JMIR Publications

ABSTRACT

Background:

Conversational agents (CAs) are increasingly used in mental health care to enhance access and engagement. However, their safe, ethical, and user-sensitive design remains a challenge. Despite growing attention to trauma-informed approaches in human–computer interaction (HCI), there is limited work on how the trauma-informed care (TIC) framework could be applied in the design of mental health CAs and no comprehensive synthesis to date.

Objective:

Guided by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) TIC framework, this scoping review explores how TIC principles (safety, trustworthiness and transparency, collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical, and gender issues) are currently represented in the design and evaluation of mental health conversational agents (MHCAs) and identifies gaps and opportunities to promote more trauma-informed design practices.

Methods:

Online databases, as well as a secondary survey of citation lists from an initial search, were used to identify English-language journal articles and conference proceedings from 2000-2024 that empirically evaluated an independent, web- or app-based, unassisted CA used for mental health, as well as including concepts from TIC.

Results:

Our analysis included 38 publications (68.4% published in 2020 or later) covering 28 distinct MHCAs. Most studies used experimental methods (60.6%) or user studies (36.8%), with samples skewed female (average 34.92% male), young (mean age 32.52), and predominantly nonclinical (76.3%). MHCAs were largely rule-based prototypes. No studies explicitly referenced the TIC framework as a guiding lens for MHCA design or evaluation. Twenty-five studies referenced terminology from TIC core principles but rarely defined them, while all 38 included language that could be linked to one or more principles. Overall, TIC-related concepts appeared most often within intervention design descriptions, qualitative assessments, or as items embedded in questionnaires evaluating broader constructs. Trustworthiness & transparency, safety, empowerment, voice and choice, and collaboration & mutuality were comparatively well addressed, while peer support and cultural, historical, and gender issues were largely absent. Design recommendations, where present, were relatively broad and emphasized secure, customizable, reliable, human-like, and context-sensitive MHCAs that offered multimodal interaction, goal setting and tracking, and transparency.

Conclusions:

Studies did not self-identify as using SAMHSA’s framework for TIC, making it more difficult to identify its elements. The fragmented terms, disciplines, and metrics used make it difficult to draw more systematic conclusions about the current research landscape related to TIC, but our analysis indicates TIC to be a descriptive and potentially unifying framework and provides a starting point for explicit trauma-informed MHCA research and design.