From Alliance to Nexus: Rethinking Digital Therapeutic Relationships

Clinical Snapshot

Key Findings

• Effect Size: Not applicable — no empirical data reported

• Primary Outcome: Proposal of the 'digital therapeutic nexus' — a three-level hierarchical framework for categorising the quality and nature of relationships between users and AI-based therapeutic systems, with the highest level posited as the only tier where meaningful parallels to human therapeutic alliance can be drawn

• Nnt Or Sensitivity: Not applicable — theoretical viewpoint; no diagnostic, therapeutic, or prognostic metrics reported

• Confidence Interval: Not applicable — no quantitative analysis conducted

Clinical Application

The framework is conceptually accessible but currently lacks the operational specificity required for direct clinical implementation. Adoption would require further empirical validation, development of measurable criteria for each nexus level, and integration into existing digital health governance structures. Feasibility for routine clinical use is low until validated instruments are developed. In Australia, AI-based mental health tools are subject to TGA oversight as Software as a Medical Device (SaMD) under the TGA's Digital Health framework, with classification dependent on intended purpose and risk level. The RACGP has published guidance on digital health and telehealth but has not yet specifically addressed AI-based psychotherapeutic agents. The Better Access initiative and headspace services increasingly incorporate digital tools, making the conceptual distinctions proposed in this paper relevant to Australian commissioning and safety governance. The PBS does not currently fund AI-based psychotherapy, but the framework could inform future TGA regulatory submissions and MSAC assessments for digital mental health interventions. Australian clinicians should note that the paper's concerns about sycophancy and parasocial attachment are particularly salient in the context of vulnerable populations accessing digital mental health tools outside of supervised clinical settings. Clinicians, researchers, and health technology developers working with AI-based mental health interventions across any diagnostic group; particularly relevant for those designing or evaluating digital therapeutics for anxiety, depression, and other common mental health conditions where AI-assisted tools are increasingly deployed

Abstract

In traditional human psychotherapy, the therapeutic alliance (TA) is regarded as a fundamental factor that describes the client-therapist relationship, mainly due to strong evidence demonstrating its impact on treatment outcomes regardless of theoretical orientation. More recently, advances in artificial intelligence (AI) and other technologies have led to the emergence of the concept of digital TA, used to characterize the relationship between clients and AI-based therapeutic systems. This approach replicates human dynamics but overlooks key differences between human therapists and digital agents. Prematurely translating the concept of TA into the digital context fails to address issues such as the sycophantic tendencies of current systems and the inherent limitations of algorithmic interaction. We propose the digital therapeutic nexus, a framework that recognizes these differences and provides a set of structured criteria for categorizing digital interactions into 3 progressive levels. This Viewpoint argues that only at the highest level can parallels be drawn to the human TA and stratifies the main risks associated with each nexus level. Transitioning from the concept of alliance to that of a nexus offers a more precise conceptual basis for describing and evaluating digital therapeutic relationships, with implications for research, design, and the ethical development of AI-based mental health interventions.

References

1. 1.B Cadena, D., Walther, J. U., & Brünahl, C. A. (2026). From alliance to nexus: Rethinking digital therapeutic relationships. JMIR Mental Health. https://doi.org/10.2196/89378