{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T18:01:31Z","timestamp":1790359291345,"version":"4.1.0"},"reference-count":50,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Ment Health"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Borderline personality disorder (BPD) is associated with substantial distress and a high risk for suicide. Individuals with BPD may be unable to access evidence-based treatments like dialectical behavior therapy (DBT). Artificial intelligence conversational agents (AI-CA) are increasingly discussed as scalable tools for mental health support, but little is known about how DBT clinicians understand the possible role of AI-CA in treatment.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aimed to explore DBT psychologists\u2019 perspectives on integrating AI-CA into DBT for BPD in the future.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Seventeen psychologists in Sweden, each with at least 1 year of clinical DBT experience (mean 6.4 years, SD 5.6), participated in semistructured interviews as part of this qualitative study. Interviews were conducted in Swedish, transcribed verbatim, and analyzed using reflexive thematic analysis within a constructivist framework. Participants did not test a specific AI-CA.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Three main themes were developed from the data. The first main theme, \u201cWho Are We in Therapy?\u201d explored how participants defined AI-CA relationally, positioning it variously as a tool, team member, or supervisor, and a sometimes harmful competitor. How these positionings were configured shaped what AI-CA was seen as allowed to do. The second main theme, \u201cThe Stoic Helper,\u201d captured how AI-CA was constructed as an extension of the ideal helper: available, competent, adaptable, and tireless, able to provide support in moments when human therapists could not or preferred not to be present. Participants\u2019 hopes for what AI-CA could become often mirrored qualities they found difficult to sustain in their own clinical work. The third main theme, \u201cThe Well-Intended Accommodator,\u201d captured concerns that AI-CA may reinforce dependency and function as a safety behavior by supporting reassurance-seeking rather than autonomy. A central concern was not whether AI-CA could generate validating responses, but whether it could know when validation supports change and when it becomes maladaptive accommodation (AI functional ambiguity).<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Perceived benefits mainly centered on accessibility and support for DBT skills generalization, whereas key concerns involved alliance disruption, reinforcement of behaviors that would ideally be targeted for change, dependency, and questions regarding responsibility in high-risk situations. Integrating AI-CA into DBT is not only a technical question but a relational and ethical one. How AI-CA is positioned in relation to the therapist, person in treatment, and team shapes which tasks are considered acceptable and what form integration can take. The findings highlight the need for implementation frameworks that account for relational dynamics, treatment-specific considerations, and AI functional ambiguity that may arise when AI-CA operates in complex therapeutic contexts.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/98840","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T13:30:06Z","timestamp":1786714206000},"page":"e98840-e98840","source":"Crossref","is-referenced-by-count":0,"title":["Possible Role and Function of AI Conversational Agents in Dialectical Behavior Therapy for Borderline Personality Disorder: Qualitative Interview Study"],"prefix":"10.2196","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-0137-1195","authenticated-orcid":false,"given":"Niklas","family":"Liljedahl","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7027-4371","authenticated-orcid":false,"given":"Lilas","family":"Ali","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6505-9818","authenticated-orcid":false,"given":"Sophie I","family":"Liljedahl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0705-1957","authenticated-orcid":false,"given":"\u00d6rjan","family":"Falk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8320-5607","authenticated-orcid":false,"given":"Steinn","family":"Steingrimsson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,9,25]]},"reference":[{"issue":"1","key":"R1","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1002\/wps.21156","article-title":"Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies","volume":"23","author":"Leichsenring","journal-title":"World Psychiatry"},{"issue":"9","key":"R2","doi-asserted-by":"publisher","first-page":"772","DOI":"10.1176\/appi.ps.201900073","article-title":"Treatment of borderline personality disorder: is supply adequate to meet public health needs?","volume":"70","author":"Iliakis","journal-title":"Psychiatr Serv"},{"issue":"1","key":"R3","doi-asserted-by":"publisher","DOI":"10.1186\/s12888-024-06243-8","article-title":"Factors associated with the implementation of dialectical behavior therapy by Spanish speaking mental health professionals who treat suicide risk","volume":"24","author":"Navarro-Haro","journal-title":"BMC Psychiatry"},{"issue":"1","key":"R4","doi-asserted-by":"publisher","DOI":"10.1186\/s12888-020-02610-3","article-title":"Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach","volume":"20","author":"Flynn","journal-title":"BMC Psychiatry"},{"issue":"1","key":"R5","doi-asserted-by":"publisher","DOI":"10.2196\/54941","article-title":"Digital interventions for symptoms of borderline personality disorder: systematic review and meta-analysis","volume":"26","author":"Lindsay","journal-title":"J Med Internet Res"},{"issue":"1","key":"R6","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s40501-024-00340-x","article-title":"Generative artificial intelligence in mental healthcare: an ethical evaluation","volume":"12","author":"Blease","journal-title":"Curr Treat Options Psych"},{"issue":"2","key":"R7","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1002\/wps.21299","article-title":"The evolving field of digital mental health: current evidence and implementation issues for smartphone apps, generative artificial intelligence, and virtual reality","volume":"24","author":"Torous","journal-title":"World Psychiatry"},{"issue":"3","key":"R8","doi-asserted-by":"publisher","first-page":"538","DOI":"10.1192\/bjp.2021.204","article-title":"Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis","volume":"221","author":"Stoffers-Winterling","journal-title":"Br J Psychiatry"},{"key":"R9","unstructured":"Linehan MM . Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press; 1993. ISBN: 978-0-89862-183-9"},{"key":"R10","unstructured":"Linehan MM . DBT Skills Training Manual. 2nd ed. Guilford Press; 2015. ISBN: 978-1-4625-1699-5"},{"issue":"4","key":"R11","doi-asserted-by":"publisher","first-page":"459","DOI":"10.1002\/jclp.20243","article-title":"Mechanisms of change in dialectical behavior therapy: theoretical and empirical observations","volume":"62","author":"Lynch","journal-title":"J Clin Psychol"},{"issue":"3","key":"R12","doi-asserted-by":"publisher","first-page":"504","DOI":"10.1111\/papt.12325","article-title":"Skills-homework completion and phone coaching as predictors of therapeutic change and outcomes in completers of a DBT intensive outpatient programme","volume":"94","author":"Edwards","journal-title":"Psychol Psychother"},{"issue":"1","key":"R13","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1016\/j.cbpra.2019.10.005","article-title":"Challenges and potential solutions to implementing phone coaching in dialectical behavior therapy","volume":"28","author":"Landes","journal-title":"Cogn Behav Pract"},{"issue":"2","key":"R14","doi-asserted-by":"publisher","first-page":"744","DOI":"10.1002\/cpp.2668","article-title":"Phone consultation and burnout among providers of dialectical behaviour therapy","volume":"29","author":"Ruork","journal-title":"Clin Psychol Psychother"},{"issue":"1","key":"R15","doi-asserted-by":"publisher","DOI":"10.1186\/s40359-025-02491-9","article-title":"The use of artificial intelligence in psychotherapy: development of intelligent therapeutic systems","volume":"13","author":"Spytska","journal-title":"BMC Psychol"},{"issue":"4","key":"R16","doi-asserted-by":"publisher","DOI":"10.1056\/AIoa2400802","article-title":"Randomized trial of a generative AI chatbot for mental health treatment","volume":"2","author":"Heinz","journal-title":"NEJM AI"},{"issue":"1","key":"R17","doi-asserted-by":"publisher","DOI":"10.1038\/s41746-023-00979-5","article-title":"Systematic review and meta-analysis of AI-based conversational agents for promoting mental health and well-being","volume":"6","author":"Li","journal-title":"NPJ Digit Med"},{"key":"R18","doi-asserted-by":"publisher","DOI":"10.2196\/78340","article-title":"Clinical efficacy, therapeutic mechanisms, and implementation features of cognitive behavioral therapy-based chatbots for depression and anxiety: narrative review","volume":"12","author":"Im","journal-title":"JMIR Ment Health"},{"key":"R19","doi-asserted-by":"publisher","DOI":"10.2196\/67114","article-title":"Expert and interdisciplinary analysis of AI-driven chatbots for mental health support: mixed methods study","volume":"27","author":"Moylan","journal-title":"J Med Internet Res"},{"issue":"1","key":"R20","doi-asserted-by":"publisher","DOI":"10.2196\/77951","article-title":"Seeking emotional and mental health support from generative AI: mixed-methods study of ChatGPT user experiences","volume":"12","author":"Luo","journal-title":"JMIR Ment Health"},{"issue":"1","key":"R21","doi-asserted-by":"publisher","DOI":"10.1038\/s41746-025-01611-4","article-title":"A scoping review of large language models for generative tasks in mental health care","volume":"8","author":"Hua","journal-title":"NPJ Digit Med"},{"issue":"1","key":"R22","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-025-17242-4","article-title":"Performance of mental health chatbot agents in detecting and managing suicidal ideation","volume":"15","author":"Pichowicz","journal-title":"Sci Rep"},{"key":"R23","doi-asserted-by":"publisher","DOI":"10.2196\/60432","article-title":"Exploring the ethical challenges of conversational AI in mental health care: scoping review","volume":"12","author":"Rahsepar Meadi","journal-title":"JMIR Ment Health"},{"key":"R24","doi-asserted-by":"publisher","DOI":"10.2196\/46548","article-title":"Factors influencing the acceptability, acceptance, and adoption of conversational agents in health care: integrative review","volume":"25","author":"Wutz","journal-title":"J Med Internet Res"},{"key":"R25","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyt.2024.1505024","article-title":"Artificial intelligence conversational agents in mental health: Patients see potential, but prefer humans in the loop","volume":"15","author":"Lee","journal-title":"Front Psychiatry"},{"key":"R26","doi-asserted-by":"publisher","DOI":"10.1177\/20552076251351088","article-title":"\u201cShaping ChatGPT into my Digital Therapist\u201d: a thematic analysis of social media discourse on using generative artificial intelligence for mental health","volume":"11","author":"Luo","journal-title":"Digit Health"},{"issue":"1576135","key":"R27","doi-asserted-by":"publisher","DOI":"10.3389\/fdgth.2025.1576135","article-title":"Exploring user characteristics, motives, and expectations and the therapeutic alliance in the mental health conversational AI Clare\u00ae: a baseline study","volume":"7","author":"Sch\u00e4fer","journal-title":"Front Digit Health"},{"issue":"1","key":"R28","doi-asserted-by":"publisher","DOI":"10.1038\/s44184-024-00097-4","article-title":"\u201cIt happened to be the perfect thing\u201d: experiences of generative AI chatbots for mental health","volume":"3","author":"Siddals","journal-title":"Npj Ment Health Res"},{"key":"R29","doi-asserted-by":"publisher","DOI":"10.2196\/71065","article-title":"Practitioner perspectives on the uses of generative AI chatbots in mental health care: mixed methods study","volume":"12","author":"Goldie","journal-title":"JMIR Hum Factors"},{"issue":"3","key":"R30","doi-asserted-by":"publisher","first-page":"218","DOI":"10.1111\/j.1468-2850.2010.01213.x","article-title":"Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders","volume":"17","author":"Helbig-Lang","journal-title":"Clin Psychol Sci Pract"},{"issue":"6792","key":"R31","doi-asserted-by":"publisher","DOI":"10.1126\/science.aec8352","article-title":"Sycophantic AI decreases prosocial intentions and promotes dependence","volume":"391","author":"Cheng","journal-title":"Science"},{"key":"R32","doi-asserted-by":"publisher","DOI":"10.2196\/73623","article-title":"An examination of generative AI response to suicide inquires: content analysis","volume":"12","author":"Campbell","journal-title":"JMIR Ment Health"},{"issue":"7","key":"R33","doi-asserted-by":"publisher","first-page":"1620","DOI":"10.1080\/10447318.2022.2146227","article-title":"Influence of Rapport and Social Presence with an AI Psychotherapy Chatbot on Users\u2019 Self-Disclosure","volume":"40","author":"Lee","journal-title":"International Journal of Human\u2013Computer Interaction"},{"issue":"3-4","key":"R34","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1080\/09537320600777002","article-title":"The sociology of expectations in science and technology","volume":"18","author":"Borup","journal-title":"Technol Anal Strateg Manag"},{"key":"R35","unstructured":"Braun V Clarke V . Thematic Analysis: A Practical Guide. SAGE; 2022. ISBN: 978-1-4739-5323-9"},{"issue":"9","key":"R36","doi-asserted-by":"publisher","first-page":"1245","DOI":"10.1097\/ACM.0000000000000388","article-title":"Standards for reporting qualitative research: a synthesis of recommendations","volume":"89","author":"O\u2019Brien","journal-title":"Acad Med"},{"issue":"13","key":"R37","doi-asserted-by":"publisher","first-page":"1753","DOI":"10.1177\/1049732315617444","article-title":"Sample size in qualitative interview studies: guided by information power","volume":"26","author":"Malterud","journal-title":"Qual Health Res"},{"issue":"2","key":"R38","doi-asserted-by":"publisher","first-page":"201","DOI":"10.1080\/2159676X.2019.1704846","article-title":"To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales","volume":"13","author":"Braun","journal-title":"Qual Res Sport Exerc Health"},{"issue":"1","key":"R39","doi-asserted-by":"publisher","DOI":"10.2196\/66163","article-title":"Behavior emotion therapy system and you: co-design and evaluation of a mental health chatbot and digital human for mild to moderate anxiety in healthy participants","volume":"9","author":"Thunstr\u00f6m","journal-title":"JMIR Form Res"},{"issue":"1","key":"R40","doi-asserted-by":"publisher","DOI":"10.2196\/54581","article-title":"Usability comparison among healthy participants of an anthropomorphic digital human and a text-based chatbot as a responder to questions on mental health: randomized controlled trial","volume":"11","author":"Thunstr\u00f6m","journal-title":"JMIR Hum Factors"},{"issue":"1","key":"R41","doi-asserted-by":"publisher","first-page":"3616773","DOI":"10.1155\/hbe2\/3616773","article-title":"Therapists and technology: a qualitative study on AI\u2032s role in counseling","volume":"2026","author":"Nazir","journal-title":"Hum Behav Emerg Technol"},{"issue":"1","key":"R42","doi-asserted-by":"publisher","DOI":"10.2196\/11752","article-title":"Measuring the implementation of behavioral intervention technologies: recharacterization of established outcomes","volume":"21","author":"Hermes","journal-title":"J Med Internet Res"},{"key":"R43","doi-asserted-by":"publisher","DOI":"10.1016\/j.brat.2014.10.003","article-title":"Only connect: the working alliance in computer-based cognitive behavioral therapy","volume":"63","author":"Kiluk","journal-title":"Behav Res Ther"},{"issue":"4","key":"R44","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2026.6713","article-title":"Efficacy of a conversational AI agent for psychiatric symptoms and digital therapeutic alliance: a randomized clinical trial","volume":"9","author":"Shoshani","journal-title":"JAMA Netw Open"},{"key":"R45","doi-asserted-by":"publisher","DOI":"10.2196\/88932","article-title":"Psychotherapists\u2019 trust, distrust, and generative AI practices in psychotherapy: qualitative study","volume":"28","author":"Kuang","journal-title":"J Med Internet Res"},{"key":"R46","doi-asserted-by":"publisher","DOI":"10.2196\/63126","article-title":"Applications of large language models in the field of suicide prevention: scoping review","volume":"27","author":"Holmes","journal-title":"J Med Internet Res"},{"key":"R47","doi-asserted-by":"publisher","DOI":"10.1016\/j.invent.2025.100841","article-title":"Artificial intelligence vs. human expert: licensed mental health clinicians\u2019 blinded evaluation of AI-generated and expert psychological advice on quality, empathy, and perceived authorship","volume":"41","author":"Franke F\u00f6yen","journal-title":"Internet Interv"},{"issue":"2","key":"R48","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmen.0000145","article-title":"When ELIZA meets therapists: A Turing test for the heart and mind","volume":"2","author":"Hatch","journal-title":"PLOS Ment Health"},{"issue":"1","key":"R49","doi-asserted-by":"publisher","DOI":"10.1038\/s41746-024-01232-3","article-title":"Navigating the EU AI act: implications for regulated digital medical products","volume":"7","author":"Aboy","journal-title":"NPJ Digit Med"},{"key":"R50","doi-asserted-by":"publisher","DOI":"10.1016\/j.chbr.2026.101094","article-title":"When will AI transform society? Swedish public predictions on AI development timelines","volume":"22","author":"Fors Connolly","journal-title":"Computers in Human Behavior Reports"}],"container-title":["JMIR Mental Health"],"original-title":[],"language":"en","deposited":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T17:41:59Z","timestamp":1790358119000},"score":1,"resource":{"primary":{"URL":"https:\/\/mental.jmir.org\/2026\/1\/e98840"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,25]]},"references-count":50,"URL":"https:\/\/doi.org\/10.2196\/98840","relation":{},"ISSN":["2368-7959"],"issn-type":[{"value":"2368-7959","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,25]]},"article-number":"v13i1e98840"}}