JMIR Publications

ABSTRACT

Background:

Borderline personality disorder (BPD) is associated with substantial suffering, clinical complexity, and limited access to evidence-based treatment such as 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 AI-CA possible role in treatment.

Objective:

This study described clinicians’ perspectives on integrating AI conversational agents into DBT for BPD in the future.

Methods:

Seventeen psychologists in Sweden, each with at least one year of clinical DBT experience (average 6.4 years), participated in semi-structured interviews as part of this qualitative study. Interviews were conducted in Swedish, transcribed verbatim, and analyzed using reflexive thematic analysis within a constructivist framework.

Results:

Three main themes and two subthemes were developed from the data. The first main theme, "Who are we in therapy?" with subthemes “The search for boundaries” and “AI and human therapists are unique and alike”, explored how participants defined AI relationally, positioning it variously as a tool, team member, or supervisor, and sometimes harmful competitor. How these positionings were configured shaped what AI was seen as allowed to do. The second main theme, "The stoic helper", captured how AI was constructed as an extension of the ideal therapist: calm, adaptable, and emotionally composed, able to provide support in moments when human therapists could not or preferred not to be present. What participants reportedly hoped AI could be often mirrored qualities they found difficult to sustain in their own clinical work. The third main theme, “The well-intended accommodator,” captured concerns that AI may reinforce dependency and function as a safety behavior by supporting reassurance-seeking rather than autonomy. A central concern was not whether AI could generate validating responses, but whether it could know when validation supports change and when it becomes maladaptive accommodation (functional ambiguity).

Conclusions:

Perceived benefits mainly centered on accessibility and support for DBT skills generalization, whereas key concerns involved alliance disruption, overaccommodation/reinforcement of behaviours 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 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 functional ambiguity that may arise when AI operates in complex therapeutic contexts.