Arthur Bran Herbener

The question of whether artificial agents (e.g., chatbots and social robots) can replace human therapists has received notable attention following the recent launch of large language models. However, little is known about the processes of change in psychotherapy delivered by artificial agents. To facilitate hypothesis development and stimulate scientific debate, the present article offers the first theoretical framework of the processes of change in psychotherapy delivered by artificial agents. The theoretical framework rests upon a conceptual analysis of what active ingredients may be inherently linked to the presence of human therapists. We propose that human therapists’ ontological status as human beings and sociocultural status as socially sanctioned healthcare professionals play crucial roles in promoting treatment outcomes. In the absence of the ontological and sociocultural status of human therapists, we propose what we coin the genuineness gap and credibility gap can emerge and undermine key processes of change in psychotherapy. Based on these propositions, we propose avenues for scientific investigations and practical applications aimed at leveraging the strengths of artificial agents and human therapists respectively. We also highlight the intricate agentic nature of artificial agents and discuss how this complicates endeavors to establish universally applicable propositions regarding the processes of change in these interventions.

In recent years, there has been growing optimism about the potential of conversational agents, such as chatbots and social robots, in mental healthcare. Their scalability offers a promising solution to some of the key limitations of the dominant model of treatment in Western countries. However, while recent experimental research provides grounds for cautious optimism, the integration of conversational agents into mental healthcare raises significant clinical and ethical challenges, particularly concerning the partial or full replacement of human practitioners. Overall, this theoretical paper examines the clinical and ethical implications of deploying conversational agents in mental health services as partial and full replacement of human practitioners. On the one hand, we outline how these agents can circumvent core treatment barriers through stepped care, blended care, and a personalized medicine approach. On the other hand, we argue that the partial and full substitution of human practitioners can have profound consequences for the ethical landscape of mental healthcare, potentially undermining patients’ rights and safety. By making this argument, this work extends prior literature by specifically considering how different levels of implementation of conversational agents in healthcare present both opportunities and risks. We argue for the urgent need to establish regulatory frameworks to ensure that the integration of conversational agents into mental healthcare is both safe and ethically sound.

Existing ethical guidelines that aim to guide the development of mental health apps tend to overemphasize the role of Western conceptual frameworks. While such frameworks have proved to be a useful first step in introducing ethics to a previously unregulated industry, the rapid global uptake of mental health apps requires thinking more deeply about the diverse populations these apps seek to serve. One way to do this is to introduce more intercultural ethical perspectives into app design and the guidelines that aim to encourage best practices. In addition to this, existing ethical guidelines can also benefit from the ethical scholarship from the feminist and disability traditions, both of which highlight specific ethical considerations for vulnerable users. Rethinking the ethical responsibilities of mental health app designers through the prisms of feminism, disability studies, and intercultural philosophy leads us to a more global and inclusive set of ethical considerations in app design. This white paper explores what existing guidelines for the regulation of mental health apps are missing. It also explores how these guidelines could be improved for users who inhabit an increasingly diverse and globalized world.

The present narrative review seeks to unravel where we are now, and where we need to go to delineate the active ingredients in psychotherapy delivered by conversational agents (e.g., chatbots). While psychotherapy delivered by conversational agents has shown promising effectiveness for depression, anxiety, and psychological distress across several randomized controlled trials, little emphasis has been placed on the therapeutic processes in these interventions. The theoretical framework of this narrative review is grounded in prominent perspectives on the active ingredients in psychotherapy. Based on search terms derived from various theoretical perspectives, we conducted a systematic literature search of four scientific databases and identified 17 studies. Across the selected studies, three themes emerged: relationship variables, emotional venting, and cognitive factors. While methodological issues compromise the epistemic value of this evidence base, core questions also remain to be answered. Such questions include, but are not limited to, whether humans can form affectionate bonds to inanimate beings and whether these kind of mental health treatments should be understood as psychotherapy or something else. Researchers should therefore be cautious when applying theories of psychotherapy in the realm of conversational agents. We conclude the paper by introducing recommendations for future research, which we hope will help instigate methodologically sound studies in this field.