Persistent (chronic) pain is a significant burden to individual well-being, societal health, and the sustainability of healthcare systems (1–3). Despite advances in and widespread availability of biomedical and psychological interventions, persistent pain continues to affect nearly one-third of the global population—a treatment-prevalence paradox (4–6). Pain is a complex and deeply human phenomenon that encompasses hidden subjective inner states, observable physiological and behavioural correlates, and interconnectedness to shared cultural and socio-ecological systems. Pain science is the systematic study of the biological, psychological, and social mechanisms underlying pain experience associated with actual or potential damaged and/or dysfunctional tissue (7). Historically, the focus of pain science on damaged and/or dysfunctional tissue led to biomedical dominance and reduced emphasis on subjective, cultural, and existential dimensions (8–10). The biopsychosocial model of pain redresses the imbalance created by the dominance of the biomedical model.

The term biopsychosocial denotes an interdisciplinary approach to health, illness, and care delivery, grounded in the interplay between biological processes (e.g., genetics, physiology), psychological dimensions (e.g., emotions, cognition, behaviour), and social contexts (e.g., culture, relationships, socioeconomic status). While representing a significant advancement over reductionist biomedical paradigms—which reduce complex human experiences to their simplest biological components—the biopsychosocial model has faced critique for its limited sensitivity to the subjective experience of pain and for the conceptual fragmentation of its biological, psychological, and social domains (11–20). These domains often become disjointed in both theoretical discourse and clinical practice, resulting in fragmented care and a lack of explanatory coherence that is disconnected from the lived reality of being human.

This conceptual disjunction is further compounded by the cultural and epistemological underpinnings of the model itself, which originated within a Western, Educated, Industrialized, Rich, and Democratic (WEIRD) cultural worldview (21). The WEIRD worldview tends to privilege individualism, analytical reasoning, mechanistic interpretations, and impersonal prosociality, which emphasizes cooperation among strangers based on abstract norms, institutions, and rule-based fairness rather than close interpersonal ties (22–26). Such orientations may have driven the reductionist biomedical paradigm and marginalization of relational, spiritual, and existential dimensions of pain that are often foregrounded in non-WEIRD cultural contexts (27, 28). In many indigenous and collectivist traditions, pain is not merely a pathological disruption but a meaningful aspect of life's natural rhythm—interwoven with communal, emotional, and spiritual realities (29–32).

The continued influence of biomedical paradigms has contributed to the recognition of persistent (chronic) primary pain as a distinct (pathological) disease entity in the latest revision of the World Health Organization's (WHO) International Classification of Diseases (ICD-11) (33–35). While this framing offers many advantages, it also legitimizes biomedical interventions that have, at least in part, contributed to systemic harms—such as the global opioid crisis (1, 36). Moreover, the empirical foundation of many clinical interventions remains tenuous, with numerous treatments demonstrating limited efficacy in practice—often attributed to a broader crisis in research quality (37–39). Conceptual ambiguities within pain science, including the conflation of nociception with pain and the reliance on speculative constructs further undermine theoretical clarity (40–42).

A growing body of scholarship contends that pain is too idiosyncratic, context-dependent, and meaning-laden to be adequately captured by mechanistic or reductionist models (43–47). Meta-ethnographic perspectives have likened pain to an ecosystem—dynamic, adaptive, and shaped by intersecting biological, psychological, social, and environmental forces (48, 49). The sobriquet of "sticky pain"—a term coined by Borsook et al. (50) to describe persistent, treatment-resistant pain—reflects the failure of certain pain episodes to resolve. As a colloquial term "stickiness" can be used to draw attention to the ecology of pain and factors in contemporary life that may hinder pain resolution (i.e., socio-ecological risk factors).

While the biopsychosocial model nominally incorporates multiple domains, it does not explicitly engage with existential or phenomenological frameworks—those that foreground temporality, meaning, and the lived experience of suffering (11–17). There is increasing recognition that such perspectives are essential for understanding pain not merely as a clinical symptom but as a socially grounded, deeply human condition (45, 46, 51). However, the prevailing structure of professional knowledge production continues to favour specialization over integration, thereby impeding the development of comprehensive models that reflect the full scope of pain as a lived and relational experience.

In response to these limitations, this article proposes a contextual “integral” view of pain and its persistence that includes all dimensions in a unified way. An integral approach weaves together inter- and transdisciplinary knowledge, lived experience, and reflective inquiry to synthesise subjective experiences of pain with its objective mechanisms, all within the broader cultural, systemic, and environmental contexts of contemporary life. It seeks to avoid reductionism, embrace complexity, and honour both the inner life of the person in pain and the scientific understanding of pain processes. An integral approach emphasises the interconnectedness of the individual within their social and environmental context—supporting a whole-person, whole-system, whole-health perspective (52–56).

The aim of this article is to present an integral vision of pain that seeks to unify diverse disciplinary insights, fostering a whole-person, whole-system, and salutogenic perspective on understanding and addressing the persistence—or stickiness—of pain. Building on previous work, this article extends the author's earlier mapping of pain onto a simplified version of Ken Wilber's All Quadrants All Levels (AQAL) framework (57). Rooted in a contemporary, non-religious understanding of spirituality—as meaning, purpose, and connection to self, others, and nature—the integral, AQAL framework enhances the traditional biopsychosocial approach by incorporating subjective experience, objective mechanisms, cultural meaning, and systemic influences. In doing so, it offers a more holistic, context-sensitive, and experientially anchored understanding of pain and its persistence, framed through an evolutionary mismatch, salutogenic, and socially embedded model of health.

This integral perspective is shaped by the author's own positionality as a white, male academic based at a post-1992 UK university, with over four decades of experience in pain research. Drawing on critical realism, positivist science, and reflexive inquiry, this work blends methodological rigour with integral thinking that combines multiple perspectives—including individual and collective, interior and exterior, science and spirituality. It is informed by Integral Theory, biopsychosocial and salutogenic paradigms, and evolutionary psychology. The author remains critically aware of how his social and disciplinary positioning informs his interpretations of the persistence of pain and its cultural significance, acknowledging the influence of both personal and epistemological standpoints in shaping this multidimensional approach.

The understanding of pain has evolved from spiritual and humoral interpretations to Descartes' mechanistic model and the dominance of biomedicine, before being reframed by Melzack and Wall's 1965 Gate Control Theory, which introduced the nervous system's modulatory role (58). This set the stage for Engel's introduction of the biopsychosocial model in 1977 arguing that complex health conditions require considering not only biological factors but also psychological and social influences (59). Following the adoption of the biopsychosocial model (60), its translation into clinical practice has remained partial, with the social dimension frequently marginalised or insufficiently addressed. Advances in neuroscience reframed pain as a complex brain-generated output shaped by context, emotion, and cognition, prompting the emergence of psychologically informed physiotherapy and interdisciplinary pain management. More recently, scholars have advocated for post-biopsychosocial approaches—such as enactive and 5E frameworks—that emphasise the embodied, embedded, enacted, emotive, and extended nature of pain (11, 13). These developments reflect a growing recognition of pain as a dynamic, lived experience shaped by both internal processes and external environments, reinforcing the need for holistic, patient-centred care.

Ken Wilber, a populist American psychologist/philosopher, developed the concept of the integral mind as a means of unifying the physical, emotional, mental, and spiritual dimensions of human experience (61, 62). His work is characterized by an effort to bridge longstanding divides between Eastern and Western philosophies, science and spirituality, and individual and collective perspectives. At its core, integral thinking seeks to cultivate a holistic understanding of reality in which diverse perspectives are not merely acknowledged but actively harmonized (61, 63). In practice, the integral mind reflects an individual's capacity to synthesize multiple dimensions of experience into a coherent worldview. This integral orientation aligns particularly well with existential models of pain, which offer a deeply humanistic perspective—one that recognizes both inner subjective experience and objective bodily processes as inseparable from the shared cultural, environmental, and spiritual dimensions of contemporary life.

Wilber developed the AQAL framework to create a comprehensive model for understanding complex human experiences (61, 64). All Quadrants (AQ) refers to four different perspectives on experience: •

individual-interior [upper-left (UL)]: intrasubjective, personal, inner experience

The AQAL framework is underpinned by several core principles that render it particularly suitable for advancing an integral perspective of pain: •

Non-Exclusion: All perspectives—psychological, biological, social, environmental, and spiritual—are considered valid and necessary for a comprehensive understanding.

While the biopsychosocial model acknowledges multiple domains, it lacks the structural coherence and contextual depth. In contrast, AQAL integrates: •

Subjective experience and existential meaning of the individual (UL)

This dynamic is evident in the evolution of pain models themselves. The biomedical [“pain pathway”(sic)] model, with its emphasis on tissue damage and pathology, historically shaped clinical practice around physical (biomechanistic) interventions. Nowadays, the biopsychosocial model, incorporating psychological and social dimensions, shapes multidimensional understandings and multidisciplinary clinical practices adopting patient-centred approaches. Building on this progression, an integral model—framed through an AQAL, evolutionary-mismatch and salutogenesis (origins of health) lens—seeks to hold multiple perspectives simultaneously to construct person-centred, context-sensitive, meaning-making approaches to empower people to actively reshape their living experiences of pain in the modern world. Thus, the vision for an integral framework is not only to represent the persistence of pain more comprehensively, but to actively reshape how it is lived and addressed—expanding the possibilities for healing.

Previously, the author mapped features of pain onto a simplified version of the AQAL framework highlighting certain limitations of the biopsychosocial model while preserving its foundational insights, thereby enabling an extension of the biopsychosocial model's conceptual scope (57). As a heurist tool the simplified AQAL framework is capable of accommodating both personal experience and systemic context in an organizing structure that visualises the location of multidimension aspects of pain, as represented by the four quadrants in Figure 1.

Looking ahead, the AQAL framework offers a powerful tool for enhancing service design and delivery by ensuring that all fundamental dimensions of the pain experience—individual and collective, internal and external—are systematically addressed. Its integrative architecture promotes conceptual and contextual coherence, helping services avoid reductionist tendencies and instead embrace the full complexity of human experience. By accommodating different levels of psychological development and cultural worldviews, AQAL can guide the tailoring of interventions and narratives to meet the evolving needs of diverse individuals and communities. This makes it especially valuable for designing dynamic, community-based, person-centred care models that are both inclusive and adaptive—advancing the biopsychosocial model into a truly integral paradigm.

Despite its conceptual strengths, the AQAL framework has had limited exposure in peer-review academic literature and lacks empirical validation. While theoretically rich, levels of psychological development as formulated by Wilber (61, 62, 64, 106) are conceptually fluid and may be prone to overinterpretation, e.g., transpersonal levels of development lack mainstream psychological acceptance (107, 108).

A common critique of Wilber's integral framework is its perceived complexity, which not only encompasses quadrants and levels but also includes lines of development, states of consciousness, and types—making it challenging to apply in practical or clinical contexts without significant interpretive effort (63, 107, 108). A challenge in applying the integral model to clinical practice lies in the overwhelming complexity that emerges when attempting to account for every possible variable. This level of detail introduces a substantial computational burden, making real-world implementation difficult without deliberate simplification. To address this, model reduction becomes essential—a process of selectively narrowing the scope to focus on the most relevant and influential variables. Achieving model reduction within an integral vision of pain, while preserving its theoretical depth and multidimensional scope, requires balancing conceptual richness with clinical usability. This can be accomplished by adopting the four quadrants as the primary heuristic framework and selectively incorporating developmental levels to align narratives with an individual's worldview, thereby simplifying the model into a more accessible and clinically useful tool (57).

Rather than aiming for exhaustive quadrant coverage, clinicians can use the quadrants as a reflective guide to identify patterns and gaps in care. Translating the model into practical tools for practitioners and livers—such as structured checklists or narrative-based guides—would further enhance applicability. Distributing quadrant responsibilities across interdisciplinary teams fosters shared ownership and would reduce cognitive burden, enabling the AQAL framework to function as a flexible, coherent, unifying lens. When integrated with established models such as the biopsychosocial framework or Bayesian and Active Inference theories, AQAL supports enhanced clinical reasoning without overwhelming practitioners.

To enhance the applicability and scholarly credibility of the AQAL framework within pain science, several research priorities warrant attention. Cultural and contextual analyses are needed to examine how sociocultural and environmental factors contribute to the persistence of pain and influence treatment outcomes. At the macro level, it is important to investigate the impact of broader social forces—such as public policy, socioeconomic inequality, and media representations—on the lived experience of pain. Evaluative studies of AQAL-informed policies and community-based programs can help assess their effectiveness in improving health outcomes and promoting health equity. Integrating diverse research paradigms may also facilitate a more holistic understanding of pain, shifting the focus beyond symptom alleviation to encompass broader outcomes such as wellbeing and quality of life. Interdisciplinary collaboration across all quadrants—biological, psychological, cultural, and socio-ecological—is essential to ensure comprehensive analysis. Engaging a wide range of stakeholders, particularly individuals with lived experience of persistent pain, is vital for validating research findings and ensuring their relevance. Finally, the design of interventions should remain adaptive, incorporating ongoing stakeholder feedback and responding to evolving cultural narratives.

This article proposes that an integral perspective—drawing on the AQAL framework, evolutionary mismatch theory, and salutogenic principles—offers a novel way to reconceptualize the nature and treatment of persistent or "sticky" pain. From this foundation emerges an integral model, a practical tool that maps the biological, psychological, social, cultural, and existential dimensions of pain across individual and collective contexts, offering a more coherent and holistic approach that acknowledges pain as a deeply embedded, meaning-rich experience.

By conceptualising pain as both a physiological event and a meaning-laden experience, this approach interprets its persistence as a reflection of broader cultural and environmental conditions in contemporary life. It challenges the limitations of reductionist paradigms and fragmented understandings by reframing the biopsychosocial model to account for the dislocated domains of pain—where biological, psychological and social influences are often treated in isolation rather than as interconnected elements. This reconceptualization positions pain as a dynamic, relational, and context-sensitive phenomenon, capable of more fully engaging with the complexity of lived experience, cultural meaning, and modern habitats.

By enhancing conceptual clarity, the AQAL framework invites the general public into a more nuanced and relatable understanding of pain by building on established pain education concepts—such as an “overprotective brain (sic)” and reductive explanations focussing solely on a hyperexcitable nervous system. Through narrative and storytelling, mapping lived experiences across four interrelated domains can be brought vividly to life. For instance, a woman living with fibromyalgia may describe how her body flares up under stress (UR), how she feels emotionally dismissed and misunderstood (UL), how her daily environment lacks appropriate adaptations to support her condition (LR), and how her family struggles to believe that her pain is as severe as she reports (LL). These stories help individuals explain their pain within a broader, integrative framework—one that validates their experience, challenges fragmented models of care, and opens new pathways for healing that are both compassionate and contextually grounded through salutogenesis to catalyse a sense of coherence. Such conceptual clarity lays the foundations to develop an integral vision that empowers communities and the VCSE sector services to co-create health-promoting solutions. With the support of healthcare providers, this model exemplifies a shift toward relational, whole-person, whole-system care.

Ultimately, an integral vision calls for a cultural transformation in how persistent pain is conceptualized, communicated, and addressed—emphasizing the importance of meaning-making and ensuring access to resources that support coping and psychological growth through health promotion. An integral vision of pain places individual empowerment at its core—recognizing each person's capacity to transform painful experiences into transformative purpose (109). Realizing this integral vision requires a shift from institutional control to fostering personal agency within empowered communities rooted in the cultural and environmental realities of contemporary life.