Daily Papers

Should a large language model (LLM) be used as a therapist? In this paper, we investigate the use of LLMs to *replace* mental health providers, a use case promoted in the tech startup and research space. We conduct a mapping review of therapy guides used by major medical institutions to identify crucial aspects of therapeutic relationships, such as the importance of a therapeutic alliance between therapist and client. We then assess the ability of LLMs to reproduce and adhere to these aspects of therapeutic relationships by conducting several experiments investigating the responses of current LLMs, such as `gpt-4o`. Contrary to best practices in the medical community, LLMs 1) express stigma toward those with mental health conditions and 2) respond inappropriately to certain common (and critical) conditions in naturalistic therapy settings -- e.g., LLMs encourage clients' delusional thinking, likely due to their sycophancy. This occurs even with larger and newer LLMs, indicating that current safety practices may not address these gaps. Furthermore, we note foundational and practical barriers to the adoption of LLMs as therapists, such as that a therapeutic alliance requires human characteristics (e.g., identity and stakes). For these reasons, we conclude that LLMs should not replace therapists, and we discuss alternative roles for LLMs in clinical therapy.

Wider access to therapeutic care is one of the biggest challenges in mental health treatment. Due to institutional barriers, some people seeking mental health support have turned to large language models (LLMs) for personalized therapy, even though these models are largely unsanctioned and untested. We investigate the potential and limitations of using LLMs as providers of evidence-based therapy by using mixed methods clinical metrics. Using HELPERT, a prompt run on a large language model using the same process and training as a comparative group of peer counselors, we replicated publicly accessible mental health conversations rooted in Cognitive Behavioral Therapy (CBT) to compare session dynamics and counselor's CBT-based behaviors between original peer support sessions and their reconstructed HELPERT sessions. Two licensed, CBT-trained clinical psychologists evaluated the sessions using the Cognitive Therapy Rating Scale and provided qualitative feedback. Our findings show that the peer sessions are characterized by empathy, small talk, therapeutic alliance, and shared experiences but often exhibit therapist drift. Conversely, HELPERT reconstructed sessions exhibit minimal therapist drift and higher adherence to CBT methods but display a lack of collaboration, empathy, and cultural understanding. Through CTRS ratings and psychologists' feedback, we highlight the importance of human-AI collaboration for scalable mental health. Our work outlines the ethical implication of imparting human-like subjective qualities to LLMs in therapeutic settings, particularly the risk of deceptive empathy, which may lead to unrealistic patient expectations and potential harm.

In mental health counseling, a variety of earlier studies have focused on dialogue modeling. However, most of these studies give limited to no emphasis on the quality of interaction between a patient and a therapist. The therapeutic bond between a patient and a therapist directly correlates with effective mental health counseling. It involves developing the patient's trust on the therapist over the course of counseling. To assess the therapeutic bond in counseling, we introduce trust as a therapist-assistive metric. Our definition of trust involves patients' willingness and openness to express themselves and, consequently, receive better care. We conceptualize it as a dynamic trajectory observable through textual interactions during the counseling. To facilitate trust modeling, we present MENTAL-TRUST, a novel counseling dataset comprising manual annotation of 212 counseling sessions with first-of-its-kind seven expert-verified ordinal trust levels. We project our problem statement as an ordinal classification task for trust quantification and propose a new benchmark, TrustBench, comprising a suite of classical and state-of-the-art language models on MENTAL-TRUST. We evaluate the performance across a suite of metrics and lay out an exhaustive set of findings. Our study aims to unfold how trust evolves in therapeutic interactions.

People experiencing severe distress increasingly use Large Language Model (LLM) chatbots as mental health support tools. Discussions on social media have described how engagements were lifesaving for some, but evidence suggests that general-purpose LLM chatbots also have notable risks that could endanger the welfare of users if not designed responsibly. In this study, we investigate the lived experiences of people who have used LLM chatbots for mental health support. We build on interviews with 21 individuals from globally diverse backgrounds to analyze how users create unique support roles for their chatbots, fill in gaps in everyday care, and navigate associated cultural limitations when seeking support from chatbots. We ground our analysis in psychotherapy literature around effective support, and introduce the concept of therapeutic alignment, or aligning AI with therapeutic values for mental health contexts. Our study offers recommendations for how designers can approach the ethical and effective use of LLM chatbots and other AI mental health support tools in mental health care.