The Cohort Cycle of Recovery

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There was something familiar about the shaking woman sitting in the passenger seat of Cassy Smith’s car. As Cassy recalls, the woman was 110 pounds soaking wet, and so unwell she was sure she was going to die. She was scared and desperate—addiction had pushed her to the lowest low, causing her to lose control of her life and custody of her daughter. But as Cassy drove Valerie to detox that afternoon, she saw more than just an addict sitting beside her.

In fact, in many ways, Cassy saw herself in the small woman. It had only been a few years prior that Cassy had reached her own lowest low. By that point, she had been addicted to alcohol for nearly twenty years and knew she couldn’t give it up on her own. After her third DWI in a ten-year period, Cassy knew she was in trouble. She had been in prison before and considered herself to be the “worst case of a mother,” prioritizing everything above her four children. But yet, somehow this time was worse. This time, she was facing seven years in prison and the loss of her children completely.

But when Cassy arrived at court, ready to be taken to jail, the unthinkable happened. Instead of her seven-year sentence, she was offered a drug court opportunity where she would receive treatment for her two-decades-long addiction. When she heard her options, Cassy decided treatment would be “a piece of cake” compared to prison, and so she opted for that. She planned to give up drinking for the time being and “win over” her counselors with her signature smile. As simple as that, she thought.

What Cassy didn’t plan on was how challenging her recovery would be. Every day was a battle as she fought the addiction she had clung to for the past twenty years. Soon, her plan of a smile and sheer willpower getting her through was long gone.


A Rerouted Life

Fortunately for Cassy, she would soon be introduced to the staff at a community treatment center called CASA-Trinity. Cassy says in that moment, her entire life was “rerouted.” It was at CASA that she met her peer counselor—one of the most influential people on Cassy’s recovery. Through her counselor, Cassy was connected with local support networks like AA and NA, educated on how to lead a healthy lifestyle, and introduced to peers who were also battling addiction. Her community at CASA supported her in a non-judgmental, understanding environment. Cassy describes these people as the ones who won’t “give up on you”—the people she credits with saving her life.

Throughout the next three years, Cassy used what she learned at CASA to successfully complete the outpatient substance abuse program and graduate from Elmira City’s Drug Court Program. She eventually became employed full time at CASA-Trinity as a Certified Recovery Peer Advocate and Case Manager and is now attending Alfred State College online to become a credentialed substance abuse counselor. Most importantly to Cassy, after treatment she regained custody of her children and is now a devoted mother living what she is proud to call “a joyful, free, and peaceful life” with her four children.


Cohort of Care

In her role at CASA, Cassy has become the never-give-up-on-you advocate that her counselor was for her. Cassy’s hard work and talent for helping others struggling with addiction ultimately led to a position mentoring a special group of clients as part of the Cohort Management Program, a capstone project developed by Care Compass Network (CCN). In the Cohort Management Program, high-risk clients are supported through mini-networks of care designed to streamline access to medical services and community programs. Since the programs creation, clients within each cohort have been given access to the resources they need to be successful: food, transportation, childcare, housing, medical care, and self-care services—a component Cassy considers one of the keys to staying clean. The overarching goal of the Cohort Management Program is to create opportunities for providers – such as hospitals, primary care providers, long-term care facilities, substance use program providers – and community-based organizations to work together to offer quality care to clients with multiple needs.

While other case managers have 50-60 clients, the Cohort Management Program allows Cassy to have a small group of only 20. This gives Cassy time to check in with each client daily, providing the individual attention they need for recovery. While the data regarding the success of the cohorts is remarkable, the true pulse of the program is in each client’s story. When one of her clients wanted to attend college but couldn’t afford the textbooks, Cassy coordinated with the Cohort Management Program to buy them so that he could have the educational tools he needed to do well in his courses. When one client had a baby straight out of rehab, Cassy organized donations of diapers, baby clothes, and formula so that she could care for her child as a newly sober mother. And, when a scared and shaking Valerie came to Cassy ready to seek treatment but unable to because of insurance issues, Cassy helped her arrange insurance, then walked her to the car and drove her to detox.


Nothing But A Few Weeks of Sobriety Under Her Belt

The day Valerie’s cohort case manager drove her to detox is one she remembers vividly, a distinct clearing within the fog of her addiction. Valerie wasn’t sure if she was actually ready to go to rehab, to give up the life she had fallen into. However, when she got into the car, the steady assurance of the woman driving kept her from changing her mind. As they drove, Valerie remembers thinking this was the beginning of her “new life.” When she arrived at detox, she realized she had nothing with her: no clothes, no belongings, not even a bar of soap. But her options were bleak at this point; it was either treatment with just the clothes on her back or dying. So she decided to take the hardest walk of her life: the 27 steps from Cassy’s car to the rehab center.

Not long after Valerie checked in, Cassy returned carrying a heaping bag with everything Valerie would need at rehab: clothes, soap, and other hygiene products. This act of care was a life raft for Valerie, a simple kindness she’s never forgotten. For the next few weeks, she devoted herself to getting sober—sober for herself and sober for her daughter.

Then, the day finally came for her to leave rehab. As she walked outside, the pride of what she’d just accomplished was quickly washed away by the realization that she had nothing she needed to build her new sober life. That’s when she turned to the only place she knew to go: her cohort. “I remember needing food for my little girl and myself because I was fresh out of treatment and had nothing but a few weeks of sobriety under my belt,” Valerie recalls. “With the help of the cohort food stand I was able to be provided with groceries and hygiene products for months to come. Still to this day, the offer stands every time I come in for an appointment or even with a simple check-in text.”

After treatment, Cassy once again played a key role in supporting Valerie. She helped Valerie find a home, played with her daughter while she did housework, and most importantly, taught Valerie how to “love her baby all over again.”


Capable Clients

Since then, Cassy and the cohort have ensured Valerie has 360-degree care. They connected her with YWCA, where she has access to free childcare and a gym—a service she feels has led to a more positive, healthy lifestyle. The Cohort Management Program also introduced Valerie to Bryon Swartout, an employment specialist at Capabilities—a not-for-profit organization that helps people obtain employment. In his role, Bryon often works with clients from CASA-Trinity. In fact, since April 2019, Bryon has received 58 referrals from CASA. Bryon is proud to say that 26 of those referrals have gotten jobs and a majority of them are still in those positions today.

When it comes to his CASA clients, one of Bryon’s first steps is to help them overcome the belief that their past mistakes will always be held against them. Many clients come to him with the false assumption that because they have been in prison or struggled with addiction, no one will hire them. After those misconceptions are dispelled, Bryon teaches his clients how to build their soft skills: interviewing, resume writing, punctuality, and communication. He also guides them on the logistical side of finding a career: obtaining a driver’s license, creating a professional email address, and getting fingerprinted.

What makes Bryon and Capabilities so successful, though, is their understanding of the delicate nature of working with clients with a history of addiction. “Their recovery has to be the main concern,” Bryon says. “The last thing I want is for a job to stress out my client and hinder their recovery process.” And when considering placement, job satisfaction is Bryon’s top priority. Rather than focusing on placement rates, Bryon is most concerned with teaching his clients how to find jobs and coaching them as they apply for positions they are passionate about. He prides the program on their retention rates, noting that most of his clients stay in their positions due to high job satisfaction and positive performance.

Above all, Bryon’s goal is for his clients to feel a sense of pride in themselves throughout the job search process. This is why Capabilities relies on opportunities available to the general public rather than pre-arranged employment. They teach their clients how to use tools like Indeed and online postings to obtain jobs on their own. “I want to demystify the process of finding a job and help my clients realize they are as able to apply as anyone,” Bryon says. “Ten years from now, I want them to have the skills I’ve taught them to do this on their own.”

In addition to helping clients find employment, as part of the Cohort Management Program, Capabilities also helps clients attend occupational trainings and even receive funding for educational tools. When one of his clients decided she wanted to become a certified peer specialist, she knew she would need a laptop to be able to complete the 45 hours of online training modules. When the cohort found out, they got to work partnering with a local Community Foundation grant to apply for funding to help the woman reach her goals. After an extensive process including letters of support from community groups and cohort providers, she was awarded the grant and is now currently working on completing her training. Bryon is especially proud of his client’s progress: “She feels very strongly about giving back to others who may be struggling with the same issues with alcohol and substance use that she has experienced,” he says. “The teamwork and efforts of the cohort, along with the drive and the determination of the patient, clearly illustrate the power of supports that can be provided to cohort members who want to move forward and are committed to using their struggles and life experiences to give back to the community in ways that are true and tangible.”

Bryon attributes the success of the Cohort Management Program to the team’s person-centered philosophy. “You can’t take a cookie-cutter approach with this type of program,” Bryon says. “At our cohort meetings, everybody that sits at the table wants to know how the person is doing, rather than the program. And that is a recipe for success.”


Hope and Desire to Move Forward 

It’s this “recipe for success” that has helped Valerie reroute her own life. After over one year of sobriety, she is currently working on obtaining her provisional Certified Peer Advocate degree so that she can meet her goal of helping others. Through the Cohort Management Program, she has discovered “how to be an attentive mother” and credits Cassy with teaching her how to “navigate learning to be a sober mother.” Valerie firmly believes her success would not have been possible without her cohort. “Because of the cohort I have been able to have the support I needed with my recovery to keep wanting to push, knowing that someone is there for me,” Valerie says. “Without the cohort I would not have been able to be as successful in my life as I am now. The cohort has given me so much hope and desire to move forward and help others and hopefully assist them the way the cohort team assisted my family.”

As for Cassy, it has been an honor to watch Valerie progress—something she cites as one of the best experiences of her life—and she is proud of the “thriving, sober woman” Valerie has become. “She is an amazing woman who loves her child and loves to be a mom,” Cassy says. “She doesn’t lack anything.”

Today, that shaking, scared woman Cassy drove to detox is nowhere to be found. Instead, those shaking hands have been replaced with a steady grip that washes her family’s dinner dishes. Those scared eyes have turned to joyful glances, watching her daughter through the window as she happily picks flowers with the woman who saved her life.

Written by Sarah Bull