Generative AI Purpose-built for Social and Mental Health: A Real-World Pilot

Large language models are being deployed as mental health support agents at scale, yet only 16% of LLM-based chatbot interventions have undergone rigorous clinical efficacy testing, and simulations reveal psychological deterioration in over one-third of cases. We evaluate four generative models on 250 Prolonged Exposure (PE) therapy scenarios and 146 CBT cognitive restructuring exercises (plus 29 severity-escalated variants), scored by a three-judge LLM panel. All models scored near-perfectly on surface acknowledgment (~0.91-1.00) while therapeutic appropriateness collapsed to 0.22-0.33 at the highest severity for three of four models, with protocol fidelity reaching zero for two. Under CBT severity escalation, one model's task completeness dropped from 92% to 71% while the frontier model's safety-interference score fell from 0.99 to 0.61. We identify a systematic, modality-spanning failure: RLHF safety alignment disrupts the therapeutic mechanism of action by grounding patients during imaginal exposure, offering false reassurance, inserting crisis resources into controlled exercises, and refusing to challenge distorted cognitions mentioning self-harm in PE; and through task abandonment or safety-preamble insertion during CBT cognitive restructuring. These findings motivate a five-axis evaluation framework (protocol fidelity, hallucination risk, behavioral consistency, crisis safety, demographic robustness), mapped onto FDA SaMD and EU AI Act requirements. We argue that no AI mental health system should proceed to deployment without passing multi-axis evaluation across all five dimensions.

Chatbot usage has increased, including in fields for which they were never developed for--notably mental health support. To that end, we introduce Validations of Ethical and Responsible AI in Mental Health (VERA-MH), a novel clinically-validated evaluation for safety of chatbots in the context of mental health support. The first iteration of VERA-MH focuses on Suicidal Ideation (SI) risks, by assessing how well chatbots can responds to users that might be in crisis. VERA-MH is comprised of three steps: conversation simulation, conversation judging and model rating. First, to simulate conversations with the chatbot under evaluation, another chatbot is tasked with role-playing users based on specific personas. Such user personas have been developed under clinical guidance, to make sure that, among others, multiple risk factors, demographic characteristics and disclosure factors were represented. In the judging step, a second support model is used as an LLM-as-a-Judge, together with a clinically-developed rubric. The rubric is structured as a flow, with a single Yes/No question asked each time, to improve answers' consistency and highlight models' failure modes. In the last stage, results of each conversation are aggregated to present the final evaluation of the chatbot. Together with the framework, we present the result of the evaluations for four leading LLM providers.

Large language models (LLMs) are increasingly used for emotional support despite lacking mechanisms to safely govern evolving mental health risk. Existing safety approaches primarily detect risk but rarely shape how models respond as conversational risk unfolds. We developed a model-agnostic safety governance architecture that combines contextual risk detection, reasoning-based verification, and protocol-guided response generation for multi-turn mental health interactions. Synthetic conversations grounded in real-world mental health narratives were used to evaluate the architecture's performance, tested with GPT-5-chat and Qwen3.5-27B, achieving high risk detection performance (specificity: 0.85 (95%CI: 0.78;0.91), sensitivity: 0.92 (95%CI: 0.88;0.95)) and increasing clinician-preferred escalation responses by 25.6--59.2pp while preserving rapport and connection. Performance remained stable across conversation length and generalized across both proprietary and open-source models. These findings demonstrate that clinically-grounded safety governance can extend beyond risk detection to improve how LLMs manage evolving mental health risk, providing a scalable framework for safer deployment across models.