DelusionEval: Measuring Delusion-Linked Behaviors in AI Chatbots
Authors: Jared Moore, Andrea Mock, Yifan Mai, Jacy Reese Anthis, Ryan Louie, William Agnew, Ashish Mehta, Kevin Klyman, +4 more
Abstract
Mental health professionals have raised concerns about risks of psychological harm from interaction with large language models (LLMs), including "delusional spirals" in which concerning human and LLM behaviors reinforce each other over time. With growing public use of LLM-powered chatbots, there is an urgent need to build evaluations grounded in real-world episodes of psychological harm experienced by users. We developed DelusionEval, an evaluation protocol that tests a model's tendencies to exhibit behaviors linked to promoting user delusions. We prompt each model with 589 unique conversation histories from 18 participants, comprising 12,591 messages from users who experienced delusions and psychological harm. We find that the tendency of an evaluated LLM to exhibit delusion-linked behavior does not reliably correlate with model size, release date, or the presence of test-time reasoning. However, extending the context of prior messages substantially increases rates of delusion-linked behaviors, providing evidence for the importance of context in LLM safety evaluation. For example, the rate of failing to discourage self-harm when the user expresses suicidal ideation increases from 30.0% to 41.1% when an additional 350 messages are prepended to the conversation history. All model families (e.g., GPT, Claude) exhibit substantial rates of delusion-linked behaviors. Within families, later, larger, or higher-reasoning models are not uniformly better across all behavior categories. Our results raise concerns regarding the potential psychological impact of LLMs and the need for more rigorous studies of real-world human-AI interaction.
LLM chatbots increasingly serve as a first source of support for people in psychological distress, including those whose distress is entangled with delusional beliefs. Prior work on LLM mental-health safety largely evaluates general therapeutic quality or single-turn crisis detection, leaving unclear how models behave when distress is intertwined with delusion over sustained conversations. We address this gap with matched multi-turn simulations, across clinically grounded personas and six LLMs, that pair each delusional conversation with a distress-only control to isolate the effect of delusional framing. This reveals a recognition-intervention gap: models detect distress at comparable rates regardless of framing, yet sharply fail to act on it once distress is embedded in delusion, with safety interventions suppressed by up to 4.5x. The failure tracks accumulated acceptance of the user's premises rather than emotional validation. Worse, the intuitive fix of prompting models to assess user distress backfires under delusional framing; only delusion-aware prompting with explicit response guidance closes the gap, and even this depends on a delusion classifier that is itself unreliable on the most vulnerable models. Safe deployment therefore requires treating delusional framing as a distinct risk signal that overrides conversational accommodation.
Andrew Aquilina, Chetna Nihalani, Vasudha Varadarajan +3
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.
Large language models (LLMs) are increasingly explored as scalable tools for mental health counseling, yet evaluating their safety remains challenging due to the interactional and context-dependent nature of clinical harm. Existing evaluation frameworks predominantly assess isolated responses using coarse-grained taxonomies or static datasets, limiting their ability to diagnose how harms emerge and accumulate over multi-turn counseling interactions. In this work, we introduce R-MHSafe, a role-aware mental health safety taxonomy that characterizes clinically significant harm in terms of the interactional roles an AI counselor adopts, including perpetrator, instigator, facilitator, or enabler, combined with clinically grounded harm categories. Then, we propose MHSafeEval, a closed-loop, agent-based evaluation framework that formulates safety assessment as trajectory-level discovery of harm through adversarial multi-turn interactions, guided by role-aware modeling. Using R-MHSafe and MHSafeEval, we conduct a large-scale evaluation across state-of-the-art LLMs. Our results reveal substantial role-dependent and cumulative safety failures that are systematically missed by existing static benchmarks, and show that our framework significantly improves failure-mode coverage and diagnostic granularity.