JMIR Publications

ABSTRACT

This paper explores the integration of generative artificial intelligence (GenAI) into psychotherapeutic practice through the lens of mentalization theory, focusing particularly on epistemic trust - a critical relational mechanism facilitating psychological change. We critically examine AI’s capability to replicate core therapeutic components, such as empathy, embodied mentalizing, biobehavioural synchrony, and reciprocal mentalizing. Although current AI systems, especially large language models (LLMs), demonstrate significant potential in simulating emotional responsiveness, cognitive empathy, and therapeutic dialogue, fundamental limitations persist. AI’s inherent lack of genuine emotional presence, reciprocal intentionality, and affective commitment constrains its ability to foster authentic epistemic trust and meaningful therapeutic relationships. Additionally, we outline significant risks, notably for individuals with complex trauma or relational vulnerabilities, highlighting concerns regarding pseudo-empathy, mistaking phenomenal experience for objective reality (psychic equivalence), fruitless ungrounded pursuit of social understanding (hypermentalization), and epistemic exploitation of individuals in whom artificial understanding by AI triggers excessive credulity. Nonetheless, we propose ethically informed pathways for integrating AI to enhance clinical practice, therapist training, and client care, particularly in augmenting human capacities within group and adjunctive therapy contexts. Paradoxically, AI could support psychotherapist in improving their capacity to mentalize, improve their understanding of their clients, and provide such understanding within the moral constraints that normally govern their work. The paper calls for careful ethical regulation similar to that limiting genetic manipulation, interdisciplinary research, and clinician involvement in shaping future AI-based psychotherapeutic models, emphasising that AI’s role should complement rather than replace the irreplaceable relational core of psychotherapy.