Relapse: What It Means and What It Does Not
Sunday
He had done five months. Five clean months, the appointments, the tablets, the awkward wedding where he drank tea.
And on Sunday evening you smelled it on him.
What most families feel at that moment is not sadness. It is a kind of flat, tired anger — the sense that the whole thing was theatre and you were the only one taking it seriously. Five months, and the money, and the arrangements, and the hoping.
I want to say something about the next two days, because they matter far more than Sunday did.
The short answer
Drinking again after a period of stopping is common in a long-term condition. It does not mean the treatment failed, and it does not mean he never meant it. The drink is not the dangerous part. The disappearance afterwards is. Most people who go back to the old pattern do not do it on the first evening. They do it over the following week, because they have decided they have already failed and there is nothing left to protect. So the useful question is not why did he drink. It is: does he come back to the doctor this week, or does he go quiet until February? |
One drink and a return are not the same event
There is a difference between a single occasion and a full return to the old pattern, and the gap between them is usually about a week.
What decides which way it goes is rarely the alcohol. It is what he concludes about himself in the days afterwards, and the household reaction is a large part of what he concludes.
The reasoning runs almost identically in everyone: I have broken it. Five months are gone. I clearly cannot do this. So what is the point of pretending until Thursday.
That sentence — I have already failed, so it no longer matters — is the mechanism. It is not weakness and it is not an excuse. It is a well-described thing that happens in the mind after a slip, and it can be interrupted, but only by someone who saw it coming.
This is exactly why I tell people at the very first appointment that drinking again is possible. Not to give permission. To take away the trapdoor.
Why it happens at all
Detox takes a week. The brain takes considerably longer.
Months after the last drink, the systems that handle craving, stress and reward are still settling. In that period a cue can produce a want that arrives fully formed, with no thought in front of it — a smell, a particular road, a Friday, the sound of glasses at a function. He is not sitting there deciding to drink. He is managing something that has switched itself on.
Four things reliably make that harder: bad sleep, low mood that nobody has treated, being alone with nothing to do, and physical exhaustion. Notice that none of them is about willpower and three of them are treatable.
When it tends to happen
Families brace for the crisis. The crisis is not usually when it happens.
On a good day
This is the one nobody prepares for. A promotion, a wedding, a match, a son’s result. The mood is high, the guard is down, and the drink is framed as celebration rather than escape. In my experience this accounts for more first drinks than any tragedy does.
Somewhere between the third and fifth month
The early weeks have structure — frequent appointments, everyone watching, a sense of a project underway. By month four the appointments have spread out, the family has relaxed, and he is left holding it alone. That quiet stretch is where a lot of people come unstuck.
When the medicine was stopped because things were going well
Extremely common and entirely understandable. He feels normal, so the tablet seems unnecessary. Nobody is asked. Six weeks later the craving is back and there is nothing standing in front of it.
Medicines in this treatment are stopped on a plan, at a review, with a reason. Not on a good Monday.
At festivals and weddings
Predictable and therefore preparable. The season is known months in advance. A person who has not decided what he will say when the fourth person insists will improvise, and improvising at eleven at night with a glass already in someone’s hand goes the way you expect.
The first two days: what to do
Do not hold a trial. No assembling of relatives, no full account of the last six years, no “so all that money was wasted.” Say one thing, and say it once: I would rather know than not know. Let us go and tell the doctor this week. Get the appointment moved forward. This week, not after he sorts himself out — sorting himself out is the thing he could not do alone in the first place. If he has been drinking heavily again for several days, he must not stop abruptly at home. That risk returns the moment the drinking does. Do not throw away the medicines and do not restart or change anything yourself. That is a decision for the review. |
The medical bit families do not know
Two things worth understanding, because they change what you do.
First, tolerance falls during a period of not drinking. The quantity he handled comfortably a year ago can affect him considerably more now. People are often surprised at how badly a return goes physically, and the surprise is the point — his body is not where he left it.
Second, if the drinking has picked up again for more than a few days at the old intensity, stopping suddenly carries the same risks it always did. Seizures and confusion do not care that he was well last month. This is not a reason to delay treatment. It is a reason not to attempt it in the kitchen.
What a good review actually asks
When he comes back in, the useful hour is not spent on remorse. It is spent working out what the plan did not cover.
- Where was he, who was he with, and what was happening in the hour before? The specific situation, not “he was stressed.”
- Was he still taking the medicine, and if not, when did that stop and why?
- How had he been sleeping in the fortnight before?
- How had his mood been for the weeks before — not the day of. Low mood that nobody treated is one of the most common things sitting underneath a return.
- When was the previous appointment, and had the gap quietly stretched?
- What did he tell himself just before the first drink? There is almost always a sentence, and it is usually one he has used before.
Answer those six and you have a plan that is better than the one he had in June. That is what makes this worth coming back for.
Is it a failure, then, or not?
I want to be careful here, because both of the easy answers are wrong.
Telling a man that relapse is completely normal and means nothing is comfortable to hear and it is not true. Something happened. It cost him something. Five months of work were real, and the drink took a piece of it.
Telling him it proves he cannot do this is also untrue, and it is the more expensive error, because it is the one that makes him stop coming.
The accurate version sits in between and it is less quotable: this is a setback in a long-term condition, it carries real cost, and it is recoverable — and whether it is recovered is largely decided in the next fortnight rather than on the night itself.
Five months are not deleted. He has proof, which he did not have last year, that five months are possible.
What families should not say
Not because these are unkind — because of what they cost you.
“I knew this would happen.” It confirms the thing he already believes about himself, and it makes you the person he hides the next one from.
“After everything we spent.” True, probably. It converts his illness into a debt, and a debt cannot be discussed honestly.
The silence. Days of not speaking is the most common response and it does more damage than shouting, because it removes the only route he had for telling you.
And the one that seems supportive: “It is fine, forget it, do not think about it.” That closes the subject, and the subject is the treatment.
Reducing the odds of the next one
- Keep the appointments when things are going well. This is the single most ignored instruction in de-addiction treatment. The appointment in month four, when there is nothing to report, is the one that is doing the work.
- Do not stop the medicine because the crisis has passed. That is a review decision.
- Treat the sleep and the mood. Untreated low mood underneath abstinence is a slow leak.
- Rehearse the difficult situations before the season, out loud, with the actual sentence he will use. Improvisation fails.
- Plan the good days, not only the bad ones. That is where most first drinks live.
- Agree in advance, while everyone is calm, what will happen if he drinks. Deciding that on the night is how families end up shouting.
A story, put together from many
The following is fictional and composite. It is not any one patient.
A man in his thirties, seven months without alcohol, doing well enough that his family had stopped thinking about it. His sister’s engagement was fixed. He drank at the function — two, by his account, and I think that account is probably honest.
He did not tell anyone. He came to the appointment ten days later and did not mention it, and I did not know.
What brought it out was his wife, who had known since the second day and had said nothing to him because she did not want to start something before the wedding. She said it in the corridor afterwards.
By then he had been drinking for nine days.
The two drinks at the engagement were not the problem. The ten days of everyone protecting everyone else from a conversation — that was the problem. We had spent an appointment in March on what he would do at a function. We had never once discussed what he would do the morning after, if it went wrong.
That gap was mine. I put it in every plan now.
What to do this week
- If he drank in the last few days: bring the appointment forward, do not hold an inquiry, and do not let him stop abruptly at home if the drinking has been heavy for several days.
- Say the one sentence — I would rather know than not know — and then stop.
- Write down what you noticed in the fortnight before: sleep, mood, missed appointments, whether the medicine was still being taken.
- If he refuses to go back, go yourself and take that account with you.
- If he is drinking heavily again and becomes confused, has a fit, cannot be woken, or talks about ending his life, that is an emergency and it goes to a hospital tonight.
Frequently Asked Questions.
Does relapse mean we have to start the whole treatment again?
Usually not from zero. If the drinking has resumed heavily, the withdrawal phase may need repeating under supervision. The rest is a revision of the existing plan, not a fresh start.
He has relapsed three times. Is it worth continuing?
Yes. Repeated setbacks are a familiar shape in long-term conditions and people do come through after several. What worries me far more than three relapses is three relapses that were never discussed with a doctor.
Should he be admitted after a relapse?
Not automatically. It depends on how heavily he has been drinking, how long, and what his physical state is. That is an assessment, not a punishment.
He says one drink at a function is fine and he can control it now. Is that possible?
For someone who has been physically dependent, controlled drinking is a considerably harder goal than stopping, and attempting it without a doctor’s involvement usually ends where you fear. If he wants to argue for it, the place to argue is the consulting room.
Should we hide alcohol at home or lock it away?
Not keeping it in the house during the early months is sensible and worth doing. Turning the house into a search operation is not — it converts the marriage into surveillance and it has never once been the thing that worked.
Sources
- Indian Psychiatric Society. Clinical Practice Guidelines for the Assessment and Management of Substance Use Disorders.
- World Health Organization. ICD-11 Classification of Mental, Behavioural and Neurodevelopmental Disorders — Disorders due to substance use.
- World Health Organization. Global Status Report on Alcohol and Health.
- Ambekar A, et al. Magnitude of Substance Use in India, 2019. NDDTC, AIIMS New Delhi, for the Ministry of Social Justice and Empowerment.
This article is for education only. It is not a substitute for consultation with a qualified doctor, and it is not a diagnosis or a treatment plan for any individual reader.
If you or someone you know is in distress, free and confidential help is available. Tele-MANAS: 14416 or 1800-891-4416, 24 hours, in Marathi and other Indian languages.
About the author: Dr. Muktesh Daund is a Consultant Psychiatrist and De-addiction Specialist (MBBS, DNB Psychiatry) practising in Nashik, Maharashtra since 2016.