The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis
IntroductionExternalization techniques are well established in psychotherapy approaches, including narrative therapy and cognitive behavioral therapy. These methods elicit internal experiences such as emotions and make them tangible through external representations. Recent advances in generative art...
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Frontiers Media S.A.
2025-02-01
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| Series: | Frontiers in Digital Health |
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| Online Access: | https://www.frontiersin.org/articles/10.3389/fdgth.2025.1512273/full |
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| author | Yuval Haber Dorit Hadar Shoval Inbar Levkovich Dror Yinon Karny Gigi Oori Pen Tal Angert Zohar Elyoseph Zohar Elyoseph |
| author_facet | Yuval Haber Dorit Hadar Shoval Inbar Levkovich Dror Yinon Karny Gigi Oori Pen Tal Angert Zohar Elyoseph Zohar Elyoseph |
| author_sort | Yuval Haber |
| collection | DOAJ |
| description | IntroductionExternalization techniques are well established in psychotherapy approaches, including narrative therapy and cognitive behavioral therapy. These methods elicit internal experiences such as emotions and make them tangible through external representations. Recent advances in generative artificial intelligence (GenAI), specifically large language models (LLMs), present new possibilities for therapeutic interventions; however, their integration into core psychotherapy practices remains largely unexplored. This study aimed to examine the clinical, ethical, and theoretical implications of integrating GenAI into the therapeutic space through a proof-of-concept (POC) of AI-driven externalization techniques, while emphasizing the essential role of the human therapist.MethodsTo this end, we developed two customized GPTs agents: VIVI (visual externalization), which uses DALL-E 3 to create images reflecting patients' internal experiences (e.g., depression or hope), and DIVI (dialogic role-play-based externalization), which simulates conversations with aspects of patients' internal content. These tools were implemented and evaluated through a clinical case study under professional psychological guidance.ResultsThe integration of VIVI and DIVI demonstrated that GenAI can serve as an “artificial third”, creating a Winnicottian playful space that enhances, rather than supplants, the dyadic therapist-patient relationship. The tools successfully externalized complex internal dynamics, offering new therapeutic avenues, while also revealing challenges such as empathic failures and cultural biases.DiscussionThese findings highlight both the promise and the ethical complexities of AI-enhanced therapy, including concerns about data security, representation accuracy, and the balance of clinical authority. To address these challenges, we propose the SAFE-AI protocol, offering clinicians structured guidelines for responsible AI integration in therapy. Future research should systematically evaluate the generalizability, efficacy, and ethical implications of these tools across diverse populations and therapeutic contexts. |
| format | Article |
| id | doaj-art-b0b692fb68d34520a5261dec7d1e222b |
| institution | Kabale University |
| issn | 2673-253X |
| language | English |
| publishDate | 2025-02-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Digital Health |
| spelling | doaj-art-b0b692fb68d34520a5261dec7d1e222b2025-02-04T06:32:02ZengFrontiers Media S.A.Frontiers in Digital Health2673-253X2025-02-01710.3389/fdgth.2025.15122731512273The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysisYuval Haber0Dorit Hadar Shoval1Inbar Levkovich2Dror Yinon3Karny Gigi4Oori Pen5Tal Angert6Zohar Elyoseph7Zohar Elyoseph8The Program of Hermeneutics and Cultural Studies, Interdisciplinary Studies Unit, Bar-Ilan University, Jerusalem, IsraelDepartment of Psychology, Max Stern Academic College of Emek Yezreel, Yezreel Valley, IsraelFaculty of Education, Tel-Hai Academic College, Kiryat Shmona, IsraelThe Program of Hermeneutics and Cultural Studies, Interdisciplinary Studies Unit, Bar-Ilan University, Jerusalem, IsraelDepartment of Counseling and Human Development, Faculty of Education, University of Haifa, Haifa, IsraelDepartment of Counseling and Human Development, Faculty of Education, University of Haifa, Haifa, IsraelDepartment of Counseling and Human Development, Faculty of Education, University of Haifa, Haifa, IsraelDepartment of Counseling and Human Development, Faculty of Education, University of Haifa, Haifa, IsraelDepartment of Brain Sciences, Faculty of Medicine, Imperial College London, London, United KingdomIntroductionExternalization techniques are well established in psychotherapy approaches, including narrative therapy and cognitive behavioral therapy. These methods elicit internal experiences such as emotions and make them tangible through external representations. Recent advances in generative artificial intelligence (GenAI), specifically large language models (LLMs), present new possibilities for therapeutic interventions; however, their integration into core psychotherapy practices remains largely unexplored. This study aimed to examine the clinical, ethical, and theoretical implications of integrating GenAI into the therapeutic space through a proof-of-concept (POC) of AI-driven externalization techniques, while emphasizing the essential role of the human therapist.MethodsTo this end, we developed two customized GPTs agents: VIVI (visual externalization), which uses DALL-E 3 to create images reflecting patients' internal experiences (e.g., depression or hope), and DIVI (dialogic role-play-based externalization), which simulates conversations with aspects of patients' internal content. These tools were implemented and evaluated through a clinical case study under professional psychological guidance.ResultsThe integration of VIVI and DIVI demonstrated that GenAI can serve as an “artificial third”, creating a Winnicottian playful space that enhances, rather than supplants, the dyadic therapist-patient relationship. The tools successfully externalized complex internal dynamics, offering new therapeutic avenues, while also revealing challenges such as empathic failures and cultural biases.DiscussionThese findings highlight both the promise and the ethical complexities of AI-enhanced therapy, including concerns about data security, representation accuracy, and the balance of clinical authority. To address these challenges, we propose the SAFE-AI protocol, offering clinicians structured guidelines for responsible AI integration in therapy. Future research should systematically evaluate the generalizability, efficacy, and ethical implications of these tools across diverse populations and therapeutic contexts.https://www.frontiersin.org/articles/10.3389/fdgth.2025.1512273/fullgenerative artificial intelligence (GenAI)externalization techniquespsychotherapyethical considerationsSAFE-AI protocolclinical implementation |
| spellingShingle | Yuval Haber Dorit Hadar Shoval Inbar Levkovich Dror Yinon Karny Gigi Oori Pen Tal Angert Zohar Elyoseph Zohar Elyoseph The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis Frontiers in Digital Health generative artificial intelligence (GenAI) externalization techniques psychotherapy ethical considerations SAFE-AI protocol clinical implementation |
| title | The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis |
| title_full | The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis |
| title_fullStr | The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis |
| title_full_unstemmed | The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis |
| title_short | The externalization of internal experiences in psychotherapy through generative artificial intelligence: a theoretical, clinical, and ethical analysis |
| title_sort | externalization of internal experiences in psychotherapy through generative artificial intelligence a theoretical clinical and ethical analysis |
| topic | generative artificial intelligence (GenAI) externalization techniques psychotherapy ethical considerations SAFE-AI protocol clinical implementation |
| url | https://www.frontiersin.org/articles/10.3389/fdgth.2025.1512273/full |
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