Modern healthcare has become increasingly focused on data, outcomes, measurable results, and cost-effectiveness (Perdelle et al., 2020). Many related advances and challenges are the by-product of a particular way of perceiving and experiencing the world. This philosophical perspective or epistemology known as Positivism has guided much of Western society (Economics, Education, Politics, and Healthcare) over the past 200 years (Brown, 2021). The scientific method and medical model are heavily grounded within it (Wilson, 2000). This viewpoint holds that there is an objective reality that can be quantified and measured. A related perspective that has had a major impact on modern healthcare is Cartesian Dualism, more commonly referred to as the mind-body split (Short, 2020).

The benefits of objectivist medical science in terms of the advancement of healthcare have been numerous (Ahn et al., 2006). This approach to dissecting and learning about different parts of the human body has guided specialized approaches to treating disease and pathology (Federoff and Gostin, 2017). It has given rise to the development of highly evolved departments within hospitals (e.g., gastro, dermatology, urology) and as a result, healthcare systems are very organized, structured and uniform.

Hospital-based systems have many advantages because of how their development has been informed by positivism, the scientific method and the medical model. The corollary of this is that these systems often marginalize more relativistic, phenomenological, and holistic perspectives (Miles, 2009; Greene and Loscalzo, 2017; Kanzian et al., 2019; Rinofner-Kreidl, 2020). These viewpoints pay more attention to the subjective and contextual experiences of the whole person (intrapersonal, interpersonal, and transpersonal); and include a more collectivist understanding of how human beings are interconnected with each other and their environment. Given that “survival” is the core aim of a hospital, it makes sense that healthcare systems have evolved in this way. That said, and in an age where there is a move to make healthcare more compassionate and person-centered, working in a holistic manner can be difficult because the system has emerged from a very different standpoint.

It is worth considering this in terms of Gilbert’s (2017) pioneering research on compassion and Compassion Focused Therapy (CFT). Gilbert (2017) views compassion through an evolutionary lens, as a motivational system rooted in mammalian caring. It is defined as: “the sensitivity to suffering in self and others, with a commitment to try to alleviate and prevent it” (Gilbert, 2017, p. 25). Gilbert (2005) outlines three emotion regulation systems that influence compassion. The threat system (detection and protection), the drive system (resource acquisition and achievement) and the soothing system (safeness, caring, contentment). Due to the demands of busy hospital settings, many healthcare workers are frequently oscillating between the threat and drive systems with little space for soothing. This is considered further below, from a neurobiological perspective, in terms of the influence of the vagus nerve on compassion.

The process outlined above influences how healthcare professionals care for patients; how staff members engage with each other; and how teams and departments interact. The system prioritizes certain aspects of individuals’ experiences whilst de-prioritizing others. Prioritized aspects include the physical disease of the patient; the problem-solving, conceptual and intellectual tasks of staff; and differences between patients and staff. The corollary of this is that the subjective, emotional and holistic experience of the patient can get marginalized; the emotional and human impact of this work on staff is under-acknowledged; and the interconnectedness of patients and staff is given less attention. What follows, focuses on a number of these issues within a cancer context.

This paper explores how the emotional distress experienced by patients impacts staff; an understanding of this process from a psychotherapeutic and neurobiological perspective; the influence of the wider hospital-based system within this; and working with this phenomenon within a team. Fictitious case studies are used to link the broader theoretical and conceptual learnings with the clinical and experiential aspects of working on the frontline. The perspectives informing the development of the paper are pluralistic, integrative and interdisciplinary (Norcross and Goldfried, 2005; Boix Mansilla, 2010; Teo, 2010). It combines learnings from a range of fields, including Psycho-Oncology (Watson and Kissane, 2011), Transference and Countertransference (Jacobs, 2017), Process Oriented Psychology (POP; Mindell, 1988, 2017), Group Psychotherapy (Yalom and Leszcz, 2005), Mirror Neuron Research (Rizzolatti and Craighero, 2004; Iacoboni, 2008), Poly Vagal Theory (Porges, 2011), Compassion Focused Therapy (CFT, Gilbert, 2017) and Systems and Field Theory (Lewin, 1951; Bertalanffy, 2015).

The integration of psychological knowledge from multiple perspectives and applied to a cancer context is one of the novel aspects of this paper. A further contribution is the awareness the paper brings to relationships, situations and dynamics that often get overlooked and consequently are harmful for patients and staff.

This process of taking psychological knowledge from different areas and assimilating it in a way that is relevant, meaningful and digestible to other practitioners is one of the key roles of a hospital-based psychologist. This is in keeping with the Scientist Practitioner Model (Baker et al., 2000) and being a Reflective Scientist Practitioner (Donati, 2016). The latter highlights the need for closing the mind-body gap while also integrating the more intrapersonal and transpersonal aspects of people’s experiences, and how these can exist in both an individual and interconnected way.

People who receive diagnoses and treatment for cancer face a vast range of challenges. They contend with the impact of treatment, physical pain and discomfort, procedural and hospital-related uncertainty and many other problems that arise when interfacing with a healthcare system. The effects of cancer and treatment can be profoundly destabilizing to core aspects of one’s identity, sense of physical integrity, meaning and place in the world (Yalom, 1980; Van Deurzen and Arnold-Baker, 2018) and the process of psychosocial reorganization can be non-linear and complex (Le Boutiller et al., 2019, 2021). Some aspects of this reorganization may remain unresolved, particularly if the person lacks a safe and supportive context (relational, financial, social) to process these changes. The combined effect of these issues results in cancer patients and their loved ones experiencing significant emotional distress (Watts et al., 2014, 2015; Yang et al., 2016; De Laurentis et al., 2019; Klein et al., 2019; Peng et al., 2019).

Healthcare practitioners working with this group of patients also suffer substantial distress. Compassion fatigue, burnout and occupational and vicarious stress are very prominent among people working in cancer care (Arimon-Pagès et al., 2019; Guo and Zheng, 2019; Todaro-Franceschi, 2019; Gribben and Semple, 2021). This paper considers one of the often unconscious dynamics that contributes to how emotional distress experienced by patients can affect staff.

Cotter et al. (2019) have previously discussed how frontline practitioners can use different practices to stay present to and support patients during distressing situations. These include focusing on the present moment with patients (“mindful engagement”); punctuating the day with mindful pausing; being present to one’s own behavior, body, emotions and thoughts; moving toward (rather than away from) patient interactions that evoke difficult emotions; and not only “doing” but also “being with” patients. As well as facilitating dignified and holistic care for patients, these practices support practitioners’ coping at an individual level, which can have further positive knock-on effects for patients. From a systemic perspective, staff-support is patient-support (Cotter et al., 2020).

This paper builds on this earlier work and focuses on how practitioners can be further supported to cope, and how team working can be a chief component of this. Box 2 describes three scenarios that practitioners might find themselves in while trying to cope with the situation outlined in Box 1. Different areas of study are used to develop a greater understanding of group processing within these situations and how it can be helpful or unhelpful.

From a Systemic and POP perspective (Bertalanffy, 2015; Mindell, 2017), hospital-based systems often centralize certain ways of working, communicating and interacting. For instance, problem-focused coping can be more central than emotion-focused or relationship-focused coping (Lim et al., 2010; Labrague et al., 2017). The individual positions of patients and staff are more dominant than recognition of the degree to which people within the system are interconnected. The impact of people on each other is greater than is often acknowledged; and as a whole the influence of the overall system on the people within it is often overlooked.

This dynamic contributes to the kind of “Systemic Blanking” of Serena’s emotional distress outlined in Scenario I. This culture may be evident across the overall system (e.g., hospital), sub-systems within it (e.g., individual departments), groups within sub-systems (e.g., cancer CNSs), and individual relationships (e.g., patients and staff or staff and staff). Where such a culture dominates, it results in practitioners feeling unable to view their emotional experiences as needing time, attention and care. The kind of “Collective or Team Blanking” described in Scenario II is an example of this phenomenon occurring at a more localized level. For a range of systemic and personal reasons, and the interaction between them, the team does not attune to, or engage with, Serena’s emotional experiences. They focus on problem and solution-focused coping, as opposed to a more emotion-focused approach within relationship.

In contrast to scenarios I and II, scenario III represents a situation where collective processing is valued and integrated into regular daily working. MNS (Gallese et al., 2007) and PVT (Flores and Porges, 2017) research with people in groups highlights some of the neurobiological mechanisms through which an emotionally understanding team can be supportive. Where a practitioner is faced with a group of colleagues who are attuned, mindful and present to their emotional distress it can be very relieving. When each member of the team connects via their MNS and remains socially engaged via the ventral vagus nerve it creates an environment in which the distressed practitioner can process their emotions and relieve themselves of the emotions they have had “transferred” on to them. Bubler (1958) famously spoke of the “I—Thou” encounter that becomes possible when two people become present with each other. A group of practitioners supporting each other might be considered an “I—Thee” encounter. This cannot be separated from the wider system and creating an environment in which people feel safe enough to be open with their emotional vulnerability is key.

Some teams ably operate in this way. This occurs where the number of people within a team who are more emotion-and-relational-focused surpasses a threshold, changing the prevailing culture, or rather altering it slightly. This can be especially true where a team leader supports this way of working and models it for the team, much in the way that compassionate leadership is described by de Zulueta (2016) and West (2021). Where the person with the greatest positional or contextual power (Mindell, 2014) supports a more marginalized way of working, it can be easier to integrate it. This is also the case where unofficial leaders or “influencers”—people with high social or psychological rank (Mindell, 1995)—support this way of working and relating.

Where a more problem-focused culture (in isolation) prevails, teams are likely to struggle with this part of their work. This is an inevitability where groups of people have to contend with significant amounts of emotional distress on a daily basis without any dedicated means of processing this emotion. Extrapolating from the examples provided in scenarios I and II, it is easy to imagine how collective or team blanking may result in a cumulative build-up of stress over time and feelings of inadequacy amongst employees. Without allowing time and space for team members to understand each other’s perspective and emotional experiences, team members can become critical of each other and interact in interpersonally ineffective ways. For example, feelings of inadequacy or difficulty processing emotions may be projected onto other colleagues, leading some practitioners to take a very critical, expert stance. For others, difficult emotions may be repressed, leading to significant anxiety and a sense of threat or emotional “shut down” within the work context.

The dynamics that promote or inhibit this kind of culture are often partly unconscious and to a degree unspoken about. The further a team is from this way of working or the further influential people within the team are from encouraging it, the more unconscious and unspoken about it may be. This makes it difficult to work with and bringing an awareness to it requires timeliness and caution. There are often historical individual (e.g., Alberta growing up in Apartheid South Africa) and group (e.g., David and Maggie doing their best to cope for many years) issues that have given rise to the situation evolving as it has. Marginalizing emotions in this way is often a necessary way of coping and there may be much hurt that has given rise to it. In short, marginalizing the emotional experiences of staff impacts team cohesiveness and capacity for team working, in turn affecting the capacity for collective processing. Understanding and facilitating group process can take time, but is ultimately supportive of better team functioning.

This final section considers how a culture that fails to acknowledge the impact of patients’ distress on staff, and leaves practitioners isolated in trying to cope, can have a negative impact on both healthcare workers and patients. Box 3 outlines three scenarios that reflect the types of interactions that can emerge when this type of working is under acknowledged. These scenarios are presented individually for clarity but it is likely that versions of all three happen together and in an unpredictable manner.

In the first scenario, the pressure that Tim is under and consequent busy-ness does not allow him to be present to Hamish and attune to his verbal or non-verbal behaviors. In scenario II, Mary’s past experience of being emotionally distressed following encounters with Hamish (and not being able to process these experiences) gives rise to an unconscious anxiety that results in her surpassing her window of tolerance. As a result, she doesn’t socially or emotionally engage with Hamish. A similar process occurs to Serra in scenario III but in an even more unconscious and instantaneous manner. In each of the latter situations, the ventral vagus nerve is overtaken by the anxiety response. In all situations the consequence is Hamish feeling alone.

This loneliness or isolation may occur at a number of different levels. Interpersonal isolation arises when a person feels lonely in the presence of other people and is most obvious in the situations outlined. However, this interpersonal isolation can have further knock on effects on patients with cancer diagnoses, especially for those who fear their own death or are actively nearing end-of-life. Intrapersonal and transpersonal isolation arises where someone becomes disconnected from parts of the self or a sense of something beyond the self, respectively—the latter may vary significantly, depending on a person’s belief system (Kearney, 1996; Shaver, 2002). Existential isolation represents the separation between the individual and all the other individuals in the world (Yalom, 1980). It represents the extent to which humans come into this world alone and leave it alone. Mindful, present-focused interpersonal engagement and interaction from healthcare professionals can support patients in coping with these different manifestations of loneliness (Chochinov and McKeen, 2011; Cotter et al., 2019).

As long as practitioners have to contend with significant levels of emotional distress in their patients and themselves, without having appropriate avenues for processing and coping, this can contribute to complex team conflicts and impact people’s lives outside of work (Rosen et al., 2019; Maglalang et al., 2021). If patient-facing work requires one to regularly “shut down,” as a means of protecting oneself or coping, this “shutting down” may affect other personal relationships. When this pressure interacts and combines with current healthcare workplace pressures (e.g., resource constraints, excessive expectations, workforce shortages) it is likely to be contributing to levels of compassion fatigue, burnout and job satisfaction becoming ever more problematic (Cocker and Joss, 2016; Lu et al., 2019; Shi et al., 2022), especially since the onset of COVID-19 (Xu and Zhang, 2020).

As a prelude to considering implications for practice and future research, it is important to understand the phenomenon outlined throughout—and not just intellectually but also at an emotional and relational level. It is important that we do not move too quickly to: “What can we do? What can we change? And how can we solve the problem?” This is the very mindframe that requires changing in the first instance. If a change of perspective is not introduced as a starting point, all efforts thereafter will likely be ineffective or at least much less effective. This is often more complex, requiring greater awareness, than making external alterations at structural or policy level and often why it is the step that is overlooked.

Taking the above as a necessary starting point, there is potentially much to be gained for staff and patients if the kind of collective processing outlined in Scenario III can be engendered within frontline teams. Much has been written about the impact of a supportive group setting in helping people to process emotional and relational difficulties. Group psychotherapists have been doing this across a range of settings and populations for many years (Yalom and Leszcz, 2005). POP groups have flourished in particular in post-conflict settings (Audergon et al., 2010; Audergon and Audergon, 2017). Group-based approaches may be especially important where emotional distress occurs within group-oriented or systemic situations in the first place (Reiss, 2018). For instance, Psychodynamic-oriented groups have been used with frontline NHS staff working in mental health settings (e.g., Thorndycraft and McCabe, 2008).

In the daily practices of hospital teams, forms of collective processing can be woven into procedural, organizational, task and problem-focused working. This is best conceived of as a way of working and facilitating group discussion as opposed to some separate or additional intervention. It may also be introduced from different existing models or approaches. For example, from a mindfulness perspective (Kabat-Zinn, 2018), this would involve a team being mindfully present to the practitioner holding the distress (Cotter et al., 2019), whereas from a narrative therapy orientation (Payne, 2014), it would involve the practitioner retelling their story with the support of their listening colleagues.

One specific example of a group-based collective processing approach that has been used with frontline healthcare practitioners is staffSPACE (Stopping to Process and Consider Events) (Cotter, 2021b). This is currently being adapted for use in cancer care and is being trialed as a pilot project by the authors. This will be explored initially from a qualitative perspective and later evaluated from a more quantitative standpoint (Creswell and Creswell, 2018). A mixed-methods approach will be used as part of this work. Schwartz Rounds (Robert et al., 2017) are a further group-based approach that involve collective processing. They have been evaluated using a realist informed mixed-methods approach and shown to offer distinctive support for healthcare workers and positively impact staff wellbeing, empathy and compassion for colleagues and patients (Maben et al., 2018).

The issues raised throughout are also relevant at a broader level. “Interdisciplinary” working (Boix Mansilla, 2010) is viewed as being very important within modern systems, however, it is generally recognized that it has not been as effective as was hoped (MacLeod, 2018). More has to be done to support people within hospitals to work together, especially given the high levels of stress, limited resources and heterogeneous patient and staff groups. Process-oriented and systemic facilitation, thinking and planning around complex dynamics between patients and staff, within teams and between departments, has a lot to offer. Hospital-based systems would do well to develop departments focused on supporting team working that sit alongside individual medical specialities, in the same way as do teams responsible for infection control or information governance. It is important that support for collective working is given a place in its own right—as a specialism in itself—within the hospital-based system. If there is to be truly holistic and integrative care, there needs to be an entity within the system whose primary role is devoted to this. This process is likely to be ever changing and evolving, as well as necessary in order for systems and sub-systems to work in a more cohesive manner.

In sum, there is ever growing recognition of the need for healthcare to supplement the gains it has made in improving survival with more integrative, holistic and systemic working. Social medicine, network medicine, systems medicine and systems biology have much to offer in this regard (Ahn et al., 2006; Miles, 2009; Federoff and Gostin, 2017). These sub-fields are focused on creating “a medicine of the whole person” and “putting the patient back together” (Miles, 2009; Greene and Loscalzo, 2017). The authors are of the viewpoint that one step further is needed. In addition, to putting the patient back together it is also necessary to put the whole hospital back together. The future of hospital-based healthcare lies in not only working with the whole patient but the whole hospital system, all of the people within it and the interactions between them.

This manuscript was based on practice-based working within a public health service psycho-oncology department. It involved regular consultation and discussion between all authors. PC drafted the manuscript, was responsible for conceptualizing the manuscript and was the first author. AH, SN, and CJ participated in consultations regarding the content of the manuscript, reviewed the manuscript, and provided feedback on it. CU provided overview of manuscript. AK participated in consultations, reviewed the manuscript, provided feedback, and was the supervising author. All authors contributed to the critical review and approved the final version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.