Case 3, Episode 2: Layers of Experience – Constructing the Biopsychosocial-Institutional Timeline
“They kept asking me what happened.
But things didn’t happen all at once.
They happened over time. That’s how you break someone.”
— Cynthia, 62
In Episode 1, we met Cynthia—a 62-year-old woman navigating life after 20 years in prison, struggling with fear, disorientation, and what looks like paranoia.
But now we go deeper.
Before we assign a diagnosis, initiate treatment, or write a care plan, we ask:
What is the story beneath the symptoms?
Because Cynthia didn’t arrive here in one moment.
She arrived here through decades of institutional trauma[1], abandonment, adaptation, and silence.[2]
And if we’re going to help her reclaim any part of herself, we must reconstruct not just a biopsychosocial history[3], but a biopsychosocial-institutional timeline.
Why a Timeline Matters
For someone like Cynthia, trauma is not always loud or singular.
It’s cumulative. Quiet. Systemic.
And it builds an internal world where danger is assumed, trust is foreign, and the self must be hidden to survive.
A timeline allows us to:
See how each layer of her life shaped her current presentation
Identify where her adaptations became misinterpreted as symptoms
Understand how healing must be sequenced, not rushed
Reconstructing Cynthia’s Timeline
Let’s walk through her story—not just the facts, but the psychological weather of each life chapter.
Childhood (0–12):
Raised by her grandmother in a crowded Bronx apartment
Mother struggled with addiction; father was incarcerated
Physical abuse at home; sexual abuse by a neighbor
Cynthia describes herself as “quiet, scared, invisible”
Key imprint: The world is unsafe. People who love you can hurt you.
Adolescence (13–18):
Dropped out of school at 15
Involved with older men; introduced to heroin at 16
Arrested at 17 for petty theft; spent 3 months in juvenile detention
Key adaptation: Be tough. Don’t ask for help. Emotions get you hurt.
Early Adulthood (19–41):
Series of abusive relationships, periods of homelessness
Sex work for survival, multiple psychiatric hospitalizations (brief)
Diagnosed with “borderline traits” in her 30s
Never had consistent care; always “non-compliant”
Key adaptation: If you show pain, they’ll medicate or restrain you. Stay guarded.
Incarceration (42–62):
Arrested after a violent altercation with a long-time partner
Sentenced to 25 years, served 20 with parole
Diagnosed in prison with “schizoaffective disorder” after she reported “hearing her grandmother’s voice”
Medication was mandatory. Therapy was rare. Solitary confinement occurred after refusal to “calm down”
Key imprint: Your body is not yours. Your voice is a risk. Control equals safety.
Reentry (Present):
Placed in a transitional shelter
Has no income, ID, or cellphone
Struggles to sleep indoors; hears her grandmother’s voice at night
Refuses most services, but returns for appointments
Key question: What does it mean to be “free” when your nervous system has never known safety?
What the Timeline Tells Us
Cynthia’s current presentation—withdrawn, guarded, speaking to unseen figures—makes sense in light of her life.
Her so-called “psychosis” may be:
A spiritual anchor (hearing her grandmother’s voice)
A trauma-based dissociative state
An institutional adaptation to chronic dehumanization[4]
And the flat affect?
Not a symptom of schizophrenia, but a survival strategy:
“If I feel too much, I fall apart.”
Clinical Implications: The Treatment Plan Begins Here
From this timeline, we begin to design care with dignity, sequencing, and safety:
Normalize reentry trauma
“You’ve been through a lot. Your system learned how to protect you. It makes sense things feel strange right now.”
Stabilize the external before addressing the internal
Help with food, sleep, and predictable routines first
Honor survival strategies
Don’t try to eliminate the voices yet. Ask what they mean to her.
Avoid retraumatization through over-labeling
She may need support—not a new diagnosis
Coming Up Next: Episode 3 – Diagnostic Possibilities
Next, we’ll explore:
What is Cynthia’s diagnosis?
Is it schizophrenia? PTSD? Dissociation? Or something else entirely?
How do we diagnose without reinforcing shame or stripping meaning?
And how do we differentiate psychosis from the echoes of institutional trauma?
Because sometimes the most important diagnosis is not a code.
It’s a compassionate understanding.
Reflective Prompt for You
Have you ever met someone whose “symptoms” made sense only after you understood their story?
What would it mean to treat the timeline, not just the chart?
How might that change the way you engage the next person who walks through your door?
References
[1] Goldsmith, Rachel E., Christina Gamache Martin, and Carly Parnitzke Smith. "Systemic trauma." Journal of Trauma & Dissociation 15.2 (2014): 117-132.
[2] Cederstrom, Christian. "Healing a Broken Spirit: A Look into Institutional Trauma and Spiritual Resilience." (2024).
[3] Collins, Shane P., Matthew D. Iles-Shih, and Seema L. Clifasefi. "Living with chronic structural vulnerability: A biopsychosocial-structural formulation of a patient exhibiting “medical noncompliance” in the setting of historical trauma and social suffering." Journal of Substance Use and Addiction Treatment 172 (2025): 209656.
[4] White, Wesley D., and Wolf P. Wolfensberger. "The evolution of dehumanization in our institutions." Mental Retardation 7.3 (1969): 5.