Within the biopsychosocial model of neurodiversity, understanding work-related intervention and treatment becomes more about adjusting the fit between the person and their environment than about treating a disorder. Critical review of the extant biopsychosocial research supports the social model proposition that the individual is not disabled, but the environment is disabling.
Exclusion rates point to an economic, social and moral imperative to improve outcome-based research, from which we can advise practition-ers and individuals on which adjustments improve inclusion, within a biopsychosocial model.
A reductive, medical paradigm of research is incongruent with the legal status of neurominorities as protected conditions in most developed countries, to which organizations must adjust.
The aim of occupational accommodations for neurominorities is to access the strengths of the spiky profile and palliate the struggles.Neurodiversity at work: a biopsychosocial model and the impact on working adults | British Medical Bulletin | Oxford Academic
The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person’s medical condition it is not simply the biological factors to consider, but also the psychological and social factors 1.
Bio (physiological pathology)
Psycho (thoughts emotions and behaviours such as psychological distress, fear/avoidance beliefs, current coping methods and attribution)
Social (socio-economical, socio-environmental, and cultural factors suchs as work issues, family circumstances and benefits/economics)Biopsychosocial Model – Physiopedia
Autistic People Recognize Challenges Associated with Autism
Despite viewing autism as central to identity, autistic participants in the study by Kapp et al. (2013) did not differ from non-autistic participants in negative emotions toward autism or in the perceived importance of supports to help autistic people gain adaptive skills. This overlap between the neurodiversity movement and the medical model indicates a more nuanced perspective on disability than the standard social model wherein impairments are believed to arise solely from societal factors. The perspective of autism endorsed by many members of the neurodiversity movement is more consistent with a biopsychosocial model (Engel, 1977) of autism, wherein internal differences interact with social factors to create challenges associated with autism (Kapp, 2013). For example, an autistic researcher pointed out that reduced theory of mind, which has been postulated to be a core deficit within autistic people (Baron-Cohen et al., 1995), is not an impairment that resides within autistic people but rather a mutual difficulty relating, as neurotypical people also face often unacknowledged challenges understanding the minds of autistic people (Milton, 2012). Further evidence that autistic adults’ perceptions of autism align with a biopsychosocial model arises from research demonstrating that some autistic adults recognize that autistic traits interfere with employment and socialization, and attempt to pass as “normal” (Griffith et al., 2012).
These findings provide support for the importance of listening to autistic people and becoming more familiar with their experiences in order to address and counter stigma. Indeed, people aware of the neurodiversity movement are more likely to view autism as a positive identity that does not need a cure (Kapp et al., 2013). Although superficially surprising, our finding that numerically more autistic participants supported (55%), rather than opposed (26%), the medical model in their definitions of autism is consistent with prior research demonstrating overlap between the medical model and the neurodiversity movement in terms of shared recognition of challenges associated with autism (Kapp et al., 2013), which is consistent with a biopsychosocial model of autism (Kapp, 2013).Frontiers | Whose Expertise Is It? Evidence for Autistic Adults as Critical Autism Experts
Self-identification as autistic and neurodiversity awareness were associated with viewing autism as a positive identity that needs no cure, suggesting core differences between the medical model and the neurodiversity movement. Nevertheless, results suggested substantial overlap between these approaches to autism. Recognition of the negative aspects of autism and endorsement of parenting practices that celebrate and ameliorate but do not eliminate autism did not differ based on relation to autism or awareness of neurodiversity. These findings suggest a deficit-as-difference conception of autism wherein neurological conditions may represent equally valid pathways within human diversity. Potential areas of common ground in research and practice regarding autism are discussed.Deficit, difference, or both? Autism and neurodiversity. – PsycNET
This study provides support for the notion of disability as an interaction between social factors and personal deficits, the challenges of which do not necessarily make life less valid or worth- while but an equally valid part of human diversity, especially in the subjective experience of disabled people. Considering that autism is diagnosed primarily on the basis of social deficits (American Psychiatric Association, 2000), autistic people’s apparent acknowledgment of their deficits and acceptance of means to ameliorate them challenge a purely social model of disability in which oppression alone creates disability, a notion disability rights advocates increasingly criticize as not recognizing that deficits themselves lower quality of life (Beauchamp-Pryor, 2011; Palmer & Harley, in press). Neurodiversity advocates, while often emphasizing social barriers, have acknowledged this interrelationship between internal and social challenges (Baker, 2011; Ne’eman, 2010).
Indeed, an international biopsychosocial model of causation of and support for disability now prevails (Leckman & March, 2011; Palmer & Harley, in press). This emerging, nuanced understanding of disability may require disentanglement of symptoms and adaptive functioning (Anckarsa ̈ter, 2010) and care supporting significantly challenged people, including considering the perspectives, abilities, and opportunities of people with disabilities (Baker, 2011; Beauchamp-Pryor, 2011; Madeo et al., 2011; E. T. Savarese & Savarese, 2010; Silverman, 2012).
Nevertheless, the spectrum nature of disability supports the legitimacy of multiple agendas (Baker, 2011). Scientists, working with the community, can help stakeholders with competing agendas make informed choices between rights, responsibilities, and needs at personal, social, and political levels by affirming that diverse societies respect multiple perspectives (Baker, 2011; Beauchamp-Pryor, 2011; Madeo et al., 2011; Silverman, 2012), as empathy, communication, and relationship work both ways (E. T. Savarese et al., 2010; Silverman, 2012).Deficit, difference, or both? Autism and neurodiversity. – PsycNET
A historic window of opportunity has emerged to support more nuanced understandings of disability, with biomedical authorities increasingly admitting their shortcomings and disabled people strengthening our community. For example, this project, funded by the Autistic adult-oriented the Daniel Jordan Fiddle Foundation, represents a product of the larger neurodiversity movement instead of perpetuating a narrow focus on the autism spectrum. Biopsychosocial classifications that reflected the complex realities of disability threatened the psychiatric profession’s authority, as it seemed to pathologize everyone (Wilson, 1993), so it invented an arbitrarily restrictive version of the medical model (Hyman, 2010). Now a more expansive system appears ready to return, causing concern among clinicians in addition to the public. We could welcome this trend if it comes with a comprehensive, valid, acceptable way to measure adaptive functioning, because ultimately everyone wants to improve people’s quality of life (Anckarsäter, 2010), and if we counter the unrealistic, harmful deficit-only and normative focus.“Interactions between theoretical models and practical stakeholders: The basis for an integrative, collaborative approach to disabilities” in Empowering Leadership: A Systems Change Guide for Autistic College Students and Those with Other Disabilities – Autistic Self Advocacy Network
The dominance of psychoanalysis and behaviorism meant that psychologists often attributed psychiatrically diagnosed conditions – those without known causes and without clear effects on physical appearance – to environmental causes like poor parenting. The modern understanding of the brain began in the 1970s, and a broad, continuous, biopsychosocial model of so-called “mental disorders” became replaced with a symptom-based, categorical medical model (Wilson, 1993). The publication of the third edition of the main diagnostic classification system, the Diagnostic and Statistical Manual (DSM), in 1980 cemented the shift (Mayes & Horwitz, 2005). It created many more categories, and the DSM-IV in 1994, the edition in use today, built on its predecessor.
As the name implies, the model tends to attribute biological causes to health conditions and disabilities, replacing a goal of restoring people to natural conditions with making them normal, based on statistical deviation from the average (Bury, 2001). This becomes a problem when natural differences may have inherent strengths or at least neutral function, and when normal functioning lacks anything inherently better or good. This can lead to a confirmation bias that pathologizes extreme differences between typical and disabled people, whether observed in the biology or behavior, without considering the possibly adaptive function they may serve. The medical nature of this deficit basis also potentially groups together all people with unusual functioning or health issues as “sick,” “diseased,” or “broken,” without distinguishing between challenging but stable, non-injurious conditions that may ease over time, and degenerative, fatal, and otherwise obviously harmful problems. The biological essence of the model relates to the traditional view of people as a collection of organs (sometimes measured behaviorally as “symptoms”) and its separation of the mind, body, and what some might call the spirit (Brickman et al., 1982). Yet they work together, as shown by the placebo effect, where people’s health improves (or they perceive that it does) based on taking a “treatment” that lacks the direct ability to help. Moreover, the model’s overemphasis of biology means that it ignores the contribution that the environment (such as culture and family) and personal characteristics beyond the condition (such as factors more closely related to self-determination, including motivation) may play in their effect on the person (Putnam,.2005; Shakespeare, 2008).
Despite potential protections the biomedical model offers from the moral model, it has the potential for its own form of oppression. Its view of people as submissive “patients” compliant with medical authority as the source of all knowledge deprives laypeople of the self-determination to make their own decisions based on comprehensive access to information.
Thanks in large part to the disability rights movement, the medical and social models have moved toward one another and interactionist models gain momentum in research and dominate in practice, likely reflecting that reality lies somewhere between the extremes. In the late 1970s, around the time the biomedical model became most formulated into the DSM, medical researchers and practitioners began to publish on a biopsychosocial model (Engel, 1977). In theory, the model means that biological (such as the basis of conditions), psychological (thoughts and emotions that do not necessarily originate from a condition), and social (such as stigma and the surrounding community) factors all contribute to functioning (and impairment, when present, that interferes with adaptive functioning or daily living). In practice, the model means that the client and provider form a connection or relationship that involves the provider’s incorporation of the client’s subjective experience for more personalized care (Borrell-Carrió , Suchman, & Epstein, 2004). It has taken a few forms, and the general paradigm has contributed to many fields. Perhaps the most authoritative, detailed variant underlies the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The ICF conceptualizes and measures disability as an interaction between the specific condition, other personal characteristics, and the environment. It complements the International Classification of Diseases, which like the DSM currently, lists symptom-based categories as diagnoses.
Now a biopsychosocial model in origin of and response to disability prevails in the medical and clinical fields (Lechman & March, 2011; Palmer & Handley, in press; Rutter, Moffit, & Caspi, 2006). Today professionals often would often disagree that they staunchly follow a pure form of the medical model (Baker, 2011). Many reasons account for this change. The disability and other civil rights movements, and perhaps often cultural phenomena like the digital revolution or globalization, have resulted in a more open, less hierarchical society where more people take ownership of their needs and resist playing the traditional “sick” or “patient” role. Certainly, the proliferation of the media and information on the Internet have produced more democratic self-empowerment. Unprecedented access to information, along with the rising cost of high-tech medicine, also leads more people to counter the establishment with alternative medicine or lifestyles (including vitamins, supplements, specialized diets, meditation, and deep breathing; Bury, 2001). Mainstream doctors have started to accept many alternative or holistic practices as complementary rather than in opposition to their work (Astin, Shapiro, Eisenberg, & Forys, 2003), and psychologists have a recent surge of interest in mindfulness for stress reduction and everyday living. Healthcare reform in the United States probably increases priorities around primary care, furthering a trend toward holistic medicine and giving less power to disease-minded specialists.“Interactions between theoretical models and practical stakeholders: The basis for an integrative, collaborative approach to disabilities” in Empowering Leadership: A Systems Change Guide for Autistic College Students and Those with Other Disabilities – Autistic Self Advocacy Network
In terms of scholarship, discourse, and praxis, there are two basic ways to approach the biopsychosocial phenomenon of neurodiversity. Sometime around 2010, I started referring to these two approaches as the pathology paradigm and the neurodiversity paradigm.
The pathology paradigm starts from the assumption that significant divergences from dominant sociocultural norms of cognition and embodiment represent some form of deficit, defect, or pathology. In other words, the pathology paradigm divides the spectrum of human cognitive/embodied performance into ‘‘normal’’ and ‘‘other than normal,’’ with ‘‘normal’’ implicitly privileged as the superior and desirable state.
The neurodiversity paradigm starts from the understanding that neurodiversity is an axis of human diversity, like ethnic diversity or diversity of gender and sexual orientation, and is subject to the same sorts of social dynamics as those other forms of diversity—including the dynamics of social power inequalities, privilege, and oppression. From this perspective, the pathologization of neurominorities can be recognized as simply another form of systemic oppression which functions similarly to the oppression of other types of minority groups.Toward a Neuroqueer Future: An Interview with Nick Walker
When we recognize neurodiversity as a form of human diversity, and recognize the pathology paradigm as a form of systemic oppression like racism or heterosexism, it’s easy to see that the concept of a ‘‘normal mind’’ is just as absurd and innately oppressive as the idea that white people are the default ‘‘normal’’ race or that heterosexuality is the one ‘‘normal’’ sexuality. And the pathologization of neurominorities—the framing of autism, for instance, as a ‘‘mental disorder’’ or a medical ‘‘condition’’—is no more valid and no less oppressive than the framing of homosexuality as a ‘‘mental disorder.’’
The two paradigms—the pathology paradigm and the neurodiversity paradigm—are as fundamentally incompatible as, say, homophobia and the gay rights movement, or misogyny and feminism. In terms of discourse, research, and policy, the pathology paradigm asks, ‘‘What do we do about the problem of these people not being normal,’’ whereas the neurodiversity paradigm asks, ‘‘What do we do about the problem of these people being oppressed, marginalized, and/or poorly served and poorly accommodated by the prevailing culture?’’
I’d define the neurodiversity movement as the movement to shift the prevailing culture and discourse away from the pathology paradigm and toward the neurodiversity paradigm. The neurodiversity movement is by no means monolithic; there are a lot of different ways that people are working to bring about this shift in different realms and contexts, and of course there’s some variation in how the neurodiversity paradigm is interpreted by different groups and individuals within the movement.Toward a Neuroqueer Future: An Interview with Nick Walker