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Ambiguity is an Itch You Can't Scratch

Summary:

For someone who had been to a lot of therapy sessions, Elliot hadn't actually participated in much therapy. It didn't really work if you stonewalled your therapist and lied to her. But after Vera's insane meddling, Elliot decided to meet with Krista again.

 

This is a more-or-less accurate portrayal of effective talk therapy for someone with Elliot's problems, adjusted as needed to keep it narratively interesting - actual therapy is very repetitive.

Content warning: Very graphic and detailed discussion of child sexual abuse.

Notes:

Content warning: This is exactly what it says on the tin - it's a very detailed, very graphic discussion of child sexual abuse. Effective therapy for trauma involves dealing with the details, even - perhaps especially - the revolting ones. The purpose of this content is not to arouse or titillate, which is why I elected not to give it an "Explicit" rating, but there will be specific talk of sexual feelings, body parts, and behaviors in the context of trauma.

Don't-try-this-at-home warning: I wrote this because I'd always wanted to write an accurate portrayal of therapy. Still, I've edited for space, repetition, coherence, etc. Don't mistake this for a formal case study. While I've made an effort to apply and explain real, evidence-based therapeutic techniques, don't attempt these on yourself or others without guidance from a professional.

Elliot's recalled narratives are told from a child's perspective - I've written them as flashbacks rather than present-day Elliot speaking. That's why they're marked off as flashbacks rather than using quotation marks.

(See the end of the work for more notes.)

Chapter 1: Back to the Past

Notes:

The focus of this story is on the treatment of PTSD in a person with severe dissociative symptoms, not on treating dissociative identity disorder per se. Clinicians vary a lot in their understanding of and approach to DID. If you have strong feelings about DID or its treatment, you may find Krista's approach upsetting.

Chapter Text

When I was three or four years old, my dad taught me Boolean operators by playing a game he made up called Shoe Store. We would gather all the shoes in the house and lay them out on the living room floor. Then, dad would pretend to be a customer and ask for a shoe that was small-AND-red or has-laces-AND-NOT-black-soles. I would find a match and win the game. Then we would put the shoes away exactly where we found them so mom wouldn’t get mad.

Once I got good at Shoe Store, dad made up bigger puzzles that were like a riddle and a scavenger hunt put together. I would have to find a thing that was clear-AND-NOT-made-of-glass-AND-bigger-than-twelve-inches-OR-smaller-than-two-inches. (It was a plastic Lego windshield.)

We were playing one of those search string games when I learned a new word. My dad had sent me to find a Tinkertoy that was round-AND-NOT-blue-OR-green. It was too easy. I found a red wheel and I was going to take it to my dad when it hit me that there was another answer. A green object of any shape would also fit. There were two ways to group the words. One was (round AND (NOT (blue OR green))). The solution had to be round and it must be neither blue nor green. The other was ((round AND NOT blue) OR green). In that one, the solution could either be round-AND-NOT-blue OR it could be green. I brought my dad a green triangular panel and he taught me about ambiguity.
 
“Ambiguity is the enemy of programmers,” he said to me, rubbing his hands together. “Ambiguity is when a command has two meanings. Good code is never ambiguous. But talking, talking sometimes is. Just the way of the world, kiddo.”


“How are you feeling on the medication?” Krista clicked her pen, preparing to take notes.

Elliot looked very slightly relieved, maybe that they were beginning with something banal instead of jumping right into the thick of it. “Hungry. For sugar. Yesterday I ate half a box of Cinnamon Toast Crunch dry.”

“Appetite changes do happen sometimes. As your body acclimates, side effects like that will usually go away. Are you worried about weight gain?”

Elliot shook his head. “I don’t really care one way or the other.”

“Any other changes?”

“I can still hear him and see him, but he seems… less opaque. He’s not literally translucent, but his presence doesn’t block reality.”

“And how do you feel about that?”

“I’m okay with it. He’s pretty pissed.” Elliot shrugged, indifferent to his other self's annoyance.

“Did you explain to him why you’ve chosen to take this medication?”

“Yeah. He gets that the narrative thing you talked about won’t work if I keep dissociating and that the meds will cut back on the dissociation, he just doesn’t think I should be doing it at all.”

“By ‘it’, do you mean therapy in general? Or narrative therapy in particular?”

“He wasn’t real specific. He yelled at me for a bit, then he complained about copyright law for almost an hour and fucked with the default settings on my computer.” 

Krista nodded. That sounded like pouting more than forcible resistance. She looked at the completed worksheets Elliot had turned in. If he was being honest (while she recognized that was not a given, she nonetheless had to hope), he had rehearsed each skill at least once per day over the past two weeks. The treatment she had selected for Elliot – trauma-informed cognitive-behavioral therapy, or TF-CBT – went in three phases. They were currently in the first, which involved laying out a roadmap for treatment and explaining its rationale (relatively easy) as well as psychologically stabilizing Elliot (much harder). The goal wasn’t to completely normalize his emotions – that wouldn’t be possible without addressing the underlying trauma – but to ensure he had enough inner resources to face what had happened without dissociating or decompensating.

To that end, she had taught him several new skills and asked him to practice daily. Diaphragmatic breathing and progressive muscle relaxation were fairly straightforward, simple physical techniques to guide the body into a more relaxed state. Grounding skills were more varied and therefore more complicated. Grounding used the senses to anchor the body in the present moment, whether that meant touching the cold metal of a chair leg, listening to the car horns outside, or calculating the exact number of tiles in the ceiling. Since the environment changed, the sensory foci did as well. According to Elliot’s worksheet, he had spent time every day focusing on each of his senses, with modest success.

Which meant it was time to begin the second phase of the treatment. At various continuing education conferences, she’d heard it called narrative integration, imaginal exposure, or simply exposure therapy. To clients, she usually used the term ‘narrative therapy’ because the word ‘imaginal’ was unfamiliar and the word ‘exposure’ had sexual connotations.

“The next step is to make a list of memories that especially trouble you. If you’re not sure what to include, that’s okay. For many people, it helps to focus on ‘the first and the worst’ – that is, the first time particular acts occurred and instances that were unusually bad for any reason. For each memory, you’re going to rate it on that zero to one hundred scale that we’ve talked about: subjective units of distress or SUDS.”

Krista lay a worksheet on the table between them. It was just a two-column chart, with a space to list events and a space to list SUDS ratings.

Elliot stared at it. Not for the first time, Krista found herself wondering what it was about his face that made his eyes so prominent.

“This doesn’t have to be final. We can modify it later. We just need a starting point.”

Elliot continued staring at the worksheet for several moments before raising his eyes to meet Krista’s. He looked cold.

“It’s you again, isn’t it?” Krista sounded slightly disappointed.

“What kind of greeting is that?” Mr. Robot smacked his lips. “Gonna give a man a complex.”

“I’m trying to talk to Elliot.”

“And I wish you the best.”

“You’re still angry with me. Because I hurt him.”

Mr. Robot said nothing, but rubbed his thumb against his index and middle fingers, as if he were fidgeting with an unseen cigarette.

“You’re right to be angry. It was too soon for him to know. And even if it weren’t, it was certainly the wrong way for him to find out.”

It was difficult to argue with someone who agreed with him, so Mr. Robot allowed his expression to relax slightly.  “What am I doing here, anyway? I didn’t force my way out, and you obviously didn’t call me up.”

“Just before you emerged, I asked Elliot a question about his childhood. I imagine you’re here to play the role you’ve always played, to help him avoid thinking about his trauma.”

“And why is that a bad thing, hm? The world’s fucked up enough as it is. Why shove another misery suppository up his ass?”

“Avoidance isn’t always a bad thing, but some of the techniques Elliot has developed to avoid distress ultimately cause more problems.  Such as his substance use. Can you tell me that’s never put him at risk?”

“No arguments there. He can’t watch his back when he’s stoned off his ass. But how do you know he’s not going to leave here and go looking for a hit?”

“I don’t. I hope he won’t. But if I waited until he was fully emotionally stable to begin processing his trauma, I might be waiting a very long time. Possibly his whole life.”

Mr. Robot grimaced resentfully. He didn’t like agreeing with people who he was pissed at.

“Whether you approve of this course of treatment or not, I hope I can count on you to help Elliot to face his pain, or if he feels he must avoid it, to do so in the safest possible manner.”

“I don’t control him.” Mr. Robot snorted. “But yeah, if I can keep him from stripping down in front of a dealer called Hard Andy, I’ll do what I can.”

“Thank you.”

They both sat in silence for a moment. Neither had expected to reach détente so quickly.

Krista broke the silence.  “Since you’re here, I’d like to ask you some questions.”

“Can you sound a little less like a cop when you say that?”

“Do you remember when you came into existence?”

“Do you?” snapped Mr. Robot.

“Some personalities come into existence gradually. Others report a single, specific event.”

“Must’ve been gradual. I was his imaginary friend. I mean, he actually called me Mr. Robot.”

“Were you a robot?”

“Sometimes. Sort of. Most of the time I think I might have been an android – looks human, acts human, but Intel inside.”

“Did you always look like his father?”

“I don’t know. He didn’t usually think a lot about what I looked like.”

“Did you have a body capable of having sex? I mean did you have a penis? Mouth? Anus?”

“You’re asking if I was smooth like a goddamn Ken doll? That’s a weird fucking question to ask about a kid’s imaginary friend. You sure you’re not some kind of pervert?”

Krista waited.

“Yeah, I had parts. Still do, thank you very much. Not that long, but very girthy.”

“How did you know?”

“Know what? My own body? What the fuck kind of question is that?”

“You came from Elliot’s mind. It was up to him which physical attributes to include and which to elide over.” She paused. “You don’t know what the doll’s body looks like unless you take off its clothes.”

“What are you getting at?”

“Elliot told me that when he was incarcerated, you took a beating for him.”

“Ohh,” Mr. Robot managed to give the word three or four extra syllables.  “You’re asking if I ever took it up the ass on behalf of Captain Bug-Eye here, aren’t you?” He gestured to his own chest at the ‘Captain Bug-Eye’ comment, somehow managing to look as though he were indicating someone else.

Mr. Robot glared. Krista just looked sad. She broke the stalemate by explaining her line of questioning.  “I’m assessing your ability to tolerate distress without pushing it away, dissociating, and avoiding the way Elliot does. For this treatment to work, Elliot will need to integrate your memories with his own. He will need to come to terms with the fact that anything which happened to you, in fact happened to him.”

“That sure as fuck doesn’t sound like helping Elliot,” snapped Mr. Robot. “That sounds like more of the shitty therapizing that broke him down in the first place.”

Krista waited. A level of comfort with silence was an important therapeutic skill.

“You want proof I can handle it? I can. I played altar boy to Father Edward’s pervy benedictions. See, I can say that no problem.”

“Can you say it simply, directly, and without euphemism? In a way that connects with how you were really feeling at the time, even if what you were feeling was confused and powerless?”

“Sure. I’m a good talker.”

“Give it a try. Tell me about a time you absorbed the abuse. Doesn’t have to be the first or the worst or anything special.”

“Fine.” Mr. Robot scoffed. “This one night, I woke up and he was standing there, jerking off. He hadn’t taken my clothes all the way off, but he slid them around so stuff was showing. I could’ve told him off, but he wasn’t touching me, so I just ignored him and went back to sleep.”

“And that’s the end of the story?”

“What else is there? You said pick anything. If you wanted the felonies you should have said so.”

“I don’t think you fell back asleep. Not that quickly.” She paused. “Did he masturbate to orgasm?”

“No point in it otherwise.”

“Where did he ejaculate?”

There was a very brief moment in which Mr. Robot appeared visibly thrown by the question, before returning to his usual vulgarity. “His hand, mostly. But I got a few drops on my face. A baptism, if you’ll permit a return to the altar boy metaphor. Then he grabbed a tissue and wiped it off.”

“So you were awake at least until then. What were you thinking?”

“Nothing.”

“What were you feeling?”

“Nothing.”

“I don’t believe you.”

“It wasn’t a big deal. He didn’t even touch me.”

“He moved your clothes aside to eroticize your body. He exposed himself to you. He masturbated to your image. He ejaculated onto your face and wiped it off with a tissue.”

“And I’m sure that would have been goddamn traumatic if a little kid had been there, which is exactly why I was trying to keep a little kid from remembering it.”

“Mr. Robot, you were a little kid. You were a little boy imagining that he was big.”

“Mr. Robot,” he echoed. “Such a stupid name.”

“What were you thinking while he masturbated?”

“I didn’t think anything!” Mr. Robot snapped.

Krista waited.

 “I thought it looked…not violent but jerky? Erratic, maybe? I probably didn’t know that word. I thought it was a strange way to touch your own body. I thought it was private, something I wasn’t supposed to see, and I felt guilty for looking. I didn’t want to get caught being awake. I didn’t know what would happen, but I thought it would be bad. Worse.”

“Did you think you would be punished for seeing your father’s genitals?”

“No, this wasn’t the first time he’d shown me- it wasn’t- I thought he would think I wanted to watch.”

“You thought he would take it as a sign you were curious, or even aroused.”

Mr. Robot nodded.

“And what would happen then?”

“He would have tried to teach me something.”