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The Roles We Play: Family Therapy and Teen Substance Use Disorder

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT Meet The Team >

If your teen receives a diagnosis for a substance use disorder, the diagnosing clinician will most likely recommend treatment at one of the following levels of care:

  • Residential Treatment Center (RTC)
    • Teens with severe substance use disorder who are not stable at home and cannot participate in school life may need the full support of an adolescent residential treatment center.
  • Partial Hospitalization Program (PHP)
    • Teens with moderate or severe substance use disorder who are stable at home – but not at school – may need a full day of treatment in an adolescent partial hospitalization program.
  • Intensive Outpatient Program (IOP)
    • Teens with mild or moderate substance use disorder who are stable at home and at school may be appropriate for an adolescent intensive outpatient program.
  • Outpatient Program (OP)
    • Teens with mild substance use disorder who are stable at home and school may be appropriate for an adolescent outpatient program.

Most high-quality treatment centers offer the following types of treatment at all four of these levels of care:

This article will discuss one component above: family therapy. If your teen is diagnosed with SUD, then it’s likely their treatment plan will include family therapy, as indicated above. It’s important for you, as a parent, to participate in family therapy.


It can help your teen, it can help your family, and it can help you.

The Benefits of Family Involvement in Teen SUD Treatment

Evidence shows that if you participate in family therapy for SUD alongside your teen, you increase the likelihood your teen will:

  • Stay in treatment longer
  • Decrease substance use
  • Improve school performance

Evidence also shows that if you participate in family therapy for SUD alongside your teen:

  • Family conflict decreases
  • Family relationships stabilize
  • Communication improves

When your teen has a substance use disorder, those are all outcomes you want, because the presence of a substance use disorder can disrupt family balance and impact everyone involved – not just the teen using substances.

In 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) published “Treatment Improvement Protocol 39: Substance Use Disorder Treatment and Family Therapy.” This publication offers a comprehensive overview of why, how, and when families should participate in the SUD treatment process.

It also explains how and why a substance use disorder affects the whole family – not just the teen – and then offers something new: an explanation of the various roles family members may adopt when a family member, particularly a teen, develops a substance use disorder.

We’ll discuss those two components of the SAMHSA publication, starting with how the use of specific substances an impact the family dynamic.

Substance Use and Family Dynamics

One thing you learn when your teen enters treatment for substance use disorder is that, although there are similarities between the way each type of substance use impacts the family, there are also distinct differences.

A teen with a problem amphetamine use will create a set of problems that’s different than the problems created by a teen with a cannabis use problem, and those two sets of problems are distinct from those caused by the other substances.

The SAMHSA publication we refer to above describes how the disordered used of alcohol, opioids, and cocaine can disrupt the family dynamic.

How Different Substances Affect Families: SAMHSA

Disorder Use of Alcohol:

  • Disrupts communication
  • Creates high levels of conflict
  • Increases family chaos and disorganization
  • Degrades family rules and rituals
  • Increases risk of emotional, physical, or sexual abuse in the family
  • Family members will often try to cover up for the alcohol misuse and problems caused by alcohol

Disordered Use of Opioids:

  • Increases likelihood of illegal activity:
    • Purchasing street opioids
    • Misusing street opioids
    • Diverting opioid medication
  • Increases family chaos and disorganization
  • Increases risk of infectious disease transmission
  • Decreases ability to:
    • Help with family responsibilities
    • Participate in school
    • Work

 Disordered Use of Cocaine:

  • Increases likelihood of illegal activity related to buying or selling cocaine
  • Increases risk of stealing from money:
    • Family
    • Friends
    • Work
  • Creates high risk of legal problems
  • Decreases ability to:
    • Help with family responsibilities
    • Participate in school
    • Work

If your teenager – or another family member – has alcohol use disorder (AUD), opioid use disorder (OUD), or cocaine use disorder (CUD), you’ve likely experienced all of the above firsthand. However, if your teen has recently received a diagnosis for SUD, you can mitigate the harm caused by the SUD by seeking professional support sooner, rather than later.

We’ll repeat that, because it’s important: the sooner you find professional treatment for your teen, the better your chances of avoiding the significant family disruption caused by the disordered use of substances.

Now let’s look at how substance use can impact the family dynamic in another way.

Substance Use and Family Roles

The SAMHSA publication describes a phenomenon you may be familiar with: the way family members adapt when one member of the family has a substance use disorder. If you grew up in a family in which alcohol or substance use was a problem, you’ve seen these roles play out with your own eyes. And if your teen receives a diagnosis for a substance use disorder, reading about these various roles now can help you avoid falling into one – or more – of them by default, accident, or inattention.

Family Roles: Family Behavior in the Presence of SUD

SAMHSA identifies five primary roles family members adopt when one family member engages in the disordered use of substances:

The Enabler

  • Prevents the family member with SUD from the negative effects substance use
  • Solves the life problems – work, school, family, and social – created by substance use for the family member with the SUD
  • Neglects their personal health and happiness in order to help the family member with SUD

The Hero

  • The oldest child in the family often takes this role
  • Does their best to take care of everyone, and save them all – including the family member with SUD – from the negative effects of substance use
  • Often feels like everyone is relying on them, and may get overwhelmed

The Lost One

  • Their needs often disappear and go unmet, and their accomplishments are often unrecognized
  • Often retreats to their own world, and does not want to participate in family life
  • Often feels lonely or sad, and has problems establishing close friendships outside the family

The Mascot

  • Uses personality, humor, wit, and charm to distract the entire family from the negative impact of substance use by one family member
  • Is often the life of the party
  • Wants to avoid conflict and keep everyone happy, which may impair their ability to develop mature relationships during adulthood
  • Is often disregarder or not taken seriously by the rest of the family

The Scapegoat

  • Will attempt to divert attention away from the family member with an SUD
  • May develop maladaptive behaviors as they seek to divert attention
  • Has increased risk of misusing substance
  • Has increased risk of risky behavior leading to legal problems

While these roles were initially identified in families in which parents engaged in the disordered use of substances, they’re a useful way to understand how substance use can impact and damage the family dynamic when an adolescent develops a substance use disorder. Parents, siblings, and extended family members may take on any of the roles above in order to protect the family member with SUD, and by extension, protect themselves.

However the lesson here is simple:

Learn about these roles so you don’t play them.

Or rather:

Learn about these roles so they don’t play you.

We’ll end by acknowledging that this phenomenon, and these roles, do not automatically appear in every family that faces substance use – but they do appear often enough for mental health practitioners to identify and describe them in peer-reviewed literature.

Family Therapy: Your Teen Needs You

The experts say these roles can contribute to ongoing substance use, prevent engagement in treatment, and in some case, slow treatment progress for a person who enters a substance use disorder treatment program.

That’s why we wrote this article: if your teen receives a diagnosis for substance use disorder, and their treatment team invites you to participate in the treatment process, then we recommend accepting the invitation and participating as much as you can.

You can learn how to help your teen, how to help yourself, and how to avoid playing a role that increases, rather than reduces, the harm caused by substance use disorder in your family.

Our Behavioral Health Content Team

We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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