The Double Empathy Problem: Why Communication Breaks Down Across Neurotypes
Part 4 of my series 'Exploring Neurodiversity in MSK Practice'
Why I’m Writing This Series (in brief)
If you work with people, understanding human diversity — in how we think, feel, sense, move, and communicate — can fundamentally change how you practise.
At its heart, this series is about becoming more neuroaffirmative: not just improving care for neurodivergent clients, but making clinical work more humane, accessible, and sustainable for everyone.
In Part 1, we explored paradigms; in Part 2, disability and environment; in Part 3, ecological diversity. Part 4 turns to one of the most important — and most misunderstood — ideas in contemporary neurodiversity scholarship.
The Double Empathy Problem was first articulated by autistic scholar Damian Milton in 20121. It challenges the long‑held assumption that autistic people have a “communication deficit”. Instead, it proposes something far more accurate — and far more useful for MSK clinicians:
Communication difficulties arise not from one person’s deficits,
but from a mismatch between two different neurotypes.
In other words, communication is relational, not individual.
This idea is foundational to neuroaffirmative practice, and it changes everything about how we understand interaction, rapport, and therapeutic alliance.
It’s also one of the core ideas I’ll be exploring in more depth in an upcoming live session for The Unbound Project.
1. What the Double Empathy Problem Actually Says
Milton’s original argument1 is simple but profound:
Autistic people do not inherently struggle with communication.
Neurotypical people do not inherently communicate “better”.
Communication breaks down when people with different lived experiences, sensory worlds, and communication norms interact.
Both parties may misunderstand each other — not because either is impaired, but because their frames of reference differ.
This aligns closely with ecological and social‑model thinking:
Communication is shaped by context
Meaning is co‑created
Understanding depends on shared norms, not correctness.
Research since Milton’s original paper has repeatedly confirmed this. Studies show that autistic‑autistic communication is often more efficient, more accurate, and more comfortable than autistic‑neurotypical communication2.
Again, this reflects difference in communication ecologies — not impairment.
2. Why the Double Empathy Problem Matters for MSK Practice
MSK clinicians rely heavily on communication — taking histories, explaining pain, giving instructions, setting expectations, building trust, co‑creating rehab plans.
If communication is mismatched, everything becomes harder:
the client may appear “anxious”, “avoidant”, or “unengaged”
the clinician may feel confused, rushed, or ineffective
misunderstandings accumulate
rapport weakens
adherence drops
distress increases
The Double Empathy Problem helps us see that these challenges are not personal failings — they are interactional dynamics.
Here’s what this looks like in practice:
Literal vs inferential communication
A clinician says: “Try to relax your shoulder a bit.”
A literal‑thinking autistic client may not know how much, in which direction, or what “relax” means in this context1.
Detail‑rich vs summary‑based communication
A client gives a long, precise, chronological account of their symptoms.
A clinician expecting a brief summary may misinterpret this as anxiety or tangential speech3.
Directness vs social cushioning
A client gives blunt, concise answers.
A clinician expecting small talk may misread this as disengagement1.
Predictability vs spontaneity
A clinician changes the plan mid‑session.
A client who relies on predictability may experience this as destabilising or unsafe4.
None of these are deficits.
They are different communication ecologies interacting.
3. Ecological Communication: A Better Way to Understand Interaction
The Double Empathy Problem fits naturally within the ecological framework we explored in Part 3.
Communication is not simply words, tone and body language.
It is shaped by:
sensory load4
executive function5
interoception6
social expectations1
past experiences of stigma or misunderstanding7
minority stress7
When these ecological factors differ between clinician and client, communication becomes harder for both parties.
This is why autistic‑autistic communication often works so well.
And it’s why neurotypical‑neurotypical communication often works well.
The Double Empathy Problem simply tells us:
When neurotypes differ, we must build the bridge intentionally.
4. What Communication Mismatch Looks Like in MSK Settings
Here are some common examples of Double Empathy dynamics in MSK practice:
The “uncommunicative” client
The clinician expects eye contact, small talk, and emotional language.
The client communicates through precision, detail, or silence.
→ Mismatch, not disengagement.
The “overly detailed” client
The clinician wants a summary.
The client communicates through narrative and specificity.
→ Mismatch, not anxiety.
The “non‑compliant” client
The clinician gives verbal instructions.
The client needs visual, step‑by‑step, or written guidance.
→ Mismatch, not lack of motivation.
The “defensive” client
The clinician uses indirect language.
The client interprets it literally and feels confused or criticised.
→ Mismatch, not emotional fragility.
The Double Empathy Problem helps clinicians reinterpret these moments with compassion and accuracy.
5. What This Means for MSK Clinicians
The Double Empathy Problem invites us to fundamentally shift how we understand communication.
Instead of assuming that misunderstandings reflect a client’s deficits, we begin to see communication as co‑created, contextual, and ecological.
When a client seems:
“hard to read”
“blunt”
“overly detailed”
“vague”,
“unresponsive”
we can begin to ask:
What communication norms am I assuming?
What norms might this client be using?
How can I make the bridge clearer, safer, and more predictable?
This aligns perfectly with the central message of this series:
People thrive when their environments, including communication environments, fit their needs.
From Understanding To Action
Understanding the Double Empathy Problem is only the first step.
The deeper question is:
How do we design clinical environments and interactions that reduce mismatch in the first place?
This is exactly the focus of a session I’ll be delivering for The Unbound Project:
‘Exploring Workplace Conversations Through a Neurodiversity Lens’
🗓 Monday 14th July
🕖 9:00 (BST / UK)
📍 Live on Zoom
🎟 Free (registration required)
👉 Register here
In this session, I’ll build directly on the ideas in this article to explore:
How communication breakdown often emerges from hidden assumptions
Why many “people problems” are actually design problems
How small, practical changes in communication, predictability, and environment can shift understanding
What it means to design interactions for real human variation, not a single “standard” way of thinking
References & Further Reading
1 Milton, D. (2012) “On the Ontological Status of Autism: The Double Empathy Problem.”
2 Heasman, B. & Gillespie, A. (2019). “Neurodivergent intersubjectivity: Distinctive features of how autistic people create shared understanding.”
3 Walker, N. (2021). Neuroqueer Heresies.
4 Dunn, W. (1997). Dunn, W. (1997). The Sensory Profile.
5 Barkley, R. (2012). Executive Functions: What They Are, How They Work, and Why They Evolved.
6 Mahler, K. (2017). Interoception: The Eighth Sensory System.
7 Botha, M. & Frost, D. (2020). “Extending Minority Stress Theory to Autistic People.”
Explore the full series
This article is part of my series Exploring Neurodiversity in MSK Practice, where I unpack key concepts shaping neuroaffirmative clinical work.
👉 You can explore all parts of the series here.
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