need rehabilitation but also for specialists. And this does not mean that all demands of individuals must be met.

Rehabilitation is not just about treatment and interventions. It is about support, empowerment, and offering meaningful experiences. It is a collaboration aimed at giving people back the feeling that their life is in their own hands. So that they are not “a person with a stroke” but a person (who once had a stroke).

Summary: Let’s Not Underestimate the Role of Rehabilitation

The message of this opinion piece is twofold. Firstly, rehabilitation is as important as treating an illness or health condition. We must not disregard it simply because it is complex or multidisciplinary. Estonia has the experience, knowledge, and people who understand this field. Let’s use them. Let’s not set rehabilitation aside simply because it doesn’t fit into existing structures.

Secondly, the goal of rehabilitation services must be to support a person’s independent coping. To achieve this, fostering self-efficacy is critically important. We should not be ashamed of it or disregard it. On the contrary – it should be at the core of our work. Rehabilitation cannot be a lifelong service – it is too expensive for that – which is why belief in one’s ability to cope, the necessary skills and knowledge, and also environmental adaptations, should be at the heart of rehabilitation. As well as the courage to ask for help again when needed.

If we can organize a system that supports a person in achieving their own goals – regardless of their age or health condition – we will have created something valuable. And if, in doing so, we can also reduce system fragmentation and focus on substance instead of reorganization, that will be progress.

Rehabilitation should not be a “luxury” – it is essential. It is precisely this that can give a person back their life. And to society, people who want to contribute.