CARE: An Explainable Computational Framework for Assessing Client-Perceived Therapeutic Alliance Using Large Language Models

The increasing use of large language models in mental health applications calls for principled evaluation frameworks that assess alignment with psychotherapeutic best practices beyond surface-level fluency. While recent systems exhibit conversational competence, they lack structured mechanisms to evaluate adherence to core therapeutic principles. In this paper, we study the problem of evaluating AI-generated therapist-like responses for clinically grounded appropriateness and effectiveness. We assess each therapists utterance along six therapeutic principles: non-judgmental acceptance, warmth, respect for autonomy, active listening, reflective understanding, and situational appropriateness using a fine-grained ordinal scale. We introduce FAITH-M, a benchmark annotated with expert-assigned ordinal ratings, and propose CARE, a multi-stage evaluation framework that integrates intra-dialogue context, contrastive exemplar retrieval, and knowledge-distilled chain-of-thought reasoning. Experiments show that CARE achieves an F-1 score of 63.34 versus the strong baseline Qwen3 F-1 score of 38.56 which is a 64.26 improvement, which also serves as its backbone, indicating that gains arise from structured reasoning and contextual modeling rather than backbone capacity alone. Expert assessment and external dataset evaluations further demonstrate robustness under domain shift, while highlighting challenges in modelling implicit clinical nuance. Overall, CARE provides a clinically grounded framework for evaluating therapeutic fidelity in AI mental health systems.

Large language models show promise for mental health support, yet therapeutic quality improves only when evaluation functions as an actionable control signal rather than a passive metric. We introduce a framework that formulates therapeutic response generation as a decision-refinement problem driven by multi-dimensional, human-aligned evaluation. In Stage I, we introduce TheraJudge, an open-source therapeutic evaluator trained via preference-based optimization on human-annotated data to produce reliable judgments across 7 psychological dimensions. In Stage II, we introduce TheraAgent, which operationalizes TheraJudge's evaluations through a coordinated refinement process with specialized Critic, Coach, and Therapist roles that translate evaluative signals into targeted response revisions. Empirically, TheraJudge achieves strong agreement with clinician ratings, with intraclass correlation coefficients (ICC = 0.87-0.95), surpassing supervised baselines and strong closed-source judges, particularly on critical dimensions such as Safety, Relevance, and Empathy. Acting on these evaluations, TheraAgent yields a +0.43 improvement in human-rated therapeutic quality (on a 5-point scale) under blind evaluation, with 96% clinician inter-rater reliability. Low-quality responses ($\leq 3$) improve by +2.45 points with a 94% recovery rate, demonstrating targeted correction of unsafe outputs. Overall, our results indicate that effective alignment of mental-health LLMs stems from acting on human-aligned evaluation, rather than relying solely on stronger generation. We release code at https://github.com/vis-nlp/TheraAlign.

Effectively addressing client resistance is a sophisticated clinical skill in psychological counseling, yet practitioners often lack timely and scalable supervisory feedback to refine their approaches. Although current NLP research has examined overall counseling quality and general therapeutic skills, it fails to provide granular evaluations of high-stakes moments where clients exhibit resistance. In this work, we present a comprehensive pipeline for the multi-dimensional evaluation of human counselors' interventions specifically targeting client resistance in text-based therapy. We introduce a theory-driven framework that decomposes counselor responses into four distinct communication mechanisms. Leveraging this framework, we curate and share an expert-annotated dataset of real-world counseling excerpts, pairing counselor-client interactions with professional ratings and explanatory rationales. Using this data, we perform full-parameter instruction tuning on a Llama-3.1-8B-Instruct backbone to model fine-grained evaluative judgments of response quality and generate explanations underlying. Experimental results show that our approach can effectively distinguish the quality of different communication mechanisms (77-81% F1), substantially outperforming GPT-4o and Claude-3.5-Sonnet (45-59% F1). Moreover, the model produces high-quality explanations that closely align with expert references and receive near-ceiling ratings from human experts (2.8-2.9/3.0). A controlled experiment with 43 counselors further confirms that receiving these AI-generated feedback significantly improves counselors' ability to respond effectively to client resistance.