Organizations: CogNosco Lab, Department of Psychology and Cognitive Science, University of Trento, Italy. · Department of Education, Psychology and Communication Sciences, University of Bari, Italy.
Psychotherapists need repeated training and supervision; however, scalability is problematic. We present MyMentorLLM, a multimodal voice- and text-based deliberate-practice environment with 2,100 complete Cognitive Behavioural Therapy (CBT) sessions. Each session links a DSM-5-TR-grounded LLM patient (with major depressive, generalised anxiety or borderline personality disorder), an LLM therapist-in-training and an LLM expert supervisor (powered by Gemma-4, Gemini-3.1-Flash-Live and Qwen-3.6). Sessions were analysed for emotional dynamics, therapeutic competence and diagnostic accuracy against human psychotherapy data. Simulated patients expressed disorder-congruent emotional profiles, which therapists mirrored as in human counselling. LLM trainee competence was rated above human levels in most conditions, while native speech-to-speech was closest to human scores. Supervisor feedback improved diagnostic accuracy in 5 of 7 LLM conditions, whereas symptom identification accuracy increased with model size. This work shows deliberate practice can be simulated for CBT training, although patient fidelity, supervisor calibration and harmful feedback require evaluation via a complex systems perspective.
Training psychotherapists in evidence-based interventions such as Acceptance and Commitment Therapy (ACT) requires repeated practice with meaningful feedback, yet opportunities for safe, standardized training are limited by ethical, logistical, and resource constraints. We introduce a system designed to support ACT-oriented psychotherapy training through spoken dialogue with an embodied virtual patient. The system uses large language models to simulate patient behavior conditioned on profiles derived from real therapy sessions and configurable clinical scenarios, while a separate automated evaluator provides turn-by-turn feedback on therapist responses based on established ACT fidelity criteria. Rather than aiming to replace supervision, the system is intended to support deliberate practice by enabling experimentation, reflection, and immediate feedback in low-risk settings. Expert evaluation with practicing psychologists confirmed high realism in patient behavior and demonstrated that immediate turn-by-turn ACT feedback increased therapists' awareness of intervention choices and enabled effective experimentation with alternative responses. Quantitative evaluation across 49 therapy transcripts identified GPT-4o-mini as the optimal feedback model, achieving the lowest mean absolute error (MAE = 6.12) in replicating human supervisor ACT fidelity ratings with statistically significant agreement. This work demonstrates the potential of fidelity-aware simulated patients as a scalable complement to psychotherapy training.
Large language models (LLMs) are increasingly being used as ad hoc therapists. While prior research has found that LLMs outperform human counselors in generating single-turn empathetic responses, fewer studies have compared their behaviors across multi-turn sessions. In this study, we compare the session-level behaviors of human peer counselors with those of an LLM, both trained on the same manual to deliver multi-turn, single-session Cognitive Behavioral Therapy (CBT). Our three-phase, mixed-methods study involved: (a) an 18-month ethnography of a peer support platform, where seven counselors iteratively refined CBT prompts through 110 self-counseling sessions and 60 weekly focus groups; (b) a novel session generation method that allows direct, controlled comparison of human and LLM counselors under matched conditions---client responses were drawn from publicly available human-led CBT sessions while counselor responses were generated by a CBT-prompted LLM; and (c) expert evaluations conducted by three licensed clinical psychologists. Through data triangulation, our results show a trade-off. Human peer counselors use relational techniques to interpret subtle cues, adapt CBT to users' values and cultural contexts, and use strategies such as small talk and contextually relevant self-disclosure to build rapport and guide the session, but often at the expense of session structure and therapeutic focus. LLM counselors, on the other hand, demonstrate greater methodological adherence to CBT techniques, but struggle to sustain turn-taking, frequently fail to distinguish between clinically important and trivial content, and are more prone to lecturing and imposing solutions. LLM counselors also tend to produce ``deceptive empathy'', excessively anthropomorphic responses that can inflate user expectations of genuine human care.
LLM-based simulated clients are increasingly used to train novice counselors, evaluate LLM therapists, and generate synthetic data. However, current simulators produce overly cooperative clients that disclose too readily, accept therapeutic reframes without resistance, and resolve core issues within a single session. We trace these issues to profiles that lack causal depth and behavioral mechanisms that treat all content as equally accessible. We present PatientAct, a framework for client simulation grounded in established clinical theories. Our profiles integrate the 5Ps clinical case formulation, providing causal depth without tying the design to any single therapeutic modality. During simulation, profiles include a dynamic memory layer in which items carry trust thresholds (e.g., symptoms are available early, whereas formative memories require a sustained therapeutic alliance). At each turn, the client's emotional reaction and behavior are modeled before generating a response. If the therapist approaches gated content, PatientAct expresses resistance in terms of quantity, content, and style rather than defaulting to cooperation or a single resistance pattern. We evaluate our framework on 40 clinical situations and demonstrate that it generates diverse profiles with high clinical plausibility. Moreover, PatientAct significantly outperforms the baselines, yielding substantial gains in resistance quality and behavioral realism. Our code and data will be publicly available via github.com/Sahandfer/PatientHub.