Inside and Outside Feeders

Another way to understand the phenomenology of the individual is by identifying the dominant source of self-confirming sustenance. The parameters of this hypothetical continuum denote, at one end, individuals who are predominantly self-confirming (inside feeders), and, at the other extreme, those who are predominantly dependent on external confirmation (outside feeders).

Inside feeders require and prefer little feedback from outside themselves. They tend to be discomforted by too much connection or regard; they tend not to seek it and often resist it. If it is pressed on them, their maladaptive expressions can be expected to become worse. The notion of inside feeder is suggested as being consistent with Paranoid, Schizoid, Schizotypal, Avoidant, and Obsessive-Compulsive Personality Disorders.

Outside feeders need a great deal of feedback, direction, and confirmation from others (the outside). This is suggested as being consistent with Histrionic, Narcissistic, Borderline, Antisocial, and Dependent Personality Disorders. When they are denied or limited in this source of sustenance, the maladaptive expressions of the personality disorder can be expected to become worse. This is often the response to frequently occurring events in old age, such as retirement and the need to move into assisted housing, among other changes, which reduce the amount of feedback they can receive.

290 Chapter 10 Treatment: General Issues and Models Rules of Personality Disorders

Actual rules to govern the expression of any personality—disordered or not disordered—do not exist. However, those with personality disorders often behave as if there were such rules. The behaviors are especially challenging to clinical work. Identifying these rules can help in treatment planning and in the anticipation of resistances and therapeutic openings:

Rule 1: The personality disorder is ego-syntonic. No matter how adaptive or maladaptive, the individual's personality feels right—it "feels like me." The notions of homeostasis and constancy are in support of the ego-syntonic quality of the personality.

Rule 2: The problem is externalized. The sources of distress resulting from the Axis II condition emanate from a referent outside of the individual. The world or others are problematic, not "me."

Rule 3: The response repertoire is closed to change. The individual with a personality disorder has difficulty experiencing himself as an agent of change. His or her response repertoire (i.e., feelings, cognitions, and behaviors) is narrow and inflexible.

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