JMIR Publications

ABSTRACT

Background:

Conversational agents (CAs) are increasingly developed and deployed in a mental health context, raising questions of how to safely and ethically implement them.

Objective:

This scoping review identifies SAMHSA's trauma-informed care (TIC) framework as one avenue to do this and examines how the framework’s six core principles are currently being operationalized in the design and evaluation of mental health CAs (MHCAs), including relevant gaps and patterns within design recommendations.

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 conversational agent (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) that explored 28 distinct MHCAs. 60.6% used experimental methods and 36.8% were user studies, with study samples skewing female (avg. 34.92% male), young (avg. age 32.52), and nonclinical (76.3%). MHCAs were largely rule-based prototypes. No studies cited TIC; 25 used terms explicitly included in TIC principles, though usually did not define them, while 38 used language that could be implicitly linked to one or more TIC principles. Overall, TIC principles were explicitly or implicitly included in disjointed and inconsistent ways across papers, but most often appeared in intervention design descriptions, assessed qualitatively, or were items in questionnaires evaluating other concepts. Trust, safety, transparency, empowerment, and collaboration were comparatively well-addressed, while peer support and cultural sensitivity were largely absent. Design recommendations, where present, were relatively broad and emphasized primarily customizability, consistency, and strengthening of user-MHCA relationships.

Conclusions:

Studies did not self-identify as using SAMHSA’s 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 explicitly trauma-informed MHCA research and design.