Views & Reviews Medical Classics

Rachel’s Holiday

BMJ 2012; 345 doi: (Published 29 October 2012) Cite this as: BMJ 2012;345:e7041
  1. Naomi Devaney, house physician, Centre for Ageing, Neuroscience and the Humanities, Adelaide and Meath Hospital, Dublin, Republic of Ireland
  1. naomi.devaney{at}

Often we encounter patients whose primary problem seems to be addiction to one or more of many substances. Although we are generally well trained to treat the physical aspects of addiction, from ascites to delirium tremens, we are generally less well attuned to the treatment of the source of the addiction.

Popular literature can provide helpful insights to complement those we glean from classic literary accounts, such as Bulgakov’s Morphine,1 and in addition provide a common space that we can share with our patients: both we and they are more likely to have read popular so called chick lit than Russian symbolist writers.

In a series of deceptively light novels, Marian Keyes has dealt with a variety of dark topics. In the spirit of all fiction arising from autobiography, the author suffered from alcohol dependency and first began to write during her rehabilitation.

In Rachel’s Holiday, we eventually come to understand and empathise with the central character, Rachel, who is addicted to prescription medications, alcohol, and class A drugs. What is most impressive is how we are drawn into her denial, and find ourselves wondering what is true and what is not. “I was skint. I owed money to nearly everyone. I laughed to myself because for a minute there I really did sound like a drug addict.” This denial pervades every stage of her progression towards sobriety. Only at the very last stage of rehabilitation does Rachel begin to realise the extent and depth of her dependency “I was trapped in a strange phantasmal place where I had realised I was an addict, but sometimes I found it so painful I switched back to not believing it.”

During her later stages of rehabilitation, reality begins to impinge on her and Keyes offers us a glimpse of an overwhelming and unbearable level of pain. This pain is the initial trigger for the addiction. Inadequacy, guilt, shame, and embarrassment all merge into one intolerable sensation, which the addict must bury through substance misuse. The level of emotion described gives us a brief window of empathy with the addict. “You come to, feeling wretched and guilty, your self-loathing and fear of the reality you’ve created, magnified. And how do you deal with that? By taking more drugs.”

As doctors we are encouraged to be empathetic. However, the cultural and socioeconomic backgrounds of doctors and the temptation to address the technical and the physical mean that we may miss the central issues in alcohol and substance dependency. Listening to perceptive writers like Keyes might help us to reframe the context of our care, better understand the potency of denial, and motivate us to find more effective communication and support for those who present to us with this most complex and challenging of syndromes.


Cite this as: BMJ 2012;345:e7041


  • Rachel’s Holiday

  • A novel by Marian Keyes

  • First published in 1998

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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