Empathy by design? evaluating relational language and emotional safety in Indonesian mental health chatbots

Authors

  • Handono Fatkhur Rahman Universitas Indonesia Author

DOI:

https://doi.org/10.67490/ijml.v1i2.948

Keywords:

artificial intelligence, cultural-pragmatic alignment, emotional safety, mental health chatbots, relational empathy

Abstract

Background: Mental health chatbots are increasingly positioned as accessible support tools in Indonesia, yet their capacity to provide care depends not only on technical responsiveness but also on relational language, emotional safety, and cultural-pragmatic fit. Objective: This study aims to evaluate how Indonesian mental health chatbot discourse constructs empathy, manages emotional risk, and aligns with local communicative norms of help-seeking. Method: Using a qualitative discourse-pragmatic design, this study analysed 23 public text units from chatbot-related platforms, institutional pages, government health resources, and scholarly documents through a relational empathy matrix, emotional safety audit, and cultural-pragmatic alignment checklist. Results: Findings show that empathy is most visible through relational presence and autonomy support, while affective recognition, validation, and explicit non-judgmental stance appear less consistently. Emotional safety is strongest when chatbot discourse foregrounds boundary transparency, diagnosis restraint, and human-in-the-loop referral, but weaker when crisis wording, refusal style, and consent framing remain underdeveloped. Implication: Cultural alignment is supported by accessible Indonesian and locally credible referral pathways, although stigma, family pressure, multilingual diversity, and regional variation receive limited explicit attention. Novelty: This study offers a novel framework for evaluating mental health chatbot empathy as a relationally expressed, emotionally bounded, and culturally situated design practice.

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References

[1] E. M. Boucher, N. Harake, H. E. Ward, S. Stoeckl, J. Vargas, J. D. Minkel, A. Parks, and R. D. Zilca, “Artificially intelligent chatbots in digital mental health interventions: A review,” Expert Review of Medical Devices, 18, 37–49, 2021, doi: 10.1080/17434440.2021.2013200.

[2] Y. He, L. Yang, C. Qian, T. Li, Q. Zhang, and X. Hou, “Conversational agent interventions for mental health problems: Systematic review and meta-analysis of randomized controlled trials,” Journal of Medical Internet Research, 25, 2022, doi: 10.2196/43862.

[3] H. Li, R. Zhang, Y.-C. Lee, R. E. Kraut, and D. Mohr, “Systematic review and meta-analysis of AI-based conversational agents for promoting mental health and well-being,” NPJ Digital Medicine, 6, 2023, doi: 10.1038/s41746-023-00979-5.

[4] R. Balan, A. Dobrean, and C.-R. Poetar, “Use of automated conversational agents in improving young population mental health: A scoping review,” NPJ Digital Medicine, 7, 2024, doi: 10.1038/s41746-024-01072-1.

[5] Z. Guo, A. Lai, J. Thygesen, J. Farrington, T. Keen, and K. Li, “Large language models for mental health applications: Systematic review,” JMIR Mental Health, 11, 2024, doi: 10.2196/57400.

[6] R. Sanjeewa, R. Iyer, P. Apputhurai, N. Wickramasinghe, and D. Meyer, “Empathic conversational agent platform designs and their evaluation in the context of mental health: Systematic review,” JMIR Mental Health, 11, 2024, doi: 10.2196/58974.

[7] A. Howcroft, A. Bennett-Weston, A. Khan, J. Griffiths, S. Gay, and J. Howick, “AI chatbots versus human healthcare professionals: A systematic review and meta-analysis of empathy in patient care,” British Medical Bulletin, 156, 2025, doi: 10.1093/bmb/ldaf017.

[8] A. Sharma, I. W. Lin, A. S. Miner, D. C. Atkins, and T. Althoff, “Human–AI collaboration enables more empathic conversations in text-based peer-to-peer mental health support,” Nature Machine Intelligence, 5, 46–57, 2022, doi: 10.1038/s42256-022-00593-2.

[9] S. Coghlan, K. Leins, S. Sheldrick, M. Cheong, P. Gooding, and S. D’Alfonso, “To chat or bot to chat: Ethical issues with using chatbots in mental health,” Digital Health, 9, 2023, doi: 10.1177/20552076231183542.

[10] Z. Khawaja and J. Bélisle-Pipon, “Your robot therapist is not your therapist: Understanding the role of AI-powered mental health chatbots,” Frontiers in Digital Health, 5, 2023, doi: 10.3389/fdgth.2023.1278186.

[11] L. Laestadius, A. Bishop, M. Gonzalez, D. Illenčík, and C. Campos-Castillo, “Too human and not human enough: A grounded theory analysis of mental health harms from emotional dependence on the social chatbot Replika,” New Media & Society, 26, 5923–5941, 2022, doi: 10.1177/14614448221142007.

[12] J. J. Shen, D. DiPaola, S. Ali, M. Sap, H. W. Park, and C. Breazeal, “Empathy toward artificial intelligence versus human experiences and the role of transparency in mental health and social support chatbot design: Comparative study,” JMIR Mental Health, 11, 2024, doi: 10.2196/62679.

[13] M. Nurtyas, “Language barriers in healthcare delivery: A sociolinguistic case study of multilingual patients in Indonesian urban clinics,” Indonesian Journal of Medical Linguistics, 1(1), 26–38, 2026.

[14] Y. D. Rusita, “Constructing empathy through language: A linguistic perspective on compassionate communication in mental health services,” Indonesian Journal of Medical Linguistics, 1(1), 67–81, 2026.

[15] M. Syaifuddin, “Narratives of illness in patient blogs: Exploring personal voices and medical identity in Indonesian digital health discourse,” Indonesian Journal of Medical Linguistics, 1(1), 52–66, 2026.

[16] V. Sorin, D. Brin, Y. Barash, E. Konen, A. Charney, G. Nadkarni, and E. Klang, “Large language models and empathy: Systematic review,” Journal of Medical Internet Research, 26, 2023, doi: 10.2196/52597.

[17] M. Abbasian, I. Azimi, M. Feli, A. M. Rahmani, and R. C. Jain, “Empathy through multimodality in conversational interfaces,” ArXiv, abs/2405.04777, 2024, doi: 10.48550/arxiv.2405.04777.

[18] A. Sharma, I. W. Lin, A. S. Miner, D. C. Atkins, and T. Althoff, “Towards facilitating empathic conversations in online mental health support: A reinforcement learning approach,” Proceedings of the Web Conference 2021, 2021, doi: 10.1145/3442381.3450097.

[19] H. Chin, G. Baek, C. Cha, and M. Cha, “Chatbots’ empathetic conversations and responses: A qualitative study of help-seeking queries on depressive moods across 8 commercial conversational agents,” JMIR Formative Research, 9, 2025, doi: 10.2196/71538.

[20] J. De Freitas, A. Uğuralp, Z. Oğuz-Uğuralp, and S. Puntoni, “Chatbots and mental health: Insights into the safety of generative AI,” Journal of Consumer Psychology, 2023, doi: 10.1002/jcpy.1393.

[21] J. Park, M. Abbasian, I. Azimi, D. Bounds, A. Jun, J. Han, et al., “Building trust in mental health chatbots: Safety metrics and LLM-based evaluation tools,” 2024.

[22] H. R. Lawrence, R. A. Schneider, S. Rubin, M. J. Mataric, D. McDuff, and M. J. Bell, “The opportunities and risks of large language models in mental health,” JMIR Mental Health, 11, 2024, doi: 10.2196/59479.

[23] M. R. Meadi, T. Sillekens, S. Metselaar, A. Van Balkom, J. Bernstein, and N. Batelaan, “Exploring the ethical challenges of conversational AI in mental health care: Scoping review,” JMIR Mental Health, 12, 2025, doi: 10.2196/60432.

[24] K. H. Bentley, L. Belli, A. Chekroud, E. J. Ward, E. R. Dworkin, E. V. Ark, et al., “VERA-MH: Reliability and validity of an open-source AI safety evaluation in mental health,” ArXiv, abs/2602.05088, 2026, doi: 10.48550/arxiv.2602.05088.

[25] H. Morrin, J. Au-Yeung, Z. Agnew, S. Østergaard, and T. A. Pollak, “It is the journey, not the destination: Moving from end points to trajectories when assessing chatbot mental health safety,” JMIR Mental Health, 13, 2026, doi: 10.2196/91454.

[26] N. Laila, “Medical jargon and patient comprehension: A linguistic analysis of informed consent practices in Indonesian hospitals,” Indonesian Journal of Medical Linguistics, 1(1), 13–25, 2026.

[27] I. L. Nazulpa, “Doctor–patient communication in rural Indonesia: A pragmatic study of directive speech acts in clinical consultations,” Indonesian Journal of Medical Linguistics, 1(1), 1–12, 2026.

[28] A. S. Nugroho, “Verbal strategies for delivering bad news in oncology settings: A discourse-pragmatic approach,” Indonesian Journal of Medical Linguistics, 1(1), 39–51, 2026.

[29] H. Chin, H. Song, G. Baek, M. Shin, C. Jung, M. Cha, J. Choi, and C. Cha, “The potential of chatbots for emotional support and promoting mental well-being in different cultures: Mixed methods study,” Journal of Medical Internet Research, 25, 2023, doi: 10.2196/51712.

[30] D. Nirupama, N. Rao, and C. Sinha, “Language adaptations of mental health interventions: User interaction comparisons with an AI-enabled conversational agent (Wysa) in English and Spanish,” Digital Health, 10, 2024, doi: 10.1177/20552076241255616.

[31] Y. Shan, M. Ji, W. Xie, X. Qian, R. Li, X. Zhang, and T. Hao, “Language use in conversational agent–based health communication: Systematic review,” Journal of Medical Internet Research, 24, 2022, doi: 10.2196/37403.

[32] S. Sarkar, M. Gaur, L. K. Chen, M. Garg, and B. Srivastava, “A review of the explainability and safety of conversational agents for mental health to identify avenues for improvement,” Frontiers in Artificial Intelligence, 6, 2023, doi: 10.3389/frai.2023.1229805.

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Published

2026-06-30

How to Cite

Handono Fatkhur Rahman. (2026). Empathy by design? evaluating relational language and emotional safety in Indonesian mental health chatbots. Indonesian Journal of Medical Linguistics, 1(2), 156-169. https://doi.org/10.67490/ijml.v1i2.948

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