The Pathology Paradigm vs the Neurodiversity Paradigm
Part 1 of my series 'Exploring Neurodiversity in MSK Practice'
Why I’m Writing This Series
We are living in a time when an appreciation of fellow human beings has never been more necessary. Division, competition, fear, and misinformation have become everyday background noise. Yet the natural world offers us a different lesson: biodiversity strengthens ecosystems, stabilises communities, and allows life to flourish. In the same way, an appreciation of neurodiversity — the natural variation in human minds — can play a crucial role in helping neighbours, communities, professions, and even societies get along a little better.
If you’re a human being who has made the wonderful choice to spend your working life helping other human beings, then certain ideas can genuinely transform that work, not by replacing what you already know, but by expanding it. Over the years, I’ve come to realise that understanding human diversity in how people think, feel, sense, move, communicate, and cope doesn’t just help us support our clients or patients more effectively; it also protects our own wellbeing as clinicians. When we understand people more deeply, we stop fighting battles we never needed to fight, and we start creating conditions where both practitioner and client can thrive.
This series of articles (beginning with Part 1 below) is my attempt to share ideas that have helped me as a clinician, educator, and neurodivergent person. My hope is that they help you too, not only in your practice, but in the wider human task of understanding one another with greater generosity, curiosity, and care.
The Pathology Paradigm vs the Neurodiversity Paradigm
For decades, healthcare has been shaped by what disability scholars call the Pathology Paradigm1 — the assumption that when something isn’t working, the problem lies within the individual. This framing has deep roots in medical and psychological traditions, where difference has often been interpreted as defect. For example, mobility impairments have historically been understood as limitations of the individual rather than as a consequence of inaccessible environments, such as buildings without ramps or lifts. Likewise, neurodivergent conditions like autism or ADHD have frequently been approached primarily as disorders requiring correction.
The social model of disability1,4 shifts the focus away from the individual and towards the structures, environments, and attitudes that create barriers. Building on this shift, a different way of understanding human variation has emerged over the past 30 years, one grounded in the work of autistic scholars, disability theorists, sociologists, and cognitive scientists. This is known as the Neurodiversity Paradigm.2,3
1. The Pathology Paradigm: The Person As The Problem
The Pathology Paradigm aligns with what disability theorists call the medical model1,4.
It assumes:
the clinician’s norms are the default
the client’s differences are deficits
the goal is to normalise the client
distress is caused by internal dysfunction
the environment is neutral
In MSK practice, this shows up as:
“non‑compliance” interpreted as lack of motivation
“avoidance” interpreted as fear or catastrophising
“poor communication” interpreted as a patient problem
“low engagement” interpreted as unwillingness
However, as Milton’s Double Empathy Problem5 suggests, many of these ‘problems’ can be more accurately understood as relational mismatches between neurotypes, rather than individual deficits or failings. If a neurotypical clinician interacts with a neurodivergent patient, the difficulty is often not located in the patient, but in a mismatch of communication styles, expectations, and ways of understanding the world.
For example, a neurodivergent patient might describe their pain very directly, focus on specific sensations, or avoid eye contact, while the clinician might expect more narrative, emotionally expressive communication. The clinician might interpret this as disengagement, lack of insight, or “unhelpful beliefs,” while the patient may experience the clinician as vague, dismissive, or confusing. According to the double empathy framework, neither person is simply lacking empathy; rather, both are struggling to interpret each other across different “social languages” shaped by their neurotypes.
Practically, this shifts the clinician’s role from correcting the patient’s communication or beliefs to actively adapting and co-creating shared understanding, recognising that communication is a two-way process dependent on mutual adjustment and context, not something one person simply “gets right” or “wrong”.
2. The Neurodiversity Paradigm: The Environment As The Variable
The Neurodiversity Paradigm reframes human variation as natural, expected, and valuable2,3.
It draws on the work of:
Autistic activists in the mid-1990s, particularly within the Independent Living mailing list, where the concepts of ‘neurological diversity’ and ‘neurodiversity’ were first articulated.
Judy Singer’s early book chapter on the neurodiversity movement in 19992
Nick Walker’s development of the paradigm3
Damian Milton’s work on mutual misunderstanding5
Michael Oliver’s Social Model of Disability1
Devon Price’s work on masking and burnout6
Robert Chapman’s work on neurodiversity and minority stress7
The paradigm assumes:
human brains vary naturally
variation is not pathology
distress often arises from mismatch, not defect
environments can disable or enable
support is relational, not corrective
In alignment with the social model of disability1,4, MSK clinicians should therefore be prepared to utilise:
sensory‑considerate rooms
predictable processes
explicit communication
flexible pacing
reducing cognitive load
respecting autonomy and self‑regulation
3. Pain Science Has Already Paved The Way
Pain science has already moved toward contextual, relational, and biopsychosocial models, particularly through the work of Melzack & Wall, and Butler & Moseley.
The Neurodiversity Paradigm fits naturally into this shift.
When we adopt it:
“non‑compliance” becomes executive load8
“avoidance” becomes sensory protection9
“poor communication” becomes mismatched communication norms5
“catastrophising” becomes interoceptive difference + lived experience10
“low motivation” becomes burnout from lifelong masking6
This reframing leads to practical, concrete adjustments that reduce patient distress and improve outcomes.
In other disciplines, the paradigm shift has already happened, or is actively happening. Pain science has moved toward contextualism, education has moved away from behaviourism, disability studies has moved away from individual blame, Autism studies has moved toward lived‑experience‑led scholarship.
MSK practice needs to catch up.
References & Further Reading
1 Oliver, M. (1983). Social Work with Disabled People.
2 Singer, J. (1998). Odd People In (Neurodiversity: The Birth of an Idea, 2016)
3 Walker, N. (2021). Neuroqueer Heresies.
4 Shakespeare, T. (2013). Disability Rights and Wrongs Revisited.
5 Milton, D. (2012/2014+) Double Empathy Problem.
6 Price, D. (2022). Unmasking Autism.
7 Chapman, R. (2023). Neurodiversity and the Social Ecology of Mental Health.
8 Barkley, R. (1997). ADHD and Executive Function.
9 Dunn, W. (1997). The Sensory Profile.
10 Barrett, L. F. (2017). How Emotions Are Made.
Future parts to this series
This article is the first in a series titled ‘Exploring Neurodiversity in MSK Practice’. I am releasing the series in the lead-up to my presentation at this year’s Therapy Show (26 November 2026, Birmingham NEC): ‘Changing the Room, not the Person: Neurodiversity and MSK clinical Practice’.
In each article, I aim to unpack a key concept, grounded in the work of its originating scholars. At the time of writing, I plan to explore the following areas in greater detail:
The Pathology Paradigm vs the Neurodiversity Paradigm (this article)
Ecological Diversity & Neurodiversity
The Double Empathy Problem
Sensory Processing
Executive Function
Communication Across Neurotypes
Masking & Burnout
Co‑Regulation & Safety
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