Traditional bullying may be in a greater spectrum or continuum of aggressive and abusive behavior that may have more intense psychological dysfunction at the core. In some situations for some clients, cultural foundations may be particularly rigid and intensify the abusive behavior. Of significant concern are personality disorders and/or substance abuse that may significantly increase abusive behavior and decrease ability to alter couples dynamics. Borderline lashing out from attachment injuries, narcissistic rage and punishment, paranoid hostility, and antisocial domination need to be addressed in addition to the common boundary and consequence oriented approaches. Personality disorders may increase bullying behavior, but also cause abusive behavior that have important variations of the core issues of self-esteem and power and control characteristic of common bullying. In couples where there are one or more of these personality disorders, the therapy has to address the personality disorder over and above setting boundaries and empowering the victim.
Substance abuse especially stimulant drug use (cocaine or crack, methampethamine: crank, speed, etc.), which can mimic the anger, violence, and paranoia of paranoid personality disorder destabilizes mood and psychological stability. In such situations, the couple therapy may need to focus on the substance abuse and the individual's need for treatment. Alcohol is often an important issue as a disinhibiter, which blunts inhibitions that would otherwise restrain aggressive or hurtful actions or words. In addition, the entire process of self-medication, control issues, hiding use, damages, and associated behavior and social relationships and environments can contribute to avoidant, defensive, and aggressive behavior directed at a partner. Substance use or drinking are particular challenges if one partner may have already asserted prior to entering therapy that his or her use is not to be brought up. The therapist may miss this secret prohibition unless he or she directly asks about drinking or drug use in an intake or early session. If drinking or drug use were dismissed by one of the partners as an issue, the therapist and the therapy would be well served to discuss why it is so important to dismiss the issue. The denial or minimization can be brought up and the partner's concern about its relevance can then enter therapeutic discussion. The therapist can assert that he or she has the clinical diagnostic expertise and will make the eventual judgment as to the relevance of the drinking or drug use.
Or, in a different therapeutic approach, the therapist may "wonder" why alcohol, drugs, or some other issue is so important to have already been precluded from discussion in therapy. Regardless, the therapist must not acquiesce to the implicit or explicit threat of termination of couple therapy if drinking or drug use is discussed. When a member of a couple is able to make the topic out of bounds, he or she is continuing the dysfunctional controlling behavior issues endemic to substance abuse. The therapist who allows this has been drawn into the dysfunctional compartmentalization and secret holding dynamics of the couple. There are innumerable potential issues that require examination in the light of therapy. The therapist may have some idea of which issues from partners' disclosure or from theoretical training and instinct. However, the therapist may miss relevant issues unless well versed in intimate partner violence. The therapist needs to examine the each partner's current and developmental process and the dynamics of the couple relative to the patterns, characteristics, and dynamics of psychological abuse and domestic violence.