Mental Health Counseling

Automatic assessment of communication quality in dyadic counseling conversations is bottlenecked by data: expert-rated corpora are small and expensive to grow. We study cross-domain transfer of expert overall-impression prediction across three German corpora of simulated counseling (two general-practice medical, one school-related parent-teacher; $n=195$ expert-rated sessions, one corpus after scale equating). Training on the other domains beats training in-domain: leave-one-domain-out transfer reaches nested Spearman $ρ= 0.54$ against $\le 0.48$ within the target domain, a paired session-level gap of $+0.15$ that holds at $+0.12$ when the training-set sizes are matched, so it is not simply data volume. The decisive features are session-level construct scores from small open-weight LLMs reading the two-speaker transcript, with the constructs largely derived from the experts' rating instruments: the instrument-derived battery lifts a single judge from $0.32$ to $0.41$ over generic dialogue qualities, judges from three model families ensemble to $0.51$ language-only, and a nonverbal-dyadic block adds $+0.03$ more, not separable from noise at this sample size. We also price the recording setup: one corpus lost its per-speaker audio, 16% of its diarised segments carry the wrong speaker, and repair is worth $+0.07$ there. At practically attainable corpus sizes, the expert's overall impression is carried by what is said, and by other communication programs' data more than by one's own.

Emotion dynamics are critical for understanding crisis-support conversations, yet most computational work treats emotion as static utterance-level labels. We introduce EMPATH, a framework for understanding affective dynamics in mental health dialogues across three granularities: turn-level labels, transition probabilities, and global conversation archetypes. Applying EMPATH to text-based crisis conversations with self-identified Black texters discussing grief, we find persistent negative affect, gradual hope-ward transitions, distinct texter-volunteer emotional roles, and heterogeneous recovery trajectories. These results highlight the informative patterns that emerge from computationally understanding crisis support and expressions of grief as dynamic processes within conversations, as well as the overall value of emotion-dynamic analysis for analyzing and comparing affect in dialogues.

Recent advancements in large language models have revolutionized the field of psychological counseling, especially in the context of Cognitive Behavioral Therapy (CBT). While the success of CBT relies heavily on dynamic decision-making informed by the client's real-time mental state, this aspect has often been overlooked in current research, limiting both flexibility and therapeutic outcomes. In this paper, we introduce StratCBT, a dataset specifically designed for psychological counseling conversations with CBT Strategies, consisting of 9,688 sessions and around 256K utterances, with each counselor's response aligned with one of eight distinct strategies. The creation of StratCBT involves modeling clients based on their negative thoughts and generating high-quality counseling conversations through self-chat, incorporating realistic sessions as guidance, thereby significantly surpassing existing datasets in both general counseling and CBT-specific skills. We conduct extensive experiments to demonstrate the effectiveness of strategy-aligned generation and evaluate its efficacy in delivering professional and effective counseling with LLM-simulated clients to reflect real-world scenarios. The dataset can be obtained from https://github.com/zimuwangnlp/StratCBT.

People increasingly use large language models (LLMs) for mental health support, yet their safety in evolving, high-risk conversations remains poorly characterised. We developed K-Bench, a clinician-calibrated, protected benchmark evaluating 125 model configurations representing 33 base models from 14 providers across a fixed cohort of 200 multi-turn vignettes involving suicide, self-harm, domestic violence, substance misuse, and no-risk presentations. Synthetic patient conversations showed substantial distributional overlap with real human-AI conversations. A frozen GPT-4o judge achieved 94.2% exact agreement with clinician consensus across 6,751 eligible item comparisons from 151 clinician-rated transcripts. Leading models combined strong supportive conversation with combined-risk scores above 95, whereas risk exploration exposed substantial variation among lower-performing configurations. Therapeutic prompting produced configuration-specific gains concentrated among weaker models, while elevated reasoning produced no average improvement. K-Bench combines broader clinical coverage and configuration-scale comparison with a continuously updated public leaderboard whose operational test materials are protected from direct optimisation. The leaderboard is available at www.k-bench.ai.

Tracking depression from multi-session counseling dialogues requires estimating both current symptom severity and how it changes across sessions. Yet progress on this task is constrained by the scarcity of longitudinal counseling data with standardized session-level depression labels. Existing resources typically provide either multi-session conversations without depression labels or labeled interviews in a single session. Building such a benchmark poses three challenges: maintaining longitudinal consistency and diversity, grounding symptom progression in empirical patterns, and expressing controlled depression states naturally without exposing target labels. To address these challenges, we introduce LongCounsel-8, a benchmark suite of three independently generated datasets totaling 7,749 five-session counseling trajectories, grounded in real-world client profiles, depression trajectories, symptom compositions, and counseling patterns. We combine profile-grounded simulation, empirically informed state construction, and indirect behavioral realization to address these challenges. Across the benchmark, simulated self-reports closely recover the controlled states, supporting label fidelity. Experiments on existing depression tracking methods reveal three key findings: (1) lower single-session score error does not guarantee accurate identification of trend, i.e., improvement or worsening; (2) existing methods are consistently less reliable on worsening trajectories; and (3) additional session history may reduce the accuracy of trend prediction. Together, these findings establish LongCounsel-8 as a foundation for advancing depression assessment from static, single-session prediction toward reliable longitudinal tracking of mental-health change.

Retrieval-augmented generation (RAG) can improve the specificity and grounding of large language model responses, but its effect is not uniformly beneficial in single-turn mental-health question answering, where user queries often combine emotional distress, treatment concerns, and safety-sensitive needs. We study when retrieval helps or hurts mental-health QA, and whether a lightweight selective retrieval policy can better control this trade-off. We operationalize retrieval need using three draft-conditioned utility dimensions: psychoeducational need, coping need, and response specificity, together with a rule-based safety trigger. Following psychotherapy-grounded RAG systems such as coTherapist, we construct a compact and controllable guideline corpus comprising coping-strategy, psychoeducational, and safety resources. We fine-tune an instruction-tuned generator on MentalChat16K using QLoRA and compare Closed-book, Always Retrieval, and Selective Retrieval settings on CounselBench-Eval and CounselBench-Adv. Experiments show that retrieval is not uniformly beneficial in this domain. Always Retrieval improves specificity but lowers overall quality and introduces additional safety-sensitive failures. Selective Retrieval preserves closed-book behavior for low-need cases while avoiding the additional degradation caused by unconditional retrieval, supporting the view that retrieval activation is a safety-sensitive control decision.

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.

Synthetic generation of Cognitive Behavioral Therapy (CBT) sessions is challenged by two competing demands: adhering to strict therapeutic structure while modeling the resistant, unpredictable behavior of real patients. Existing script-based methods fail to capture dynamic therapeutic interactions, while multi-agent approaches struggle to adhere to CBT's sequential structure; both suffer from sycophancy, producing overly compliant patients that misrepresent real clinical settings. In this work we introduce ODRA, a novel framework for synthesizing therapy dialogues through a Chain-of-Thought (CoT) strategy grounded in foundational CBT guidelines (Beck, 2020). ODRA further incorporates a resistance orchestrator to solve patient sycophancy, which employs steering techniques to elicit behaviors aligned with their resistance level. Automated and expert evaluations show that ODRA significantly outperforms existing methods across therapeutic skills, CBT alignment, and patient behavioral fidelity, with licensed psychologists preferring ODRA sessions across 12 of 13 clinical metrics. Furthermore, models fine-tuned on our dataset demonstrate superior therapeutic performance against both cooperative and resistant patients, validating that explicit resistance modeling in synthetic training data directly translates to downstream clinical robustness.

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.

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.

Using large language models (LLMs) to assist psychological counseling is an important task in the field of natural language processing. The construction of high-quality psychological support dialogue corpora serves as a critical foundation for training counseling-oriented conversational models. However, existing data generation approaches generally suffer from several limitations, including emotionally stable seekers, limited variation in emotional dynamics, and a high degree of compliance with counselors' guidance. These issues result in LLM that lack the capability to effectively respond to emotionally unstable scenarios. In addition, counselor responses are typically driven by problem-solving objectives, thereby overlooking the role of emotion-focused interaction, which are essential in psychological counseling. To address these gaps, we propose EmoTrace, a multi-turn dialogue corpus generation framework centered on modeling seekers' emotional trajectories. we construct seekers' cognitive profile and introduce a seeker module with emotional schemas and an associated activation mechanism, a counselor module, and an emotional trajectory control module, thereby enhancing the layering of the seeker's emotional expression and the counselor's targeted empathic expression. Experimental results demonstrate that the proposed method outperforms existing approaches in terms of emotional richness and empathy quality.

This paper presents GEMCo, a releasable, human-written proxy for inaccessible counselling data: 86 complete German e-mail counselling conversations (728 messages), expert-authored cases and counsellor sessions with trained role-players. It is validated against a held-out reference of 124 real counselling conversations. The proxy and the real conversations are measured against each other on counsellor strategies and client emotions. The gap is detectable but small. A generative validation supports the analysis. The corpus is the primary contribution. The validation method generalises to any domain where real data cannot be shared but a human-made proxy can. Privacy and ethics keep real counselling data closed. GEMCo carries none by design and can be released, a first step toward language research in this domain.

Despite recent advances in large language models (LLMs), their ability to generate empathetic mental health counseling responses in low-resource languages remains largely unexplored. To address this gap, we curate 625 authentic mental health cases from three complementary sources: (1) publicly available Facebook posts discussing mental health concerns, (2) transcripts from the Bangladeshi television program "Ami Akhon Ki Korbo", and (3) anonymized student questionnaire responses covering diverse emotional and psychological challenges. Based on these cases, we build an evaluation corpus comprising advice written by licensed clinical psychologists and responses generated by three modern proprietary LLMs: GPT-4o Mini, Claude 4.5 Haiku, and Gemini 2.5 Pro. We further propose the Role-Playing Reflective Chain-of-Thought Advisory Framework (RP-RCAF), a task-specific prompting strategy that combines expert-authored few-shot examples with structured self-reflection to produce supportive, culturally aware, and ethically aligned counseling through a compassionate advisor persona. We also introduce the Grok 4-Based Response Evaluation and Scoring Framework (G-REFS), which integrates automated assessment with expert psychologist validation across emotional sensitivity, cultural appropriateness, linguistic clarity, and ethical soundness. Experimental results show that RP-RCAF consistently outperforms conventional prompting across all evaluated models and produces responses that more closely align with professional psychological counseling.

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.

Reasoning large language models (LLMs) have recently made much progress in complex problem-solving, leveraging internal reasoning (or thought) to guide their solution generation. However, existing LLM-based counseling agents, including those using Motivational Interviewing (MI), generate responses without explicitly aligning thoughts with counseling techniques, limiting their effectiveness. We propose MIThinker, a lightweight thinking model that generates therapeutic thoughts to guide MI counseling agents in strategy selection and response generation. To overcome the lack of annotated thought data, we introduce AugR1-MI, an automated pipeline that reverse-engineers counselor's thoughts from observed responses. Through two-stage training combining supervised fine-tuning and reinforcement learning, MIThinker demonstrates improved theory-of-mind assessment and strategy alignment. Comprehensive evaluations show that MindfulMI, our agent leveraging MIThinker, achieves MI competency comparable to state-of-the-art systems with an order of magnitude less computation.

As mental health concerns continue to rise globally, social media has emerged as a vital space where individuals seek emotional support. While prior work on personalized emotional support has leveraged seekers' emotional states, personas, and situational context, these approaches primarily capture the seeker's current state, overlooking the formative experiences that shape present concerns. In this work, we propose MindTailor, a framework that generates personalized emotional support responses by constructing a case formulation from the seeker's post history and iteratively refining responses through collaborative critique among counselor agents grounded in distinct counseling strategies. To enable research on this history-aware task, we construct ReddiSupp, a dataset of 798 Reddit posts paired with seekers' prior post histories. Through LLM-as-a-Judge evaluation, expert human evaluation, and a user study with seekers, we demonstrate that MindTailor outperforms baselines across these evaluations, improving empathy, personalization, understanding, and achieving the highest overall preference.

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) show promise in psychological counseling, yet existing benchmarks rely heavily on highly cooperative simulated clients. We observe a critical counselor-following phenomenon: these clients often rapidly shift from resistance to compliance after only a few turns, creating an illusion of therapeutic progress and inflating scores under current evaluation protocols through superficial empathy. To address this evaluation mismatch, we propose a Cognitive Behavioral Therapy (CBT)-grounded resistance-aware framework. We introduce CARS, a client simulator that explicitly models dynamic resistance via Cognitive Conceptualization Diagrams (CCDs). We present STREAMS, a dual-module framework that decouples strategic reasoning (Thinker) from response generation (Presenter) and optimizes it via reinforcement learning. We further propose EWTS-MI, an entropy-weighted metric for evaluating responsiveness under high-friction interactions. Experiments across resistant and non-resistant counseling settings validate our findings on evaluation mismatch and demonstrate the effectiveness of resistance-aware training for improving strategic robustness under challenging counseling interactions.

Large language models (LLMs) have shown growing potential for Cognitive Behavioral Therapy (CBT) counseling. However, most existing approaches still formulate counseling as a local response generation problem, focusing on empathetic replies within short, text-only, or single-session interactions. We argue that this formulation fundamentally mismatches the nature of real psychotherapy. In clinical CBT, therapy is a longitudinal process in which therapists continuously infer, update, and intervene on evolving therapeutic states across sessions. Realistic CBT further involves multimodal inference and delayed cross-session intervention effects, requiring models to capture longitudinal therapeutic state evolution under partial observability. We propose DMT-CBT, a framework for Dynamic Modeling of evolving Therapeutic states in CBT counseling. DMT-CBT maintains structured therapeutic states across sessions while incorporating multimodal behavioral grounding and tool-augmented intervention to support adaptive therapeutic reasoning. Based on this framework, we construct DMTCorpus, a synthetic multi-session multimodal CBT counseling dataset featuring evolving therapeutic states, image-grounded client behaviors, and cross-session intervention continuity. Experimental results show that DMT-CBT improves counseling fidelity and therapeutic alliance, produces more favorable longitudinal affective trajectories, and preserves therapeutic states more faithfully than post-hoc extraction approaches.

Text-based counseling provides a valuable source of information for assessing depression severity. We study prediction of the total score on the eight-item Patient Health Questionnaire (PHQ-8), a self-report measure of depression severity, from counseling transcripts. Clinical-based methods rely mainly on large language model (LLM) inference to obtain structured session-level assessments, but these assessments provide limited information about which utterances support each score. Training-based methods train predictors directly on sentences or their semantic embeddings and preserve local conversational detail, but must learn clinical structure from limited labeled transcripts. Integrating a small set of clinical feature scores with a long sequence of high-dimensional utterance representations is challenging, as simple fusion can overemphasize dialogue evidence and fail to link clinical features to supporting utterances. Combining structured clinical assessments with sentence-level semantics, we propose EmoTrack, which jointly encodes clinical feature scores and utterance representations to predict the total PHQ-8 score. For longitudinal assessment across successive sessions, the model can also incorporate a compressed representation of the preceding session as optional memory. On the real-world DAIC-WOZ benchmark, EmoTrack reduces mean absolute error from 2.8234 to 2.4708 relative to the strongest evaluated baseline. Across five settings covering single-session estimation, cross-dataset transfer without adaptation, and longitudinal assessment, it reduces normalized aggregate error by approximately 6.1% relative to the strongest baseline.

In recent years, large language models have shown substantial potential in psychological support tasks. However, existing psychological counseling data mostly rely on single-turn question answering or short multi-turn dialogues, making it difficult to characterize how college students' psychological distress accumulates, interacts, and gradually evolves over long periods within campus life events. To address this issue, this paper proposes Psy-Chronicle, a structured data-generation framework for synthesizing long-horizon campus psychological counseling dialogues. We generate a semester-spanning temporal stress event graph to model the chronological order and evolutionary dependencies among campus stress events. Through interactive simulation between a student agent and a counselor agent, together with a structured memory integration mechanism, Psy-Chronicle generates long-horizon dialogues with continuity across counseling sessions. Based on Psy-Chronicle, we construct and open-source CPCD, a Chinese long-horizon dialogue dataset for college psychological counseling, containing 100 student profiles, 90,000 counseling dialogues. We further build CPCD-Bench to evaluate models' long-horizon campus counseling capabilities from three dimensions: session-level response, long-horizon memory recall, and temporal-causal reasoning. Experimental results show that CPCD effectively improves session-level response generation and long-horizon memory recall for models with the same base architecture. Meanwhile, improvements in temporal-causal reasoning remain limited, indicating that event-chain organization and causal explanation are key challenges in long-horizon psychological counseling modeling. The related code and data are available at: https://github.com/EdwinUSTB/Psy-Chronicle

Cognitive behavioural therapy is widely used to help patients understand and manage psychological distress. It is often delivered through spoken conversation, where therapists attend not only to what patients say, but also to how they say it, because these cues can help therapists decide how to respond and adapt treatment. Progress in building AI systems for CBT remains largely limited to text, partly because most available datasets are text based and shareable spoken CBT data are scarce under ethical and privacy constraints. This creates a blind spot because text based models and evaluations cannot capture the mismatch between the transcript and the patient's voice, even though therapists often rely on this mismatch to understand patient distress. We introduce CBT-Audio, a dataset for evaluating patient distress estimation from spoken CBT sessions with audio language models. CBT-Audio contains 1,802 patient turns from 96 publicly available CBT recordings, with turn-level distress labels validated on an experts-annotated subset. We evaluate 10 open source audio language models under three input conditions, where models receive only patient audio, only the transcript, or both audio and transcript. Our results show that audio can provide useful information beyond text, especially when combined with transcripts. Adding audio to transcript input improves distress estimation over using the transcript alone in 8 of 10 model families, with significant gains in 4, and case studies show the clearest benefit when verbal content and vocal delivery diverge. CBT-Audio makes spoken patient behaviour measurable for AI evaluation in CBT-related tasks and supports future work on audio language models for mental health interaction.

Mental-health dialogue models are increasingly evaluated by AI-based evaluators, yet these evaluators often treat surface empathy, supportiveness, or fluency as evidence of safety. In this paper, we study a hidden failure mode that we call implicit sycophancy: a response may appear empathetic while implicitly reinforcing catastrophizing, avoidance, hopeless prediction, or CBT-style labeling. To examine this problem, we introduce a diagnostic benchmark for implicit-sycophancy detection, built from three representative mental-health dialogue sources covering everyday peer support, counseling-style emotional support, and crisis-oriented interaction, and further construct a leakage-audited clean single-response matched benchmark with 500 contexts and 1,500 matched response windows. We then propose Dynamic Emotional Signature Graphs (DESG), a structured offline audit framework that separates LLM-based state extraction from final scoring and evaluates clinical direction through semantic, affective, and cognitive-distortion state transitions rather than free-form LLM judgment. Unlike metadata, surface-style, lexical, embedding, and rubric-LLM baselines, DESG scores the direction of clinical-state change induced by a response; on the leakage-audited clean matched benchmark, DESG-StateRisk improves over the strongest non-DESG baseline by 0.0488 macro-F1 and achieves the best harmful-risk detection result. These results suggest that evaluating implicit sycophancy requires explicit clinical-state modeling together with leakage checks, shortcut controls, and competitive baselines.

Effective mental health counseling is a complex, theory-driven process requiring the simultaneous integration of psychological frameworks, real-time distress signals, and strategic intervention planning. This level of clinical reasoning is critical for safety and therapeutic effectiveness but is often missing in general-purpose Large Language Models (LLMs). We introduce SAGE (Strategy-Aware Graph-Enhanced), a novel framework designed to bridge the gap between structured clinical knowledge and generative AI. SAGE constructs a heterogeneous graph that unifies conversational dynamics with a psychologically grounded layer, explicitly anchoring interactions in a theory-driven lexicon. Our architecture first employs a Next Strategy Classifier to identify the optimal therapeutic intervention. Subsequently, a Graph-Aware Attention mechanism projects graph-derived structural signals into soft prompts, conditioning the LLM to generate responses that maintain clinical depth. Validated through both automated metrics and expert human evaluation, SAGE outperforms baselines in strategy prediction and recommended response quality. By providing actionable intervention recommendations, SAGE serves as a cutting-edge decision-support tool designed to augment human expertise in high-stakes crisis counseling.

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.

Mental health challenges are increasing worldwide, straining emotional support services and leading to counselor overload. This can result in delayed responses during critical situations, such as suicidal ideation, where timely intervention is essential. While large language models (LLMs) have shown strong generative capabilities, their application in low-resource languages, especially in sensitive domains like mental health, remains underexplored. Furthermore, existing LLM-based agents often struggle to replicate the supportive language and intervention strategies used by professionals due to a lack of training on large-scale, real-world datasets. To address this, we propose CARE (Counselor-Aligned Response Engine), a GenAI framework that assists counselors by generating real-time, psychologically aligned response recommendations. CARE fine-tunes open-source LLMs separately for Hebrew and Arabic using curated subsets of real-world crisis conversations. The training data consists of sessions rated as highly effective by professional counselors, enabling the models to capture interaction patterns associated with successful de-escalation. By training on complete conversation histories, CARE maintains the evolving emotional context and dynamic structure of counselor-help-seeker dialogue. In experimental settings, CARE demonstrates stronger semantic and strategic alignment with gold-standard counselor responses compared to non-specialized LLMs. These findings suggest that domain-specific fine-tuning on expert-validated data can significantly support counselor workflows and improve care quality in low-resource language contexts.

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) 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.

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.

Large language models (LLMs) show promise in generating supportive responses for mental health and counseling applications. However, their responses often lack cultural sensitivity, contextual grounding, and clinically appropriate guidance. This work addresses the gap of how to systematically incorporate domain-specific, clinically validated knowledge into LLMs to improve counseling quality. We utilize and compare two approaches, retrieval-augmented generation (RAG) and a knowledge graph (KG)-based method, designed to support para-counselors. Our KG is constructed manually and clinically validated, capturing causal relationships between stressors, interventions, and outcomes, with contributions from multidisciplinary people. We evaluated multiple LLMs in both settings using BERTScore F1 and SBERT cosine similarity, as well as human evaluation across five metrics, which is designed to directly measure the effectiveness of counseling beyond similarity at the surface level. The results show that KG-based approaches consistently improve contextual relevance, clinical appropriateness, and practical usability compared to RAG alone, demonstrating that structured, expert-validated knowledge plays a critical role in addressing LLMs limitations in counseling tasks.