Mental Health Conversational Agents

Young people increasingly turn to General-Purpose Conversational Agents (GPCAs), such as ChatGPT, in moments of distress. We examine young adults' (ages 18-25) experiences using ChatGPT. We first collected 19,930 ChatGPT conversations and survey data from 158 young adults. We then selected five example conversations reflecting user distress. Finally, we asked ten clinicians to review those five conversations. We found distressed participants reported greater emotional engagement with ChatGPT and greater behavioral change from using it than their peers. When they turned to ChatGPT in moments of acute distress, ChatGPT was quick to give overly dramatic responses and excessive action-oriented suggestions. Clinicians endorsed ChatGPT's availability and much of its wording, but identified seven process failures, such as prematurely jumping to solutions. We translated clinicians' feedback into design guidelines following three stages: 1) asking about safety, 2) de-escalating intensity to restore emotional regulation, and 3) exploring concerns without agreeing with them.

With the existing digital mental health tools specifically developed for Western settings, Pakistani students are exposed to a uniquely compounded stress situation in their university that includes academic, financial, familial, and relational stressors, which have become a serious concern for academic and psychological development of students in Pakistani universities. This paper introduces a new, AI-driven and culturally sensitive stress detection and wellness support system that is tailored to the context of Pakistani university students. The system is based on a machine learning model called Random Forest which is trained using a validated student stress data set of 1100 responses on 20 features from psychological, physiological, academic, environmental and social aspects, with an accuracy of 89.09% and a macro F1-score of 0.89, in three stress severity levels. The classification outputs are passed on to an open-source large language model through OpenRouter API, where an appropriately crafted system prompt, culturally aware, gives the model a conversation about wellness, in English, Urdu and Roman Urdu. The second most predictive stress factor in this population identified by feature importance analysis was teacher-student relationship, which is a culturally important stress factor highlighting the need for region-aware mental health systems. Future research will involve primary data collection from students at various academic levels of Pakistani Universities with the validated DASS-21 instrument focusing on the students who are moving from FSc to undergraduate studies, which is a time of being psychologically vulnerable which is under-researched.

Cognitive distortion amplifies negative emotions and contributes to mental health disorders. Cognitive Behavioral Therapy (CBT) is an effective way to address cognitive distortions, but its large-scale application is limited by the shortage of professional therapists. Although large language models (LLMs) have recently been explored for mental health applications, existing methods still suffer from limited domain specificity, overly flattering responses, and the absence of well-defined annotations for cognitive distortions. This paper proposes Cognivia, an evidence-based artificial intelligence therapist that integrates automatic cognitive distortion identification and rational response generation. Our framework is built on authoritative CBT texts widely regarded as core paradigms and standard references. It is further augmented with mental health question-answer (Q and A) data, and employs multi-stage prompting and structured generation strategies under the supervision of behavioral science experts. Then we fine-tune a lightweight LLM on this augmented CBT dataset to obtain Cognivia. In addition, we propose the first hierarchical quality evaluation framework for assessing LLM-generated rational responses, developed through collaboration between AI researchers and behavioral science experts. Cognivia is evaluated using lexical metrics, LLM-based Judges with two complementary criteria, and human evaluation by 10 behavioral science experts. It consistently outperforms the baseline methods in cognitive distortion recognition and rational response generation, demonstrating its effectiveness. Our code is available at https://github.com/SNOWTEAM2023/Cognivia.

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.

Large language models (LLMs) are increasingly being integrated into mental health support tools and other psychologically sensitive conversational applications. In such settings, behavioral stability and consistency are important for trustworthy human-AI interaction. However, semantically similar concerns can be presented through different contextual framings, potentially eliciting different model responses. Such framing-sensitive variability may challenge user expectations regarding system behavior and complicate the assessment of AI reliability. While prior studies have primarily examined such effects at the behavioral level, less is known about how framing-related variation is reflected in the internal representations of aligned language models. In this work, we investigate these effects using controlled matched prompts spanning multiple contextual framing conditions across several instruction-tuned model families. Across architectures, framing systematically alters interpretive response tendencies. Layer-wise probing analyses show that behavior-associated information remains decodable throughout transformer depth, with architecture-dependent variation in decoding strength. Moreover, held-out framing probes remained consistently above chance across architectures despite strong lexical baselines. Activation steering experiments further suggest that framing-associated representational directions can partially modulate downstream behavioral outcomes. Finally, these findings indicate that robustness to contextual variation may represent an important consideration when evaluating the consistency and trustworthiness of conversational AI systems deployed in mental-health-oriented interactions.

Context engineering has emerged as a primary lever for improving AI systems without parameter updates. Recent work showing that textual gradients do not function as real gradients motivates treating automatic prompt optimization (APO) as black-box search. We introduce SPO (Stochastic Prompt Optimization), a framework for stochastic search over prompt space, and compare three strategies of increasing sophistication: error-informed random search, a genetic algorithm with evolutionary operators, and SAGE (SPO via Agent-Guided Exploration), a multi-agent pipeline with diagnostic code execution. Across three benchmarks, no single strategy dominates; effectiveness depends on the interaction of landscape structure with error type. We further deploy SAGE on a mental-health chatbot under a continuous optimization paradigm, where it compounds eight cycles of individually-noisy A/B tests into a statistically robust gain in next-day retention. We argue that coupling qualitative diagnosis with quantitative validation is what makes agentic optimization effective for open-ended task-oriented dialogue.

Cloze is an open-source web platform for conducting controlled, monitored studies of human-AI conversation in mental health research contexts. Consumer large language model (LLM) products such as ChatGPT, Claude, and Gemini are built for individual productivity, and offer researchers little experimental control, inconsistent data export, and no shared safety scaffolding that holds across providers. Cloze gives research teams a single environment in which they configure which models participants converse with, how the AI is instructed, how conversations are scheduled over time, and which safety constraints apply unconditionally, while every message is captured with full provenance (model version, prompt configuration, timing). The platform currently supports OpenAI, Anthropic, Google, and locally hosted open-weight models served through Ollama behind a unified interface, and runs in the cloud or fully on premises so that participant data need never leave an institution. Cloze is research infrastructure for building an evidence base on human-AI interaction in mental health contexts. It is not a therapeutic product.

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.

Large language models (LLMs) are increasingly being used for emotional support. They are also being developed for formal therapy purposes. However, LLMs like ChaptGPT or Llama are often developed with content moderation guardrails that prevent them from discussing sensitive subjects with users for both liability and safety purposes, and this inability to broach these subjects may affect their capacity as therapists. In this study, we perform an algorithm audit on three state-of-the-art moderation systems (OpenAI's moderation endpoint, Meta's Llama Guard, and Google's Shield Gemma) to investigate the extent to which these systems flag the content of real-life therapy sessions as undesirable. Our results raise implications for the limitations that users and organizations may encounter when designing LLMs to play the part of a therapist.

Post-Traumatic Stress Disorder (PTSD) is fundamentally a neuroplastic problem traumatic contact events encode over-reactive neural pathways through Hebbian long-term potentiation, producing hair-triggered amygdala-HPA stress cascades that fire before conscious awareness can intercept them. Existing therapeutic approaches, prolonged exposure, EMDR, cognitive behavioural therapy, operate predominantly downstream of the reactive cascade, teaching patients to tolerate or reframe distress after it has arisen. While clinically valuable, these suppression-based approaches do not produce the upstream pathway dissolution that constitutes lasting structural neural reorganisation. This paper proposes MindGap, a privacy-preserving on-device conversational AI framework that delivers structured neuroplastic rehabilitation for PTSD through the practice of dependent origination, a Buddhist psychological framework that identifies the precise moment between the pre-cognitive affective signal and the reactive elaboration that follows as the site of therapeutic intervention. MindGap guides patients through three progressive layers of observation at this feeling tone gap: noticing the bare affective signal before reactive elaboration, recognising it as self-arising rather than caused by the stimulus, and recognising the conditioned implicit belief beneath the feeling. Each layer corresponds to progressively deeper prefrontal regulatory engagement and progressively deeper long-term depression-mediated weakening of the reactive pathway, producing genuine upstream dissolution rather than downstream suppression. Running entirely on-device with no data egress, MindGap delivers daily calibrated exposure sessions through a fine-tuned lightweight large language model, making it deployable in sensitive clinical and military contexts where cloud-based solutions are not permitted.

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.

Romantic breakups are among the most common and intense sources of psychological distress. We evaluated overit, a single-session AI chatbot that uses cognitive reappraisal to address breakup distress, informed by memory reconsolidation theory. In a pre-registered randomized controlled trial, 254 adults in the United States and United Kingdom who had experienced a romantic breakup were assigned to either an initial survey assessment followed by an AI chat session or to a survey-only control. Breakup distress was measured at baseline, 7 days, and again at an exploratory 1-month follow-up using the Breakup Distress Scale. Participants assigned to overit showed a significantly greater reduction in breakup distress than controls at 7 days (time-by-condition interaction B = -5.36, SE = 1.19, p < .001; completer-based d = -0.70). A smaller but still significant treatment advantage remained detectable at the exploratory 1-month follow-up among post-session completers (B = -2.92, SE = 1.22, p = .017). Exploratory post hoc moderation suggested a larger effect among male participants (B = 7.78, p = .003). These results suggest that a brief AI chatbot conversation can meaningfully reduce breakup distress, with exploratory evidence that a smaller advantage persists over the following month. Future work should test the intervention against active controls, evaluate repeated-session use, and recruit more diverse samples.

Rising demand for mental health support has increased interest in using Large Language Models (LLMs) for counseling, but adapting them to this safety-critical domain is hindered by limited real-world data due to privacy constraints. Synthetic datasets provide a promising alternative, but existing approaches often rely on unstructured or semi-structured text inputs and overlook structural dependencies between a client's cognitive, emotional, and behavioral states, leading to psychologically inconsistent and less realistic interactions. We introduce Graph2Counsel, a framework for generating synthetic counseling sessions grounded in Client Psychological Graphs (CPGs) that encode relationships among clients' thoughts, emotions, and behaviors. Graph2Counsel uses a structured prompting pipeline guided by counselor strategies and CPG, and explores prompting strategies including CoT and Multi-Agent Feedback. It produces 760 sessions from 76 CPGs across diverse client profiles. In expert evaluation, our dataset outperforms prior datasets on specificity, counselor competence, authenticity, conversational flow, and safety (Krippendorff's $α$ = 0.70). Fine-tuning an open-source model on this dataset improves performance on several metrics on CounselingBench and CounselBench, while matching baselines on others. We further introduce Therapy-Eval, a multi-turn evaluation framework, and demonstrate the effectiveness of our fine-tuned model in realistic therapeutic conversations. We make our code, data and fine-tuned model public.

Large language models (LLMs) can generate fluent dialogue, but prior works lack situational grounding, dynamic strategy control, and evaluation aligned with clinical standards in motivational interviewing (MI). We introduce StoryMI, a multi-LLM agent framework for controllable MI dialogue generation, where questionnaire-based client profiles are expanded into situational stories that provide narrative context for the dialogue. Therapist and client agents generate MI-coded utterances guided by MI codes selected by the interaction agent, while an interaction agent dynamically coordinates exchanges to control MI strategies during a multi-turn conversation. We propose a two-level evaluation protocol: lexical metrics and MI-specific measures of macro-level counseling strategies, alongside LLM-as-judge and human expert assessments. We construct a dataset of 6K simulated MI dialogues grounded in 1K questionnaire-story pairs, covering 12 MI codes and 13 symptom domains, and benchmark six open- and closed-source LLMs. Our results show that situational grounding and macro-level control can improve MI adherence and clinical plausibility, demonstrating the effectiveness of a structured multi-agent workflow for psychotherapy dialogue generation. We provide code and data for reproducibility.

Conversational generative artificial intelligence agents (or genAI chatbots) could benefit youth mental health, yet young people's perspectives remain underexplored. We examined the Mental health Intelligence Agent (Mia), a genAI chatbot originally designed for professionals in Australian youth services. Following co-design, 32 young people participated in online workshops exploring their perceptions of genAI chatbots in youth mental health and to develop recommendations for reconceptualising Mia for consumers and integrating it into services. Four themes were developed: (1) Humanising AI without dehumanising care, (2) I need to know what's under the hood, (3) Right tool, right place, right time?, and (4) Making it mine on safe ground. This study offers insights into young people's attitudes, needs, and requirements regarding genAI chatbots in youth mental health, with key implications for service integration. Additionally, by co-designing system requirements, this work informs the ethics, design, development, implementation, and governance of genAI chatbots in youth mental health contexts.

Conversational AI systems are increasingly used for personal reflection and emotional disclosure, raising concerns about their effects on vulnerable users. Recent anecdotal reports suggest that prolonged interactions with AI may reinforce delusional thinking---a phenomenon sometimes described as AI Psychosis. However, empirical evidence on this phenomenon remains limited. In this work, we examine how delusion-related language evolves during multi-turn interactions with conversational AI. We construct simulated users (SimUsers) from Reddit users' longitudinal posting histories and generate extended conversations with three model families (GPT, LLaMA, and Qwen). We develop DelusionScore, a linguistic measure that quantifies the intensity of delusion-related language across conversational turns. We find that SimUsers derived from users with prior delusion-related discourse (Treatment) exhibit progressively increasing DelusionScore trajectories, whereas those derived from users without such discourse (Control) remain stable or decline. We further find that this amplification varies across themes, with reality skepticism and compulsive reasoning showing the strongest increases. Finally, conditioning AI responses on current DelusionScore substantially reduces these trajectories. These findings provide empirical evidence that conversational AI interactions can amplify delusion-related language over extended use and highlight the importance of state-aware safety mechanisms for mitigating such risks.

Mental healthcare services in the UK lack tools and resources to address the cultural needs of Muslim women, often leaving them feeling as though their values are pathologised and limiting trust and engagement [1]. Despite growing awareness of cultural competency, few interventions integrate Islamic frameworks into therapeutic support. This report investigates the design and evaluation of YAQIN, a co-designed AI-based application supporting culturally and faith-sensitive mental health engagement for Muslim women. With almost 1.9 million Muslim women in England in 2021, YAQIN responds to a gap in care [2]. It leverages AIś anonymity and continuous support through a faith-aware chatbot and guided journaling tool grounded in user-centred design and Islamic psychology. The YAQIN design research methodology comprised three stages: contextual investigation and literature review, user research with N=14 stakeholders including Muslim women and mental health experts, and prototype development informed by deductive thematic analysis, personas, journey maps, and design specifications. Evaluation involved a co-designed user study with five participants: four Muslim women and one mental health expert who reviewed therapeutic alignment and cultural sensitivity after using the chatbot prototype. Feedback focused on tone, faith relevance, emotional resonance, and the Retrieval-Augmented Generation pipeline enabling contextual continuity. Participants highlighted YAQINś ability to bridge cultural gaps in trust and therapeutic confidence. Feedback included suggestions of including linguistic diversity and routine-based guidance. This project demonstrates how culturally sensitive AI can improve mental healthcare accessibility and trust for marginalised communities and highlights the potential of faith-integrated technology in healthcare innovation.

Large language models (LLMs) are increasingly used for mental-health support; yet prevailing evaluation methods--fluency metrics, preference tests, and generic dialogue benchmarks--fail to capture the clinically critical dimensions of psychotherapy. We introduce THERAPYGYM, a framework that evaluates and improves therapy chatbots along two clinical pillars: fidelity and safety. Fidelity is measured using the Cognitive Therapy Rating Scale (CTRS), implemented as an automated pipeline that scores adherence to CBT techniques over multi-turn sessions. Safety is assessed using a multi-label annotation scheme, covering therapy-specific risks (e.g., failing to address harm or abuse). To mitigate bias and unreliability in LLM-based judges, we further release THERAPYJUDGEBENCH, a validation set of 116 dialogues with 1,270 expert ratings for auditing and calibration against licensed clinicians. THERAPYGYM also serves as a training harness: CTRS and safety-based rewards drive RL with configurable patient simulations spanning diverse symptom profiles. Models trained in THERAPYGYM improve on expert ratings, with average CTRS rising from 0.10 to 0.60 (and 0.16 to 0.59 under LLM judges). Our work enables scalable development of therapy chatbots that are faithful to evidence-based practice and safer in high-stakes use.

We present Tell Me, a mental well-being system that leverages advances in large language models to provide accessible, context-aware support for users and researchers. The system integrates three components: (i) a retrieval-augmented generation (RAG) assistant for personalized, knowledge-grounded dialogue; (ii) a synthetic client-therapist dialogue generator conditioned on client profiles to facilitate research on therapeutic language and data augmentation; and (iii) a Well-being AI crew, implemented with CrewAI, that produces weekly self-care plans and guided meditation audio. The system is designed as a reflective space for emotional processing rather than a substitute for professional therapy. It illustrates how conversational assistants can lower barriers to support, complement existing care, and broaden access to mental health resources. To address the shortage of confidential therapeutic data, we introduce synthetic client-therapist dialogue generation conditioned on client profiles. Finally, the planner demonstrates an innovative agentic workflow for dynamically adaptive, personalized self-care, bridging the limitations of static well-being tools. We describe the architecture, demonstrate its functionalities, and report evaluation of the RAG assistant in curated well-being scenarios using both automatic LLM-based judgments and a human-user study. This work highlights opportunities for interdisciplinary collaboration between NLP researchers and mental health professionals to advance responsible innovation in human-AI interaction for well-being.

Generative AI chatbots built for mental health could extend access to care, but evidence from real-world use is limited. We report a single-arm, naturalistic pilot of a foundation model trained for mental health, among 299 US adults with at least moderate depressive or anxiety symptoms who were followed for up to 12 months. Depression and anxiety symptoms fell by 10 weeks (Cohen's d 0.93 and 0.79), with loneliness, behavioral activation, and social interaction improving. Clinicians confirmed that automated safeguards were escalated appropriately. Participants fell into non-responding (57.2%), improving (37.1%) and rapidly improving (5.7%) trajectories. Early working alliance and greater engagement were associated with better outcomes. The AI deployed ten identified intervention families whose delivery varied with baseline anxiety and depression, with the overall ratio of clinical to non-clinical content increasing according to severity without survey information access. These findings support the feasibility of purpose-built AI for mental health.

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.