Serena Grobler

Counselling doesn’t stop the pharmacology of opioids, but it changes the behaviours that turn use into a fatal event. Clinically, we teach people to recognise high‑risk patterns — using alone, mixing benzodiazepines or alcohol, taking a bigger dose after a period of abstinence — and we build concrete, rehearsed plans to avoid those situations. Counsellors also train families and patients in naloxone use, secure access to kits where available, and coordinate rapid medical responses. In Jo’burg, that means linking clients to local harm‑reduction services, public clinics that supply MAT, and community groups who distribute naloxone. Finally, good counselling identifies and treats the underlying drivers of risky use (pain, withdrawal fear, trauma, economic pressure) so the behavioural triggers for overdose are reduced, not just lectured about.

Medication stabilises withdrawal and cravings, but it doesn’t teach new coping skills or unravel why you started using in the first place. Counselling addresses thinking patterns, stress responses, relationships, and practical relapse triggers — the real reasons people return to the bottle or syringe when under pressure. Evidence shows combined treatment produces better retention and functional outcomes than medication alone. In practice, that means weekly sessions early on, moving to focused CBT, motivational techniques or family therapy as you progress, with coordination between prescriber and therapist. In Johannesburg the services can be siloed; a counsellor's role often includes navigating public clinics, securing scripts, and advocating for clients so pharmacology and psychotherapy actually work together.

Yes, and it has to be handled clinically, not emotionally. Counselling with families focuses on boundary setting that protects the patient and the household while offering realistic alternatives — for example, supervised financial controls, crisis housing plans, and clear rules for contact during intoxication. Family therapy teaches constructive responses to relapse (safety planning, calling emergency services, using naloxone) instead of punishment that pushes someone into the streets. A competent counsellor in Jo’burg will also map social supports and link the family to social workers or NGOs to prevent sudden loss of housing or income, because abrupt exclusion is one of the strongest relapse drivers we see here.

Integrated treatment is the standard. That means a counsellor assesses for PTSD, depression, anxiety and substance dependence simultaneously and uses evidence‑based methods that can be delivered together — trauma‑focused CBT, EMDR when appropriate, and behavioural activation for depression alongside relapse‑prevention work. We start with safety: stabilise substance use (often with MAT), manage suicidality or self‑harm risk, then phase into trauma processing. In Johannesburg, clinicians must also factor in ongoing community violence, loss and socio‑economic stressors, so therapy plans include practical problem‑solving, legal or welfare referrals, and realistic relapse prevention. The goal is functional recovery — better sleep, fewer panic attacks, clearer decision‑making — not polished narratives of the past.

Relapse changes the plan; it doesn’t mean therapy failed. A competent counsellor conducts a forensic, non‑judgmental review: what happened immediately before the lapse, what warnings were missed, were there gaps in medication, housing or social support, and did external pressures (work, police, family conflict) play a role? From that assessment they adjust the plan — tighter harm‑reduction measures (naloxone in the home, avoiding lone use), increased session frequency, different therapeutic techniques (e.g., adding contingency management or intensifying trauma work), or referral for inpatient stabilisation if needed. In Johannesburg that often includes advocacy — getting a quicker MAT appointment, a place in a monitored facility, or social grants sorted — because the context often dictates whether the next attempt holds.