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Virtual agents have shown promising potential in mental health applications, but current research has predominantly focused on contexts outside of traditional therapy sessions. This paper examines the impact of a virtual supporter in remote psychotherapy sessions conducted via Zoom. We used a two-phase research approach. First we conducted a formative study to understand the roles and functions of human supporters in psychotherapy contexts. Based on these findings, we developed a virtual supporter operating in two modes: Daily Mode (for mood journaling outside therapy) and Therapy Mode (as an additional participant in Zoom therapy sessions). Finally we ran a user study with 14 participants who engaged with the virtual supporter for a week and then joined a remote psychotherapy session together. Our findings revealed that the virtual supporter had positive effects on creating psychological safety, reducing anxiety, and enhancing emotional articulation without disrupting the therapeutic process. We then discussed both the benefits and potential disadvantages of virtual supporters in therapeutic contexts, including concerns about over-reliance and the need for appropriate boundaries.

Psychotherapy delivery relies on a negotiation between patient self-reports and clinical intuition. Growing evidence for technological support of psychotherapy suggests opportunities to aid the mediation of this tension. To explore this prospect, we designed a prototype of a clinical decision support system (CDSS) for treating veterans with post-traumatic stress disorder in a Prolonged Exposure (PE) therapy intensive outpatient program. We conducted a two-phase interview study to collect perspectives from practicing PE clinicians and former PE patients who are United States veterans. Our analysis distills opportunities for a CDSS (e.g., offering homework review at a glance, aiding patient conceptualization) and larger challenges related to context and deployment (e.g., navigating Veterans Affairs). By reframing our findings through three human-centered perspectives (distributed cognition, situated learning, infrastructural inversion), we highlight the complexities of designing a CDSS for psychotherapists in this context and offer theory-aligned design considerations.

While large language models (LLMs) excel at open-ended dialogue, effective psychotherapy requires structured progression and adherence to clinical protocols, making the design of psychotherapist chatbots challenging. We investigate how different LLM-based designs shape perceived therapeutic dialogue in a chatbot grounded in the Self-Attachment Technique (SAT), a novel self-administered psychotherapy rooted in attachment theory. We compare three architectural variants: (1) a multi-agent system utilizing finite state machine aligned with therapeutic stages and a shared long-term memory, (2) a single-agent using identical knowledge-base and the same prompts, and (3) an unguided LLM. In an eight-day randomized controlled trial (RCT) with N=66 Farsi-speaking participants, balanced across the three chatbots, the multi-agent system is perceived as significantly more natural and human-like than the other variants and achieves higher ratings across most other metrics. These findings demonstrate that for therapeutic AI, architectural orchestration is as critical as prompt engineering in fostering natural, engaging dialogue.

Psychotherapy is a primary treatment for many mental health conditions, yet the interplay among therapist behaviors, client responses, and the therapeutic relationship is difficult to study at scale, as process research has relied on labor-intensive human coding. We develop and validate a computational framework for modeling therapist-client interaction, using large language models (LLMs) to measure therapist behaviors (empathy, exploration), relational quality (rapport), and client outcomes (self-disclosure, self-directed and outward-directed negative emotion). After validating model-generated scores against human annotations (ICC = 0.45-0.81; rapport 0.81, self-disclosure 0.78), we apply these measures to roughly 2,000 hours of transcripts from the Alexander Street corpus and use Structural Equation Modeling to estimate moment-to-moment relationships among therapist behaviors, rapport, and subsequent client responses, controlling for prior client state and context. Therapist empathy and exploration directly predict increased client disclosure and shifts in emotional expression; empathy is more strongly associated with self-directed than outward-directed negative emotion, suggesti

Simulated patients offer a scalable way to train psychotherapy micro-skills such as empathic responding and exploratory probing, but current systems either follow fixed scripts or rely on LLMs that drift unpredictably over long sessions. We present the Adaptive Virtual Patient (AVP), which adapts its disclosure behavior -- from guarded, through moderate openness, to full disclosure -- in response to trainee skill. The AVP is grounded in a structural equation model fit to nearly 2{,}000 hours of real-world psychotherapy transcripts, which quantifies how therapist empathy and exploration shift a patient's openness over time. An LLM generates the AVP's utterances conditioned on a disclosure level that the dynamics module updates each turn. In an evaluation with 20 clinicians and trainees over 80 sessions (1{,}033 turns), the AVP's disclosure rises in response to therapist empathy and exploration, while a prompt-only baseline stays flat; ablations confirm that the empirically motivated parameterization outperforms alternatives, with exploration carrying most of the adaptive signal.

Sentiment analysis has been of long-standing interest in psychotherapy research. Recently, the Transformer deep learning architecture has produced text-based sentiment analysis models that are highly accurate and context-aware. These models have been explored as proxies for emotion measurement instruments in psychotherapy, but not investigated as stand-alone psychometric tools. Using proposed utterance-level and session-level sentiment features derived from a fine-grained sentiment model on a large corpus of psychotherapy sessions (N = 751), we investigate the distribution of session aggregated sentiment scores. Further, we characterize the relationship of these features to individual components and the overall score of the OQ-45 instrument and find that this sentiment feature is most strongly correlated to components related to emotional valence in directionally intuitive ways. Finally, we report that there are statistically significant differences between the sentiment distributions for patients flagged as at risk of deterioration or dropping out of care via either the OQ Rational or Empirical outcome models. These correlations to a fully-validated psychometric instrument demonst

Access to evidence-based psychotherapy remains limited worldwide, with long waitlists even in high-income regions. Recent advances in large language models (LLMs) offer potential for scalable mental health support when designed with clinical oversight and safety mechanisms. We present Mind Companion, an LLM-based embodied conversational agent integrating multi-layered psychological analysis with process-based therapy principles. The system performs real-time analysis of client statements across fact extraction, psychological flexibility process detection, emotion recognition, and safety monitoring. Analysis results are stored for supervising clinicians to inform therapeutic planning. Response generation incorporates retrieval-augmented generation from evidence-based therapeutic literature and context-aware prompting. Responses are delivered through an embodied avatar with synchronized speech synthesis and animation. We evaluated three LLM configurations (GPT-4.1-mini, GPT-5.2, Claude Sonnet 4.5) against therapist responses from real therapy sessions using automated LLM-judge assessment and expert evaluation with 11 professional psychotherapists. GPT-5.2 achieved higher ratings than

Virtual reality (VR) is increasingly used across psychology, from research and assessment to counseling, psychological treatment, and psychotherapy, with growing applications for children and adolescents. In these contexts, VR is often treated as a relatively neutral delivery medium. This assumption may be misleading. Most consumer head-mounted displays (HMDs) have been designed primarily for adult anthropometry, including adult interpupillary distance (IPD) ranges. As a result, some children may be excluded from participation or may receive a systematically degraded perceptual experience because the device cannot be adequately aligned to their visual anatomy. This paper argues that IPD constraints in consumer VR headsets represent an underrecognized methodological and clinical problem in pediatric psychology and psychotherapy. If headset fit affects visual comfort, depth perception, attentional load, cybersickness, willingness to remain in the simulation, and sense of presence, it may also influence engagement, emotional processing, dropout, and treatment response. The headset may therefore function as a selection mechanism, shaping who is included in studies, who can tolerate int

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

Large language models (LLMs) have been actively applied in the mental health field. Recent research shows the promise of LLMs in applying psychotherapy, especially motivational interviewing (MI). However, there is a lack of studies investigating how language models understand MI ethics. Given the risks that malicious actors can use language models to apply MI for unethical purposes, it is important to evaluate their capability of differentiating ethical and unethical MI practices. Thus, this study investigates the ethical awareness of LLMs in MI with multiple experiments. Our findings show that LLMs have a moderate to strong level of knowledge in MI. However, their ethical standards are not aligned with the MI spirit, as they generated unethical responses and performed poorly in detecting unethical responses. We proposed a Chain-of-Ethic prompt to mitigate those risks and improve safety. Finally, our proposed strategy effectively improved ethical MI response generation and detection performance. These findings highlight the need for safety evaluations and guidelines for building ethical LLM-powered psychotherapy.

Recent advancements in large language models (LLMs) have shown their potential across both general and domain-specific tasks. However, there is a growing concern regarding their lack of sensitivity, factual incorrectness in responses, inconsistent expressions of empathy, bias, hallucinations, and overall inability to capture the depth and complexity of human understanding, especially in low-resource and sensitive domains such as psychology. To address these challenges, our study employs a mixed-methods approach to evaluate the efficacy of LLMs in psychotherapy. We use LLMs to generate precise summaries of motivational interviewing (MI) dialogues and design a two-stage annotation scheme based on key components of the Motivational Interviewing Treatment Integrity (MITI) framework, namely evocation, collaboration, autonomy, direction, empathy, and a non-judgmental attitude. Using expert-annotated MI dialogues as ground truth, we formulate multi-class classification tasks to assess model performance under progressive prompting techniques, incorporating one-shot and few-shot prompting. Our results offer insights into LLMs' capacity for understanding complex psychological constructs and

Psychotherapy reaches only a small fraction of individuals suffering from mental disorders due to social stigma and the limited availability of therapists. Large language models (LLMs), when equipped with professional psychotherapeutic skills, offer a promising solution to expand access to mental health services. However, the lack of psychological conversation datasets presents significant challenges in developing effective psychotherapy-guided conversational agents. In this paper, we construct a long-periodic dialogue corpus for counseling based on cognitive behavioral therapy (CBT). Our curated dataset includes multiple sessions for each counseling and incorporates cognitive conceptualization diagrams (CCDs) to guide client simulation across diverse scenarios. To evaluate the utility of our dataset, we train an in-depth counseling model and present a comprehensive evaluation framework to benchmark it against established psychological criteria for CBT-based counseling. Results demonstrate that DiaCBT effectively enhances LLMs' ability to emulate psychologists with CBT expertise, underscoring its potential for training more professional counseling agents.

We propose a unified framework for adaptive routing in multitask, multimodal prediction settings where data heterogeneity and task interactions vary across samples. Motivated by applications in psychotherapy where structured assessments and unstructured clinician notes coexist with partially missing data and correlated outcomes, we introduce a routing-based architecture that dynamically selects modality processing pathways and task-sharing strategies on a per-sample basis. Our model defines multiple modality paths, including raw and fused representations of text and numeric features and learns to route each input through the most informative expert combination. Task-specific predictions are produced by shared or independent heads depending on the routing decision, and the entire system is trained end-to-end. We evaluate the model on both synthetic data and real-world psychotherapy notes predicting depression and anxiety outcomes. Our experiments show that our method consistently outperforms fixed multitask or single-task baselines, and that the learned routing policy provides interpretable insights into modality relevance and task structure. This addresses critical challenges in pe

Background. Chronic pain afflicts 20 % of the global population. A strictly biomedical mind-set leaves many sufferers chasing somatic cures and has fuelled the opioid crisis. The biopsychosocial model recognises pain subjective, multifactorial nature, yet uptake of psychosocial care remains low. We hypothesised that patients own pain narratives would predict their readiness to engage in psychotherapy. Methods. In a cross-sectional pilot, 24 chronic-pain patients recorded narrated pain stories on Painstory.science. Open questions probed perceived pain source, interference and influencing factors. Narratives were cleaned, embedded with a pretrained large-language model and entered into machine-learning classifiers that output ready/not ready probabilities. Results. The perception-domain model achieved 95.7 % accuracy (specificity = 0.80, sensitivity = 1.00, AUC = 0.90). The factors-influencing-pain model yielded 83.3 % accuracy (specificity = 0.60, sensitivity = 0.90, AUC = 0.75). Sentence count correlated with readiness for perception narratives (r = 0.54, p < .01) and factor narratives (r = 0.24, p < .05). Conclusion. Brief spoken pain narratives carry reliable signals of wil

This study presents PsychoLexTherapy, a framework for simulating psychotherapeutic reasoning in Persian using small language models (SLMs). The framework tackles the challenge of developing culturally grounded, therapeutically coherent dialogue systems with structured memory for multi-turn interactions in underrepresented languages. To ensure privacy and feasibility, PsychoLexTherapy is optimized for on-device deployment, enabling use without external servers. Development followed a three-stage process: (i) assessing SLMs psychological knowledge with PsychoLexEval; (ii) designing and implementing the reasoning-oriented PsychoLexTherapy framework; and (iii) constructing two evaluation datasets-PsychoLexQuery (real Persian user questions) and PsychoLexDialogue (hybrid simulated sessions)-to benchmark against multiple baselines. Experiments compared simple prompting, multi-agent debate, and structured therapeutic reasoning paths. Results showed that deliberate model selection balanced accuracy, efficiency, and privacy. On PsychoLexQuery, PsychoLexTherapy outperformed all baselines in automatic LLM-as-a-judge evaluation and was ranked highest by human evaluators in a single-turn prefer

Recent advancements in large language models (LLMs) promise to expand mental health interventions by emulating therapeutic techniques, potentially easing barriers to care. Yet there is a lack of real-world empirical evidence evaluating the strengths and limitations of LLM-enabled psychotherapy interventions. In this work, we evaluate an LLM-powered chatbot, designed via prompt engineering to deliver cognitive restructuring (CR), with 19 users. Mental health professionals then examined the resulting conversation logs to uncover potential benefits and pitfalls. Our findings indicate that an LLM-based CR approach has the capability to adhere to core CR protocols, prompt Socratic questioning, and provide empathetic validation. However, issues of power imbalances, advice-giving, misunderstood cues, and excessive positivity reveal deeper challenges, including the potential to erode therapeutic rapport and ethical concerns. We also discuss design implications for leveraging LLMs in psychotherapy and underscore the importance of expert oversight to mitigate these concerns, which are critical steps toward safer, more effective AI-assisted interventions.

This paper explores conversational self-play with LLMs as a scalable approach for analyzing and exploring psychotherapy approaches, evaluating how well AI-generated therapeutic dialogues align with established modalities.

The increasing demand for mental health services has led to the rise of AI-driven mental health chatbots, though challenges related to privacy, data collection, and expertise persist. Motivational Interviewing (MI) is gaining attention as a theoretical basis for boosting expertise in the development of these chatbots. However, existing datasets are showing limitations for training chatbots, leading to a substantial demand for publicly available resources in the field of MI and psychotherapy. These challenges are even more pronounced in non-English languages, where they receive less attention. In this paper, we propose a novel framework that simulates MI sessions enriched with the expertise of professional therapists. We train an MI forecaster model that mimics the behavioral choices of professional therapists and employ Large Language Models (LLMs) to generate utterances through prompt engineering. Then, we present KMI, the first synthetic dataset theoretically grounded in MI, containing 1,000 high-quality Korean Motivational Interviewing dialogues. Through an extensive expert evaluation of the generated dataset and the dialogue model trained on it, we demonstrate the quality, expe

The proliferation of Large Language Models (LLMs) and Intelligent Virtual Agents acting as psychotherapists presents significant opportunities for expanding mental healthcare access. However, their deployment has also been linked to serious adverse outcomes, including user harm and suicide, facilitated by a lack of standardized evaluation methodologies capable of capturing the nuanced risks of therapeutic interaction. Current evaluation techniques lack the sensitivity to detect subtle changes in patient cognition and behavior during therapy sessions that may lead to subsequent decompensation. We introduce a novel risk ontology specifically designed for the systematic evaluation of conversational AI psychotherapists. Developed through an iterative process including review of the psychotherapy risk literature, qualitative interviews with clinical and legal experts, and alignment with established clinical criteria (e.g., DSM-5) and existing assessment tools (e.g., NEQ, UE-ATR), the ontology aims to provide a structured approach to identifying and assessing user/patient harms. We provide a high-level overview of this ontology, detailing its grounding, and discuss potential use cases. W