Systemic therapy
in the room.
Nobody told me when to stop.
A fictional family across several meetings: who comes, a hypothesis shared too early, a repair through time and context, and services brought into the picture.
What this is: a worked systemic case with the therapist’s decisions made visible.
Why it matters: systemic ideas can feel like blame unless they are used carefully.
The sharpest moment: a hypothesis that leaves Bernie feeling blamed, and a repair in which the family helps change it.
One thing to take away: an arrangement built for a crisis can outlast it, especially when support is withdrawn.
The short version
A fictional family followed across several meetings. Brendan has an acquired brain injury and has moved back in with his mother, Bernie. The case shows systemic work that stays open to correction: deciding who comes, forming and revising hypotheses, using circular questions, a hypothesis that leaves Bernie feeling blamed, a repair in which the family helps revise it, a meeting that brings services into the picture, and results that are mixed.
The process in outline
Our framework- Agree who comes, and how. Including the disabled person’s wishes and communication needs.
- Hypothesise, lightly. Several possible ideas about the pattern, none treated as the truth.
- Ask about relationships and differences. Circular questions, adapted to everyone in the room.
- Share a working picture. Invite correction, and watch for anyone feeling blamed.
- Include the wider system. Services, work, friends, money, housing.
- Try something different. Small changes to the pattern, chosen by the family.
- Review, and revise. What happened, for whom.
This sequence is this site’s way of setting out systemic work. It draws on the Milan guidelines of hypothesising, circularity and curiosity, and on Rolland’s attention to time and context.
Brendan is 38. Eighteen months ago, a cycling accident left him with a brain injury affecting memory, fatigue and planning. He moved back in with his mother, Bernie, 67. His brother Niall lives nearby. Bernie does almost everything: meals, appointments, medication, money. Brendan says he feels “like a teenager again”. Bernie says she is exhausted. The community rehabilitation team discharged Brendan six months ago.
Brendan, Bernie and Niall are fictional teaching examples, not real people.
Across several meetings
Illustrative sequenceWho comes, and how
The therapist meets Brendan alone first, then with Bernie and Niall. Before the joint meeting, they agree who the client is (Brendan), what will and won’t be shared from his individual sessions, and that anyone can ask for time alone with the therapist. They also agree shorter sessions with a break, a written summary afterwards, and that Brendan can stop a session when fatigue sets in.
Therapist’s decision: see Brendan first, as an adult client in his own right, and build in access for fatigue and memory before any family work.
Circular questions, and a hypothesis shared too early
Niall, when Bernie does things for Brendan, what does Brendan do?
He goes quiet. Or he gets annoyed and goes to his room.
And Brendan, when you go to your room, what does your mum do?
Does more. Tidies up. Makes my dinner early.
So there may be a loop where the more Bernie helps, the less room Brendan has, and the more she ends up doing.
So it’s my fault he isn’t getting better.
Therapist’s decision: in hindsight, there were two problems: the timing, and the hypothesis itself, which turned out to be incomplete (see Meeting 3).
Repair, and a revised formulation
I want to go back to last week. When I described a loop, Bernie, you heard blame. I’d like to understand what I got wrong, not only how I said it. What did I miss?
That some of it isn’t habit. In March he took his tablets twice and ended up in A&E. I’m frightened of that happening again.
That’s important, and I didn’t know it. Brendan, how do you see it?
The tablets, she’s right. I want her to keep doing those. It’s the cooking and being asked if I’ve showered. That’s the teenager stuff.
So my picture was too simple. Some of the help is needed, and you both want it to continue. Some has outlasted the need. And a real scare keeps all of it in place, with no rehab team around to help sort one from the other. Does that fit better?
Yes. That I can work with.
The working picture changes, not only its wording. Help with medication is needed and chosen; help with cooking and personal routines has outlasted the need; fear after a real incident keeps both in place; and the withdrawal of the rehabilitation service left nobody to help the family review it.
Therapist’s decision: treat Bernie’s reaction as possible evidence that the hypothesis was wrong, not only badly timed. Ask what was missed, ask Brendan directly, and revise the formulation together.
Bringing the wider system in
With Brendan’s agreement, the therapist helps the family request a re-referral to the brain injury service, and Niall contacts Brendan’s old cycling club. Brendan chooses two things to take back: cooking his own dinner twice a week, using a written recipe and a timer, and managing his own phone appointments with a shared calendar. He also chooses for Bernie to keep managing his medication, with a dosette box they set up together. Choosing continued help is as much an exercise of agency as taking a task back.
What actually happened
After six weeks, Brendan has cooked eight dinners, two of which he describes as “a disaster, but mine”. Bernie found it very hard not to step in, and did twice. The re-referral is on a waiting list. Brendan has been to the cycling club’s coffee morning once and found it tiring and good.
I still feel like a teenager some days. Less, though.
I’ve sat in the garden while he cooked. That’s new.
At review, the therapist also meets Brendan and Bernie separately, because what each says alone may differ from what they say together. Brendan says the cooking matters more to him than anything else in the plan. Bernie says, alone, that sitting in the garden is the first time she has rested in a year. More family harmony doesn’t necessarily mean more agency for the disabled person, so the therapist checks both.
A few meetings is an illustrative sequence. Real family work is often slower, and patterns come back, especially when fatigue is high or services fall through.
What the case shows
- What makes this systemic: the problem is located in a pattern and its context, the family and services are both part of the system, and change is sought in the arrangement, not only in Brendan.
- A hypothesis that was partly wrong as well as badly timed, and a repair in which the family helped revise it.
- Progress that includes chosen, continuing help, not only doing more alone.
- Brendan as a client in his own right, with access built in from the start.
- A missing service named as part of the problem.
- Mixed, real progress.
What needs attention here?
A family member feels blamed
Possible focus: how the pattern made sense when it began
Watch for: defending the hypothesis
Support has been withdrawn
Possible focus: naming the gap and helping the family seek it
Watch for: treating the family as the only system
Access needs affect sessions
Possible focus: building them in from the first meeting
Watch for: adding them only when problems arise
Possible starting points, agreed with the person, not rules.
Questions worth carrying, as a therapist
Therapist Reflection- Did I see the disabled person as a client in their own right?
- Did I describe a pattern before acknowledging how it came about?
- Is the service system in my formulation?
- Whose progress am I measuring?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Hypothesising, circularity and curiosity: Selvini Palazzoli et al. (1980), Family Process, 19(1), 3–12; Cecchin (1987), Family Process, 26, 405–413. Time phases of illness and disability: Rolland (2018), Helping Couples and Families Navigate Illness and Disability (Guilford).
The process outline, the therapist’s decisions and the reading of the case are this site’s synthesis, not a manualised protocol.
Brendan, Bernie, Niall and the meetings are constructed for learning. They are not real people or real sessions.
We have not located published systemic case studies with adults with acquired brain injury living with a parent.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). Systemic Therapy in the Room. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/systemic-therapy/systemic-therapy-in-the-room/ (Accessed: [date]).
Shared under CC BY-NC 4.0: you can share, adapt and teach from this page, including on fee-paying courses, with credit. See Reusing This Material.